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HomeMy WebLinkAbout10357 (5) ,����� _ .�, . ..,,�;.._... � :..,..�.<�,,::�,_;.. . ,.,:::� - _ ___ � ,..,.��....:.;�,�., _,--.;.� - �• CTfY OF DIAMOND BAR � COMMUNITY DEVELO�MENT D$PAf2TIV1ETVT � 2166o E.Copley Drive Suite 190 PRESS r,.�,.,, (909)860-3195 Fax(9p9)861-3117 BUILDING,PERMIT'APPLICATION FIRMLY _ .:__ .. ,. �., .: .., o� JOBSITE ��� },J,�R� �I = APPLICATiON �����?.�'A PEFiMiT����''�� P/C ADDRESS � � DATE `�' r NUMBER # � ISSUE ,,� �+p TYPE OCC APN 4 T TRACT DATE [+����� ` CONST. GROUP p OWNER �1 -, _, p ADD SS � ` r U '' ZONING SETBACKS gCITY�i� �' ZIP i�� TEL. " 1� Ea FRONT RW ❑ APPLICANT .t(17�✓1��L���. TEL � � -S S D F J S I D E S T R E E T R W ❑ m CONTRAC R v`Cl� � Li'1 SIDE p � ADDRE S ';"� PROPOSED USE �'�''�"�°� f�+`�� 7�'�� � CITY +'� , T 71P TEL.jt)�'2�1�(l S Zl ,„, .c� Y'' P�+ �'A�S.�s�' A ARCHlENG! � iz DESIGNER NO.DWEL. NO. NO. Q. ADDRESS a CITY ZIP TEL. UNITS STORIES BEDROOMS � DESCRIPTION SQ.Fi: FACTOR P5F ADJ.AREANALUATION � OWNER•BL'ILDER DECLARATION �� SFR/AODlREM O (] I HEREBY AFF�RM UNDER PENALTV OF PEpJURV THAT I AM EXEMPT FHOM THE CONTRACTOAS LI- Gef89B/CSf(7D1t W CENSEUWFORTHEFOLLOW�NGflEASON(SEC.7o31.58U51NE55ANDPROFE5510N5COpE:ANYCiTYOR �(n C.� COUNTYWHICF1flEWIRESAPERMITTOCONSTRUCT,ALTER,IMPR6VE,DEMOL)SH,ORqEPA�RANVSTRUC- W PBfiO/DBCk � 7URE,PRIOR 7o IT&ISSUANCQ N.SO FlEWIRES THE APPIICANT FOR SUCN PERM�T TO FlLE A SIONED w STATEMENT 7HAT HE OR SHE IS UCENSE�PUpSt1ANT TO THE PROYISIONS OF THE CONTRACTORS U� W � CENSE�AW(CHAPTER 9(COMMENCINQ WITFI SECTION 7000�OF DIVISION�OF THE BUSMlESSAND PRO- �'�' PODUSp6: FESSIONSCODE�ORTNATHEORSHEISEKEMPTTHEREFROMAN�THEBASISFORtHEALLE0E0EREMV• (J TION.ANVVIOUTbNOFSECTION7031.5BYANVAVPUCANTFORAPERMITSl1&IECTSTHEAP7UCANTT'O Z qe-Raof A CIVIL VENALiV OF NOT MORE 7HAN FNE HUNDRED DOL(Aa5(35oD).1: ' � � � ❑I,ASOWNEROfTHEPROGERTY,ONMVEMPIOYEESWI7HWA0ESASYHEli1SOLECOMPENSATION, L7 Commerciat Z WILL DP THE WORK AND TNE STRUC7URE IS NOt MTENDED OR OFFERED FOR SAE(SEC.70�a,BUSI- J � NE55 AND PHOFESSIONS CODE:THE COMRAC70R5 IICENSE lAW�OES NOT AVPLY TO AN OWNEfl OF = PFiOPERTY WHO BUIlD30R IMPROVES THEREON,ANO WHO DOES SUCH NlORK HIMSELF OR HERSELF Oq CL iHROUGHHISORHEROWNEMPLOVEES,PROVIDE�7HA75UCH�KIPROVEMENTSAR6NOTINTENDE00R � Lt�.l OFFEREO FORSALE.IF.HOWEVER,THE BUILOING OR IMPROVEMENT t5 SOID WITHIN ONE YEAR OFCOMPLE- �-' TION.THE OWNER-BUILDER WILL MAVE THE BURDEN OF PROVIIJG THAT HE OR SNE DIO NOT ffiNLD Oq = IMPROVEFORTNEPURPOSEOFSAL�. W ❑I,ASOWNEROFTHEPROPERTY,AME%CLUSIVEL�CANTRACTINGV✓ITNLICENSEDCONTRACTORS - W CEN�SENLAWOpESHlbTAPPLYTOSAN�OWNEROFAPROPEflTVWHO58UILDSO�IMPAOYE�TFIERETd.RANO' V81Uet1011 Ap.I.AREA � WHOCONTRACTSFORSUCHPROJECTSWITHACON7RACTOR(S)LICENSEDVURSUAN7TOTHECONTRAC- QUANTITY DESCRIPTION FEE � � TORS LICENSE LAW.�. ❑I AM EXEMP7 UNDER SEC. 8.3 P.C.FOR 7HIS REASON Q � U � � OATE ONMER � � � ' � . � . �s[ LICENSED CONTRACTORS DECLARATION W Cl_ I HEREBYAFFIHM UNDER PENALTYOF PERJURY THAT IAM LICENSED UNDEP PROVIS�ONS OF CHqpTEN � � 9(COMMENCINOWITHSEC710N7000)OfUIVI510M30F7HEBUSINE55ANDPROFES51ON5CADE.AND Z MV UCENSE IS IN FULL FORCEAND EFFECT. � UCENSE CLqS?S �n�� 1 _, I.IC.NO. �^`"��ry�� �� ��,�� ,r� �j U DATE t L. � CONTRACTOR`���,��''i LL W ..... .... .. . . J � WORKERS'COMPENSATION DECLARATION � ;� � � e � I NEREBV AFFiRM UNDER PENALTY OF PEi1JUqY ONE OFTHE FOLIAWING DECLARATIONS: Z :��';� � },: � _IMAVEANDWILLNAMTAINACERTIFICATEOFCONSENTTOSELFINSUREFORWORKERS' _ GOMPENSA71pN.A5PHOVDEDBYSECTIONa7oaOFTHEIABORCODE,FOR7HEPERFORMANCE U ¢ OF THE WORK FOR WHICH THIS PERMIT IS IS9UE0. � 0 w ^IHAVEANDWILLMAINTAINWORKERS'COMPENSATIONINSURANCE,ASHEaUIREDBYSECTION �I Q 370o OF THE LABOR CODE,fOR TH&PERFORMANCE OF THE WORN FOR WHICH THIS VERMIT IS ` / ��..:r• LSSUED.MY WORKE{iS' MPENSATION INSURANCE CARHIERANO POLICv NUMBERARE: CONSTRUCTIO � ¢ �.Lz� ^f',n kG����'� r�n w � CAHRiEFi 2 POLICY NUMBER �y�,�y�� n„�,'.���_,,���^- ��„ ELECTRIC ¢ 0 (IH6S[CiNJNNE�NOTBEWMI'LETWOFTHEPELN1ffS�ORdJEHUWRED00L11�fi6�ElOD)ORI.�S) PLUMBING Z I CER7IFV THAT IN THE PERFORMANCE OF THE WpRK FOR WHidl THIS PERAIIT IS ISSUED,� MECHANICAL C!7 SHALL NOT EMPLOY ANY PEFSON IN ANY MANNER SO AS TO BEfX7ME SU&IECT TO7HE � WORKEFS'COMPENSATIONLAWSOFCALIFOflNIA,AN�AGREE7HATIFI3HOULDBECOME INSPECTIONFEE � SU&IECTTOTHEWORKER6'COMPENSATONPROVISIONSOFSECT10N3700pFTHELABOR ......� = CO�E,ISHA FORTHWITHCOMPLVWITHT SEPqOVIS�QN� / ISSUANC 1 p DATE:�� APPLIGANT: ����.�„r.�,1�_—_ �IP P •e�� � GY P!C WARNIN(i:FAILURE TO SEWRE WORKERS'CAMPENSATION COVERAOE IS UNLAWFUL,AND SHALL6E � SUBJECTANEMP�OYERTOCPIMINALPENA7IESANDCIVILFlNESUVTOONEHUNDRffDTHDUSAN� ENERGYPERMIT OOLLANS(510�,Ooo),IN AflOIT10N TO THE COST OK COMPENSATION.DAMAGES AS PROVI�Eb fOR IN � SECTION 8708 OF7HE LABOR GODE,INTEREST,ANO ATTORNEYS FEES. qETENTION FEE: OCONSTftUCTION LENDING AGENCY PRE-ALT FEE: � I HEREBYAFFIRM UN�EA PENALTYOF PERJURY THATTHERE IS A CONSTRUCTION LEND�N�AGENCY FOR THE PERPoPMANCE OFTHE WORK FOR WMICN TNIS PERMR IS ISSUEO(SEL.30B7,CIY.G.�. W � LENUER'S NMIE -_��— a..,.�:;-:� 1— LENDEiYS.C�DRE55 '� �� k `51 � TOTAL FEES ��s '`J' ° ""�" � I CER7IFY THAT I HAVE READ THIS APPLICATION AND STATE THATTHEABpVE INFOpMATION�S CARRECT. � IAGREETOCOMPLYWITIiALLC1TYi{NOCWNT{'ORbINANCE$ANOSTATEUWSRELATNGT0�8UILOMG " �. �-- CONSiRUCTION,AND HEREBV AUTHORRE qEPFlESEN7ATIVES OF hIIS COUNN TO ENfER UPON THE �` z .400VE-MENTIONED PROPERTY FOfi INSPECTION OURPOSES. 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