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HomeMy WebLinkAbout12758 (11) .r��� CITY OF DIAMOND BAR " � : x ��� , -----1�- J� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES "' ,� 21fi60 E.Copley Drive Suite 190 � "• ,°' , ,,. (909)860-3195 Fax(909)861-3117 PRES$ ._. � BUILUIIVG�It11�TT A�T�T,tCA'�'Ibl� � _. . , " FIRMLY . �,yns ' . � . . , , . , �:., .. . . ., _ _. � JOBSITE ` ' "�'' ""` ��;`��'� APPLICATION � \ PERMIT P/C Q ADDRESS_��_L-�F O DATE NUMBE � # � ISSUE TYPE �CC APN LOT TRACT DATE CONST. GROUP p OWNER �� 0�-1!o'��/�C�/�'.d$1 p ADDRESS � �'�'� ZONING SETBACKS � CITY � ZIP TEL. FRONT RW ❑ � APPLICANT � �.'�' !"�9�iifi,�� TEL�r.r�3 �� REAR ❑ � SIDE/SIDE STREET RW ❑ CONTFIACTOR ��9c"-�-�tr�,/rv'�'c a-•• nn ���s�'� � SIDE ❑ � ADDRESS ,L c"'�-e+���F e��� .r � PROPOSED U$E p CITY ! . ZIP 's�-? TEL.���'� ���� � wQ ARCWENG! �Z DESIGNER a� NO.DWEL. NO. NO. o��. ADDRESS UNITS STORIES BEDROOMS � Ct4Y ZIP TEL. � cn DESCRIPTIOM SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNEA-BUILDER DECLARATIQN _ .�� .. � . . SFRlADD/fiEM O [] I HEREBV AFFlRM UNDER PENALTY OF PERJURY THA7 I NA E%FAAPT FpOM 7HE COMRACTORS 1.4 Gflf8g0/C8f(JOR W CENSEUWFORTHEfd.IOWINOREASON(3EC.7o31.58USINE3SAN0�PRbFESS16N5CODE:ANYCITVdP, (n i� COUNTVWHICHREOUIRESAPERMIT7000NSTRLIC7ALTERIMPROVE,�E�AOL�SH,OqREPAIPANVSTqtJC- W py(j0/D9Ck Z TURE,PRqR TO ITS IS9U�VlCE;ALSO REOUIRES THE APPLICAM FOR 5UCH�PERM(T�TO FILF A S9bNF� W STATEMEN7 THAT HE OR SHE IS LICENSED PURSUANT TD?HE PNOVISIONS OF THE bONTRACTOqS Lb W ..�c CENSE LAW(CNAPTER e�COMMENCIN6 NqTH SECTION 700a)OF DIVISION 3 OF THE 6USINESS AYJD Pi10- �' POoUSPa � FESSpNS CODE)ORIHATHE OR SHE IS E%EMP77HEREFROM ANC THEBASIS FOH TFIE'ALLEGEO E7(EMP� V TION.ANYVIOL0.TIONOFSECTION7D37.5BYANVAPPUCAN7FORAPEtiMIiSUB:lEC7STHEAPPI:�C/NTYO � e-R004 � � � ACIVIL PENALTY OF NOT MORE 1}1AN FIVE HUNDflED DOLLARS(5500).): � �'��' � �I,ASOWNEROFTHEPR9PERTY,OPMYEMPLOYEESWITNWAGESASTHEIASOI.ECOMPEIJSATILMI, � COffifflefCi81 - WILl00 THE WOPoC AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOH SALE(SEG.7093;BUSb _i � NESS ANq DROFESSlONS CO�E:THE COMRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNEl7 OF � PROPERT�WIiO BUp.DS OR IMPROVES THERECN,ANDYAIO WES SUCH WORN HIMSELF OR HERSES.F OR � 7HROUONHISOHHEqMIR.IEMPLOYEES,PqOVIDmTHAT$UCHIA{pqpVF_MENTSARENOTINTENOEDOR �1 W OFFEREDFORSALEIFHOWEVER,THEB�II�INpORIMPROVEMEN7ISSOLDVJITHINONEYEAROFCOA4PLE� � �TION,7HE OWNER-BUILOER WILL HAYE TNE BURDFN OF PROVING THAT HE OR SHE pID NOT AUIfD Oq IMPFlOVE FORTHE PURPOSE OF SM,EJ. ' ' ` ❑i,AS OVMEROF THE PROPEHTY,AM EXCLUSIYELY CONTRACTINa WI'M UCEN$�D CONTtiA�ORS � TO CONSTPUCT THE PRWECT�SEC.7044,BUSINESS AND PROFESSION$600p:TH��CONTRACTdY75 Cb IuaflOn � _ADJ.AREA- � CENSE LAW DOES NOTAPPLY TOAN ONNER OFA PRaPEflTY WHd BUI4D5 DR IMPR6VES THBREO,ANb NM1iOCONTMCTSFORSUCHPROJECTSWiTFlACONTRACTOR(S)LICENSEDPURSUANTTOTMECD�AC- QUANTITY DESCRIPTION FEE � TORS 110ENSE LAW.I. :... .�-�/ T . ❑IAM EXEMPT UNDER SEC. B.8 P,C.FOR THIS R�ASON q ��J+�-C7/^�J"—'"L`'�%',y'�./J��✓� s`y a U �p � � 7'��l��CJ OA7E ONMER �" � Z U '/ '^ z1�./f�'l,�C�— � LICENSEQ CONTRACTORS DECLARATION � � � W � I HEREBYAFFlRM UNDER PENALTV OF PERJURV TNAT I AM UCENSED UNDER PROVISIdNS OF CHAPTER' /� � p� 9(l.'OMMENCINO WITM SECTION 7000)OF DIV�SION 3 OF THE BUSIME55 AND PROFESSIONS CQDE,qIVD�� 'Z '`��T'!��!+�t''.-�L"f.f'' "�, � LX MY tJCENSE IS IN FULL FORCEAND EFFECT. m '��j o� .� o UCENSE CLASS_�� LIG NO. 43 �7 � � _ � ~ DATE ��� CONTRACTOR �{��i»9�Y h 0. - Ldl � � ��✓Jv f �'c_> e%�,��/�/�//�%-'/.�a3 C.. a � WORKERS'COMPENSA710N DECLARATION �i`,Z�,..C�/� Q � r � I HEREBYAFfIRM UNDEH PENALTY OF PER.IUpF ONE OF THE FOILDYVING�ECURAT NS: Z /l s� �I uki i-e TCina d'..ead .l a:n..d ° L� � 1 HAVE ANO WILL MNINTAIN A CEHTIFICATE OF CONSENT TO SELF•INSURE FOft WORNERS' Z COMPENSATION,ASPFOVIDEDOYSECTION37ooOFTHELABORCO�E,FORYHEPERFORMANCE w OF THE WORN FOR WHidl THIS PEHMIT IS ISSUED. _� 0 W _I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION /�,� Q 37W OF THE IABOR CODE,FOR THE PEflFORMANCE OF THE WORK FOR WHICH THIS PERMITIS / � ISSUED.MY WORKERS'COMPENSATION INSURANCE CARF.IEF AN�POLICY NUMBERARE: CONSTRUCTION � lW 4 y CARRIER PLAN REVIEW � POLICY NUMBER_ ELECTRIC Q � (THISSECTM�NNEr�NOTeEOQV%.ETEDOFTIEPERWT!SWFONEHUMREDOqJMS(SfaO)OFLESSA P�UMBING W � R� I CERTIFYTHAT IN YHE PERFORMANCE OF TNE WORK FOq WHICH THIS PERt�AIT IS ISSUEO,I MECHANICI�IL (� / ,SHALINOTEMPLOYANYPER50NINANYMANNEFSOASTOBECOMESU&IECTTOTHE N � WORI(ERS'COMPENSATION LAWS OF C IFORNtA,AND AGREE THAT IF 1 SNOULD BECOME INSPECTION FEE F- SUBJECTTOTHEYdORHERS'COMP�N IONPflOVISIONSOF TION37000F7HEtABOR � ' � CODE,1 SHAL FORTHWITHCOMPLV I THOSE PROVISIO� ISSUANCE p DATE: �' �� �APPLICANT�� "��'�' �.����./��""�� SMIP __-�-(�___'Ipt1R j WARNINO:FAILURE TO SECURE WORK R COMPENSATION COVERAGE IS VNI.AWFUL,AND SHAIL DE ENERGY P/C _ _ v � SU&lECTANEMPLOYERTOCRIMINh P ALTIESANOCIVILFINESUPTOONEHUN�ftEDTHOUSANU ENERGYPERMIfryy DOLLARS(S10o,o00).WADDITIONTO, ECOSTOFCOMPENSATION,DAMAGESASPROVIDEDFORIN �j-/'�r7, � � SECT�ON37080FTHELA80RCODE,INTEflEST.ANDATTORNEY'SFEES. ��1�A i✓L'�.y� N��� - fiETENTION FE� � CONSTRUGTION LENDING AGENCV PRE-ALT FEE: -N�SAFETY Q I HEREBVAFFIRM UNDER PENALTY OF P'cRJURY THATTHERE IS A CONSTRUCTION LENOING AGENCV , , fORTHE PERFOflMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.8097.CIV.C.). ,,_ .. Z W � LENDER'S NAME ' � F-�- . LENDER'3 A9�RES5 � + ICERTIFVTMATIHAVEREAOTHISAPPUGATIONANDSTATETHAThIEABOVEINFORMATIONISCORRECT. TOTAL FEES r W I AGREE?O COMPLY WRH All CIT'AND CDUN7Y OPDINANCES AND STATE LAWS RELATING YO 6UILDING � CONSTRUCTION,ANDHEREBYAUTHOflIZEREPRESENTA71VE50FTHI5COVNTYTOENTERUPONTME � � ABOVE-MENTIONED PROPER7Y FOR INSPECTION PURP0.SES. ' . '' COMMENTS �r � �r� ����� . , m ¢ PEfl EE NAME(PRIM) CI! �,r� _"'^^+._ti..�.v..�.-_ . , Uj � N � �FPERMlTTEE �' iDATE � " �' -�� �,� RECPT.NO.__. PAID BY VALIDATION �! - WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GQLDENROD�—File Copy,GAEEN—Applicant's Copy��-�� - � � - - , � _ ,. ,:. _,,.. a ,� :. �;. r ..�e:�_. , .-:�kr.� � ..�.�.,�.;• t� v.s.� a:�F.:a">ht .. 0 5�n; �f�:.. �i. � ��;k::. �s � , „_ .�., .-,. ,�;<..� .., �: .,,...: . .. . . ..,. ,i....,: o,., ; �.... N.... :.1. 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