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HomeMy WebLinkAbout10238 , ,<:,.. ,, ,..�-��.,.:.,. CITY OF DIAMOND BAR � COMMUNTTY DEVELOPMENT DEPARTMENT ;,,,� 21660 E.Copley Drive Suite 190 PRESS (909)860-3195 Faz(909)86]-3117 ' '""'� BUILDING PERMITAPPLICATION FIRNILIY r � / 't /^� ,.� s� _ o D R�ESS .0� I J I N�If'��,,1.��-� i DAT�CATION ,�.�` S�' /� NUMB R " �,��' �/C . � APN LOT TRACT D TEE � e �a ONST. GR�UP °C OWNER O o ADDRESS �II S I ��L1r/�J �'.�� ZONING SETBACKS Z CITY A� ZIP TEL. FRQNT RW ❑ g APPLICANT� F��J�LaI" TEL.� —!!',21-f.�.f' '� REAR p � SIDFJSIbE STREET RW ❑ � CONTRACTOR � �� UI Fl�- SIDE "�,` ❑ o CDDRESS A�f A- ZIP�[Q�� TELL �� PROPOSED USE " 2?CJ u��" w AACH/ENG/ �t"QS'] iz DESIGNER NO.DWEL. _., NO.,` j _.�. NO. a ADDRESS_ . � CITY 21P TEL. UNITS STORIES BED'R�OliAS � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREAA/ALUATION p� OWNER-BI:ILDER DECIARATION SFR/ADD/AEM O p I HEREBV AFFIRM UNDER PENALTV OF PERJURV THAT I AM E%EMPT FHOM 7HE CONTRACTORS LI- GflfBJB/CBfpOR � W CENSEUWFORTHEFOLLOWINGREASON(SECJo31.58USWE5SANDPROFESSIONSCODE:ANYbIYYOP (n C.) COUNTYWHICHREQU�qESAPERMITTOCONSTftUCT,ALTER,IMPROVE,OEMOLISH,OqREPAIRANVSTRUG W Patio/peck Z TURE,PRIOR TO ITS ISSVANCE,ALSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE'A SIGNEO .W2r 5TA7EMENT 7HAT HE OR SHE IS LICET15E0 PURSUANT TO iHE PROVISIONS OF THE CQNTRACI`b�p5 LI� � � CENSE LAW(CHAPTER 9 f�MMENCING WITH SECTION 7000)OF OIVISION 3 OF THE BUSINESSAND PRO• POOUSp3 � FESSIONSCAOE)ORTHATNEORSHEISEXEMPTTHEREFROMANDTHF6ASISFORTHEALLE(3ED�EXEMP- (� V TION.ANYVIOLATIONOFSECTION7031.6BYANYAPPLICANTFORAPERAAITSUBJECTSTFIEAPPLICAPdT70 � Re-Roof � A CIVIL PENALN OF NOT MORE THAN FtVE HUNDRED DOLURS(l506�.): ' - - " ""'""'-" ' , � OI,ASOWNEROFTHEPFOPERTV,Oi7MYEMPLDYEESWITHWqOESASTHEIRSOLECOMPENSATION, C� Commercial -- VJILI DO THE WORK,AND TNE STRUCTURE IS NOT INTENDED OH OFFERED FOR SALE(SEC.7044,�BUSI� .,,J � NESS ANO PROFESSIONS CODE:THE WNTRACTOHS UCENSE LAW DOES NO7 APPLY 70 AN OWNER OF ? PROPERTY NMO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HEpSELF Op �.; fY TNROUGHHISORHEROWNEMPLOVEES.PROVIDEOTHATSUCHIMPHOVEMEMSAPENOTINtEN�EDOP m .���� �� ��-. , QOFFERE�FORSALE�F,HOWEVERTHEBUILDINGORIMPROVEAAEN7ISSOLAWITHINONEYEAROF'CAMME � • Z TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR�SHE DIU NOT BUIID OR = IMPROVE FOR THE PURPOSE OF SALE). ' ❑I,AS OWNEF OF THE PROPEiiTY,AM EXCLUSIVELY CONTRqCTING W ITH LICENSED CANTRACTOR5 � TO CONSTqUCT 7ME PROJECT(SEQ 7044,BUSINE55 AND PROFESSIONS CODE:THE CONTRACTOqS L4 V81U8IIOt1 _ � ADJ.AREA LL CENSELAWDOESNOTAPPLYTOANOWNEflOFAPROPERTVWHOBUIL�50RIGAk�ROVE57HEREON,ANO � WHOCONTHACTSFORSUCHPROJECTSWITHACONTRACTOR(S)LICENSEDPURSUANTTOTHECANTflAP G�UANTITY �ESCRIPTION FEE � TORS LICENSE LAWJ. �� - O ❑1 AM EXEMPT UNDER SEC. B.d P.C.FOR THIS flEASON Q � V �'�" DATE OWNEF �F � .. .. O W � LICENSED CONTRACTORS DECLARATION W � I HEflEBY AFFIRM UNOER PENAl7Y OF PERJURV 7HAT I AM LICENSED UNDER PROVISIONS OF CHAPYER � � 9(COMMENCINO WITH SEC710N 7000)Of DIVISION J OF 7HE BUSINESS ANO PROFE5810NS CODE,AN� Z lX MY IICENSE IS IN FULL FORCE AND EFFECT. m � LICENSE CIASS / �pr�—t LIC.NO. '"F/ � r(SS � U DATE �'r 1�� / f GONTRAC70R ��'�,,,�)�yU._� � d W � WORKERS'COMPENSATION DECLARATIQN � ���� � a � 1 HEREBV AFFIRM UNOEN PENALTY OF OERJURV ONE OF iHE fOLLOWMG DECLARATIONS: Z 4 Z _I HAVE AND WILL MAWTAIN A C�qTIFIGATE OF GONSENTTO SELF-INSURE FOR WORKEflS' S Q CqMPENSATION.AS PROYIDED Bv SECTION 3700 OF 7HE LABDN CAOE,FOR 7HE PERFORMANCE `U Q OF THE WORK FOR WHICH THIS PERMIT IS ISSUEO. � " W _I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION Q 370o OF THE LABOR CODE,FOR THE PEFFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS }�I : /'� � ISSUED.MP WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CONSTRUCTION Q �j CARfiIER �'^ �� PLAN REVIEW � � ')� Z POLICY NLIMBER I�f��,8'� ELECTRIC Q 0 (iHIS5ECf/JNN�NOTBE07MPLEfEDOFTNEPERMffISFORONEMN�DREDDCUMS(Si00�ORLESSI PLUMBING Z I CERTIFY THAT IN THE PERFORMANCE OF THE WOFK FOR WHICH THIS PERMIT IS ISSUED,1 MECHANICAL (� SHALL NOT EMPLOYANY PERSON IN ANY MANNER SO AS TO BECOME 5UBJECTTO TNE � WORKERS'COMPENSAT�ONUWSOFCALIFORNIA,ANDAGREETHA7IFISNOUTABECOME i � Tdt�L�(FEE = SUBJECT TO THE WORKERS'COMPENSATIIXJ PROVISIONS OF SECTION 3700 0F THE 1A80F L CODE,I SHALL FORTHWI7H COMPLY WI7H7HOSE PROVISIONS. - ISSUANCE ,J ` p DATE:�_ '�r6-g� APPLICANT: ���E I�6]M1�L� `�5���" f � W J WARNMG FAILURE TO SECURE WORKERS'COMPENSATION CAVERAGE IS UNUWFUL,AND SHALL BE GY P/C � SU&IECTAN EMPtAYER TO CRIMINAL PENALTIES ANO CIVI�FINES UP TOONE HUNOiiED THOUSAND ENERGY PERMIT OOLLARS(S7oo.o00).IN ADOIiION TO THE COST OF COMPENSATION.OAMAGES AS PROVIOED FOR IN J SECTION37080FTHELABORCODE,INTEREST,ANDATTORNEV'SFEES. oc RETENTION FEE: OCONSTftUCTION LEND�NG AGENCY � PREALT FEE: � 1 HEREBV AFFIqM UNDEH PENALN OF PERJURV TNAT THERE IS ACANSTRUCTION LENDING AGENCY FOR THE PEHFOfiMANCE OF1'HE WORK FOR WHICH THIS PERMIT IS ISSUEO(SEC.3097,CIV.C.}. Z W � LENDER'S NMIE �� - - ' � '- ' '� H LENOER'S ADDRE55 w ICERTIFVTHATIHAVEREADTHISAPPUCATIONANDSTATETHATTHEABOVEWFORMATIONISCORRECL TOTAL FEES � ' . - Q I AOREE TO CAMPLY WITH ALLCIN AND CAUNTY ORDINANCES AND STATE U1W3 RELATING Tp BUILOING � � � � �� .� � �� . � � CONSTRUC7IIXJ,AND HEREBYAUTHORIZE FEPHESENTATIVES OFTHIS COUNTV TO ENTER UPON 7HE ' ' Z ABOYE-MENTIONED PROPEFTY fOR INSPECTION PURPOSES. GOMMENTS � ��F ��GI' �., ��n ; ¢ PERMIttEE E f HINT1 I�� � �"' ;� �I � s.•a i � SIONA EO fl ITTEE DATE l��g� �'- �� F ;_ � ':i = fiECPT.N PAID BY � ;VAL�U�TION ~ HITE—Departmero Gopy,YELLOW—Finance Capy,PINK—Assessor Copy,GOLpENRO�—File Copy,GREEN—Applicant s Copq . � i : ��.i .,...s._:.. �xv:k�;'���"� ��-�..M.^.4'+.. 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