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HomeMy WebLinkAbout14241 (20) ,---= � ��%� - f� CITY OF DIAMOND BAR `.✓� -'� �" DEPARTMENT OF COMMUNTI'Y 8c DEVELOPMENT SER ICES .= a 21660 E.Copley Drive Suite 190 (909)660-3195 Fax(909)861-3117 P��a.,, ` ��'Y�'� BUILDING PERMTi'APPLICATION FIRMLY �'" o� JOBSITE � r APPLICATION �( PERMIT � P/C ADORESS ��'� r�� ���'"'�� DATE ` NUMBER # � APN LOT TRACT �SSUE TYPE OCC DATE CONST. GROUP p OWNE�. Yf ii.�.� fit o ADDRESS_ Z i�L�f1Yf �'- �:� yi'..� ZONING SETBACKS w CITY '� TEL. g��••,�'� FRONT RW ❑ � APPLICANT TEL. REAR ❑ � SIDFJSIQE STREET RW O � CONTRACTOR �-- �= n/�. SIDE c ADDRESS ., y � � CI7Y ZIP TEL. �.- PROPOSED USE � ARCH/ENG/ �� ��Z-��� �� DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � cn DESCRIPTiON SQ.FT. FACT�R PSF ADJ.AREANALUATION � OWNER•BUILDER DECLAFATION SFR/ADD/REM O 0 1 HEflEBY AFFIRM UNDER PEN�LTY OF PEiLIURY THAT I AM EXEMPT FROM THE CONTRACTORS LI� G8f8Q0/C31'pOfl W CENSELAWFORTHEFOLLOWINGREASON(SEG7o31.58U31NES5hNDPROFESSIONSCODE:ANYC1TYOq (n C> �pUNTYyyHICMREOUIRESAPERMRTOCONSTFUCT,ALTEH,IMPROVE,DEMOLISH,ORREPl11RANY5TRUC- W Patio/DOCk W NRE.PRqR TO ITS ISSUMICE,AL50 REW IRES iHE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W � S7ATEMENT 7HAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CANTRACTORS LI- CENSE LAW(CHAPTER 9(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- u' POOVSAa FESSqNSCODE)OATHlQHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEDE%EMP- (�'J TION.ANVVIOLATIONOFSECTION7031.68VANVAPPLICANTFOqAPERMITSUBJECTSTHEAPPLICANTTO Z Re-Raof � A CIVIL PENALTY OF NOT MORE THAN FNE HUNDRED DOLLARS�S6W).): � ❑I,ASOWNEROFTHEPROPERTV,ORMYEMPLOVEESWITHWAGESAShiEIR50LECOMPENSATION, COfiifflBfC18I - WILI DO7HE WORK�D hiE STRUCTURE IS NOT IMENDEO OR OfFERED POR SALE(SEC.7a14,BU51� � � NESS AND PROFESSIONS CODE:THE COfiTflACTORS LICEN5E UW OOES NOT APPLY TO AN OWNER OF � PROPERTY WHO BUIl.DS OR IMPROVES THEREIXJ.MID YrtiO DOES SUCH WORK HIMSELF OR HEHSELF OR � THROU(3HHISORHEflOWNEMPLDYEES,PflOVIDEDTHqTSUCHIMPFOVEMENTSARENOTINTENDEDOR m QOFFERE�WRSALEIF,HOWEVERINEBUILDINGOHIMPROVEMINTISSOIDWfiHINONEYEAROFCOMV�E- Z TlON,THE OWNER-BUILDER WILL HAYE THE BURDEN OF PHOVINO THAT HE OR SHE DIO NOT BUILD OR = IMPROVE FORTHE PURPOSE OF SALE). W ❑I,ASONMEROFTHEPROPER7V,NAEXCLUSNELYCbNTRACTING`MTHLICENSEDCANTRACTORS � TO COHSTRUCT THE PHOJECT(SEC.7014,BUSINESS M1D PROFESSIONS CADE:THE CONTPACTORS LI- VeIlldilOfl ADJ.AREA W CENSEUWDOESNOTAPPLYTOMIONRJEROFAPAOPERTVWHOBUILDSORIMPROVESTHEREON,AND = WFIOCONTRACTSWFiSUCHPROIECT5WIh1ACONTRACTOR(S)LICENSEDPURSUFNTT07HECONTMG F'" roasucEnsEuw.�. QUANTITY DESCRIPTION FEE Y 0 ❑I AM EXEMPT UNDER SEC. B,8 P.C,fOR THIS REASON Q }� U W � DATE OWNER U Z � LICENSED CONTRACTOAS�ECLARATION w � I NEREBYAFFWM UNOER PENALTV OF PERJURV THAT I AM UCENSEU UNDER PROVISIONS OF CHAPTER � p� 9(COMMENCMWNATHSECTION70W)OFDIVISION30FTHEBUSINESSANDFROFESSIONSCOOE,AND Z ?C MY UCENSE i5 IN FULI FORCEAND EFFECT. LLJ ,� � � 0 L�CENSE CLASS. �L-'C�r�, UC.NO, p � V DATE,�I�'�. �y�'7"7 CONTRACTOR, .- .- � d W � 1 � WORKEFS'C(.1MPENSATION DECLARATION -� ,f � ¢ r� _ � I HEREBY qFFIRM UNOER PENALTY OF PERJURY ONE OF TFIE FOLIOWING OECLAflATIONS: Z it-/, f�./ // C✓(J V V � _IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' _ OMIPFNSATION,AS VROVIDED BY SECTION�'lao OF THE IABOR CODE,FOR THE FERFORMANCE IU � OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. � � _I HAVE MIO WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS FEOUIflED 9Y SECTION Q 37000FTHELABORCODE,FORTkEPFRWRMANCEOfTHEWORKFORWHICNTHISPERMITIS ISSUEO.MY WOiRK�E '-001dPENSATiON INSURANCE C FIER AN�POIICV NUMBER ARE: CONSTRUCTION � CARRIER_ i"�"''� �L-�-au'�___ PLAN REVIEW Z POLiCYNUMBER���'�7`e.��� ELECTAIC �A Y� Q � (nissErri�n�noTSEcunP�trBx�n+E�wnr�swRavEriuro�ooaiaAs�5iao7oH��.ss). PLUMBING Z I CEHTIFY TFUT IN THE PFHFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSl1ED,1 MECHANICA� �� (f SMALlNOT EMPLOV ANV PEFSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE ��1 r � � Uj WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGREETHATIFISHOULDBECAME INSPECTIONFEE Y j SV&IECT TO THE WORKERS'COMPENSATION PROVISION6 Of SECTION 3'loD OF THE LABOR – :1/^`�— CODE,I SHALL FORTHWITH COMPLY WITH THOSE PROYISIONS. r ISSUANCE � � ,�_ P7���.� �`/ -�, � p DATE(�I,'��/��APPUCANT: �"'""- �- r SMIP �� � ENERGY P/C � � ��` __ WARNINO:FA�LURETO SECURE WOqKERS'COMPENSATION COVERAGE IS U VIiUL,AND SHALLBE LL SUBJECTAN EMPLOVER TO CRIMINAI PENALTIES AND CIY1L FINES UP 70 ONE HUNDRE�THOUSAND ENERGY PERMIT DOUARS(5100.OW).IN ADDITION TO THE COSTOF COMPENSATIDN,DAMAGES AS PROVIDED FOR IN � SECTION37DBOFTHEIABORCODE,INTEREST,ANDATTORNEV'SFEES. RETENTIONFEE: OCONSTRUCTION LEN�ING AGENCY PRE-ALT FEE: � IHEREBVAFFIHAIUNOERPENALNOFPERJVRVTHA7THEREISA�NSTPUCTIONLENDINGAGENCV fOR THE PER:ORMANCE OF iHE WORK FOR W41CH THIS PERMIT IS ISSUED�SEC.307l,CIV.C.). . z w � LENDEP'SNAME 1— LENDER'SADORESS J � ICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTA7ETHATTHEABOVEINFORMI.TqNISCORRECT. TUTMLFEES ' (/i0 W 1 AGREE TO COMPLv W1TH ALL CITV AND COUNTV ORDINANCESAND STATE UWS RELATING TO BUILOWG � CONSTRUCTION,ANOHEHEBVAUTFiOfiIZEREPRESENTATIVE50FTHISCAUM�'TOENTERUPONTHE ZABOVE-MENTIONEOPROPERT'FORINSPECTIONPURPOSES. . o COMMENTS _� .��r� �ia�•� _ m PER�E.E��-N E(PFUN'T) � /T - l=.�-�"�_ �C7�`�` �' '' � � � SI6N E OP PERMITTEE OATE � RECPT.NO. 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