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HomeMy WebLinkAbout16456 (17) _ _ ,,,,. �;�,a_ CITY OF DIAMOND BAR '�� �> ' DEPARTMENT OP COIVIMUNITY&DEVELOPMENT'SERVICES ` 21660 E.Copley Drive Suite 190 ��°��` � ::�; (�)s6o-�ipsF���)sbi-sii� PRESS "�°- . , $UILDIi�TG Pb,''RMYT.APPLICATTbN s ,,a FIRIU�L�Y Q D R'ESS � APPLICATION � PERMIT � P/C p DATE NUMBER # $ ISSUE TYPE OCC APN LOT RACT DATE� CONST. GROUP p OWNER � ADDRESS ZONING SET6ACKS � CITY � . IP TEL. FRONT RW ❑ APPLICANT TEL. REAR C � SIDE/SIQE STREET RW C CONTRACTOR SIDE C � ADDRES� � � .. . � : CITY IP TEL. r �7 PROPOSED USE o ARCH/ENG/ ` T�- � DESIGNER -- — NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDR'OOMS � CITY ZIP__ TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLAFATION SFR/A�D/REM O I HEREBV AFFIRM UNDER PENALTY OF PERAIRV THAT I AM EXEMPT fROM THE CONTfiACTORS Lb G2f2CJ0/CdfOOR W CENSELAWFORhiEFOLLOWINGREASON(SEG7o31.58USINESSANDPROFESSiONSCAOEiANYCITYOR (� COUNTYYVHICHREWIRESAPERMITTOCANSTRUCT,AITER,IMPROVE,DEMOLISH,ORREPAIRANYSTRUC� W pati0/DOCk W 111RE.PRIOH TO ITS ISSUANCE.AlSO REQUIRES THE APPUCAN7 P6R SUCH PERMIT TO FlLEA SIGNED W STAT6MENT THAT HE OR SHE IS UCENSEO PUflSUANT TO THE PROVISIONS OF THE CANTRACTOR3 Ll� � CENSE LAW�CNAPTER 9(COiAMENdNO WITH SECTION 7000)OF pIVIS10N 3 OFTHE BUSINESS AND PRO- V' POOUSpd FESSIONSCO�@)ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEdE��E%EMR (!f TION.ANYVIOIATIONOFSECTION7031.68VANYAPPUCANTFORAPERMITSU&IECTSTHFAPPLICANTTp Z �j@-R00f ' � A CIVIL PENALTV OF NOT MORE THAN FIVE HUNDRED DOLURS(;6co).): � ❑I,ASOWNEROFTHEPftOPERTY,DRMVEMPLOYEESWITHWAGESASTHEIRSO�ECOMPENSATION, C� COt11iT9fC18I - MALL DO7HE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7o44,'BUSI- _1 y NE55 AN�PROFESSIONS CODE:hIE COlITRACTORS LICENSE lAW�OES NOT APPLY TO AN OWNER OF � PROPERTV WFIO BUILDS OR IMPqOYES THERC-0N,AND WHO OOES SUCN WOFK HIMSELF OR HERSELF OR � THROUf3H HISOR HER OWN EMPLOYEES,PROVIDED'HAT SUCH IMPpOVEMENTSARE NOT MTENDED OR CO O .OFFEHED FOR SALE IF,HOWEVE0.'�HE BULDING OR IMPHOVEMENT IS SOLD WITHIN ONFYEAR Of COKfPLE- Z TION,THE OWNER-BUILOEFl WILL HAVE THE BUR�EN OF PROVING THAT HE OR SHE DID NOT�BUR�OR � IMPROVE FORTHE PURPOSE OF SALE). '- .' � ' W ❑1,ASONMEROFhIE PROPER'7Y,AM EXCLU^aNELYCONTRACTINf3 WRH UCENSED CONTRACTORS � 70 CONSTRUCT THE PfiUIECT(SEC.7a4n,BUSINE55 AND PRpFE5510N5 CADE:THE�CON7P'ACTORS LI- � VflIUeIlOf1 ADJ.AREA_ W CENSELAWDOESNOTAPPLYTOANqWtd[ROFAPRUPERTYWFIoOUiLO50RIMPROVESTHEPcON.AND --- � YVFpCONTRACTSFORSUCHPROJECTSWITHACONTRRCTOR(S)UCENSEDPUFSUANTTOTHECONTRAG Q�qNTITY DESCRIPTION FEE � TORS LICENSE LAW.). � � � � ❑I AM EXEMiPT UND£R SEC.__ _. 8.d P.C.fOR THIS RFP,SON Q � — U W � DATE ONMER _ � �z�y EdJ LICENSED CONTRAGTORS DECl.ARATEON � I HEREBYAFFIRM UNOF.R PENAITY OF PERJURY TiiAT I MI LICENSED UNDER PROVISION5 OF CNAPTER � d 9(OOMMENCINO WITH SECTWN 7000)OF DMSION 3 OFT41E BUSINESS AND PROfESSIONS CODC-,AN� z }C MYUCENSEI51kFULlFOflCEANDEFFCCT. m 90 _�—_ �7�„r'��/Y� � LICENSE CLASS w=� LIC.NO.�-'� J v DATE_`�_ CONTfiACTOfi�/��(�,�- 4 � W � WORKERS'COtviRENSATION DECLARATILN —� d NI HEqEBY AFFIRM UNDER PENPLTY OF PEFUURY ONE OFTHE FOLLOWING DECLARATIONS: Z � _IF1AbEANDWI4LMAINTAINACERTIFICA7EOFCONSEN'f709ELF�INSUREFORWORKERS' � CUAIPENSATION.AS PflOVIOED BY SECTK3N 37000F TNE 1A00R CODF,FOR THE PER�ORMANCE �U OF7HE KbRS FOR WFIICH THIS PERdAIT IS ISSUED. � � � �1 HA4E AND W7Ll.MAINTAIN WORKEPS'COMPENSATION INSURANCE,AS REQUIRED 8V SECTION � � ,i]0a OFTNE IABOq COpE,FOR 7F:E PERFQRMANCE OFTHE MJOflK FOR WNICHTHIS PERMITIS � ISSUED.SAY6YOfiKEFl' NS OY�NSU CARRIEH AND POUCY NUMBER PRE: CONSTRUCT�ON � �f'T � cpAaiEa_.__� _ � _ L..L-'�"�.—___ _ PLAN REVIEW � POUCYNUMBEfl� y� —_��— ELECTAIC _ � (iFftSSEGT,CNMEWNOTOECOMR....FTEOCF'IHEPF.PoVYTISFCfiOPlEMAmREDWl1JRS(57o7�ORLE5S7. PLUMBING � ICER"fiFYTHk?INTHEPEFiFORMAidCEOFTHEW4flKFORWHICHTHISPERMiTI5155UED.l MECHANICAL (� SHALL PIOT EMPLOY ANY PEFSON Ik ANV MANNER SO AS TO 9ECOME Sl1B..'ECT TO TNE � WORKERS°COM�ENSATIONLAWSOGCAUFORNIA,AN�AGREETNATIFISHOULDBECOME INSPECTIONFEE � SU&IECTTOTHEW6RKERS'COMP�NSATIONPROVISbNSOFSECTIOiV37000FTHELA80R '� � �� - � . .., � GOOE,I SHALL FOI'.THWITHCOMPLY WITH 7HO5E PROVISIONS. ISSUANCE o SMIP � p DATE:_ RPPLICANT: _______.____ _ p � WAqNINO:FAILUPETOSECJREWORKERS'COMPENSA710NCqVEflAGEi5l1NlAWf-UL,ANpSHALLBE ENERGYP/C _ ___ ___ I � SU&IECTAN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDRE�THOUSAND ENERGY PERMIT _ DOIUFS(E1oo,oCu).IN aD01T10N TO THE C0.S70F COMPENSATION,DAMAGES FS PROVIpEO FOR IN ¢ SECT�ON37oeOfTHELABORCODE,INTEREST,ANDATTORNEV'SfEES. RE7EN710NFEE: � - "_ ° --__.____ ..._ _.....__._._____.__ p�.. CONSTRUCTION tENDING AGENCY PRE-ALT FEE: O � IHEREBYAFFIflMUNDERPENALTYOFPENURYTHATTHEREISACqNSiAUCTIONLENDINGAGENCV _ FOF THE PERFORMANCE OFTNE WOftK FOR WHICH THIS PERMIT IS ISSUE�(SEC.3087,CIV.C.). . - Z W � LENOER'S NAME ��� F— LENDEfYS ADDRESS � � ��"��-� �� �� � C W ICER7IFYTNATIHAVEREADTNISAPPLICAiIONANDSTATETHAT7HEABOVEMFORMATtONISCARRECL TOTAL f E�S � j � I � I AGREE 70 CAMPLY W1TH ALL CIT/AN�COUN'V ORDINANCESAND STATE LAWS REIATING TO BUIIAING . . � CONSTRIICTION,ANONEREBYAUTH�Pi7.EREPi7ESFN'fATIVE50FTHISCOl1NTVTOFNI'fRi1PONT'HE-� ' �.�� ��"�, �� - � ABOVE�MENTIONED PROP qRTY OR INSPECTION PURPOSES. COMMENTS P� � � � _ m PERMITTEE NAME( IN'7) -� ca_n �f�l—.______�1��/l��.tf��/_— . � SIGNATUFE OF PERMITT l = RECPT.NO. . 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