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HomeMy WebLinkAbout11190 (5) .�..._.�.,_.. _,�s.�.m..�.�_�.,��.... ..,w..-�..._�_____ _.__.T___ _ �,�'����� -�"`---- CITY OF DIAMOND BAR /� � COI�IMUNITY DEVELOPMENT DEPARTMENT 7 / n - 21660 E.Copley Drive Suitc 190 U�r t��} /�(� (909)860-3195 Fax(909)R61-3117 ���"'"� PRESS BUILDING PERMiT APPLICATION FI R M LY QJOBSITE ^��� � �� ��� DATEICATI—���/a� NUMB R 11 /�� #�° Q ADDRESS p� m ISSUE TYPE OCC APN LOT RACT DATE Y� ,,, . �ri CONST. GROUP _ p OWNER �c�f —� o ADDRESS ��.�?� "(�y��(,�„n_P�.,���� ZONING SETBACKS z CITY ZIP TEL. FRONT Ryy ❑ o APPLICANT TEL. REAR ❑ z �" SIDE/SIDE STREET qt/�J � m CONTRACTOR � �GIJ�{���1��� SIDE � � ADDRESS „�f �,1n�w��' (�{'�Y�T � CITY ��—�__ZIP��� TEL � PROPOSEDUSE �w ARCH/ENG/ / • w DESIGNER 7I�'YI Wil sl�'V� _ �/L "CEG 1 NO.DWEL. NO. NO. a ADDRESS � UNITS STORIES BEDROOMS � CITY ZIP ----- TELGj_p��fj�ppn cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BI;ILDER DECLARATION � SFR/ADD/REM p 1 HEREBV AFFIRM UNOER PENALTV OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- G2Id9e/CdlpO(I W CENSELAWFORTHEFOILOWMGREA50N(SEC.7037.53USINESSANOPROFESSIONSCOOE:ANVCINOR (n C.) COUNTYWHICHRE�UIRcSAPERMiTTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH.ORFEPAIRANYSTRUP w TUqE,PRIOR i0 ITS ISSUANC[,ALSO RG�UIaES THE APPLICANT FOR SUCH PERMIT TO FILE A S�GNED W Patio/Deck � STATEMENT THAY H�OR SHE IS UCENSEO PURSUANT TO THE PROVISIONS OFTHE CONTRACTORS LI- � � GENSE LAW(CHAPTcR 9(CAMMENC�NG WITH SEGTION 7000)OF OIVIS�ON 3 OF THE BUSINESS AND PRO- POOI/Sp8 � FESSIONSCODE)ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBPSISWRTHEALLEGEDEXEMP- (� U TION.ANVVIOLATIONOFSECTION7031.56VANYAP?UCANTFORAPERMITSUBJECTSTHEAPPLICANTTO z RB-ROOf A CIVIL PENALTV OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).): 0 ❑LASOWN'eROFTHEPqOPERN.ORMI'EMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, � CommerCi01 Z WILL.�O THE WORK.AN�THE STRUC7UqE IS NOT I�fTENDED OR OFFERED FOR SALE(SEC.704a,BU51- _J � NESS AN�PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW OOES NOTAPPLY TO AN OWNEq OF ? GPOFERTV NhiO BUILOS OR IM PROVES'HEREON,AND WHO DOES SUCH WORK HIMSELF Oq HERSELF OR � THROUGHH'�.SOR4EROWNEMPLOVE[S,PROVI�EDTHATSUCH�MPROVEMENTSARENOTINTENDE�Oq m W OFFEREDFORSALE.IFHOWEVER�EBUILOINGORIMPROVEMENTISSOLDWITHINONEYEAFOFCOMPLE� � TION,THE OWNER�6UILDER WILL HAVE THE BURDEN OF PROVING THAT ME Oq SHE DID NOT Bl11LD OR Z IMPROVE FORTNE PURPOSEOF SALE). � ❑I,ASOWNEROFTHEPFOPEftTV,AMEXCLU5IVELYCONTRACTINGWITHLICENSEDCONTRACTORS W � TO CONSTRUCTTHE PROJEC?�SEC.704d,BUSINE55 AVD PROFESSIONS CADE:THE CONTRACTORS ll- V21UHtlOn ADJ.AREA W CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTVWHOBUIIASORIMPROVES7HEREON,AND � WHOCONTRACTSFORSUCHPROJECTSWITHACOMRACTOR(S�LICENSEDPURSlIPM70THECONTRAC- QUANTIN DESCRIPTION Y TORS LICENSE LAW.;�. FEE O ❑IAM EXEMPT UNDER SEC. B.&PC.FORTHIS REASON Q I �c- .�-� ?� U � OA7E OWNEF F" �G�' � � LICENSED CONTRACTORS DECLARATION � 3 ! •�Q ¢ W D ,�.7 � � IHEREBYAFFIRMUM1DERPENAL7YOFPERJURVTHATIAMLICENSEDUNDERVPOVISIONSOFCHAPTEF � d 9(COMMENCING WITH SECTION 7aDD)OF�IVISION 30FTHE eU51NE5S AND PROFESSIONS CODE,ANO Z ' �X MV LICENSE IS IN FULL FORCE ANO EFFECT. m � LICENSE CLASS LIC.NQ � • V DATE CONTRACTOFi a. W � WOFKERS'COMPENSATION DEGLARATION � IHEREBYAFFlRMUNOEAPENALTVOFPERJURYONEOFTHEFOLIOWINGDECLARATIONS: � Z _IHAVEANDWILIMAINTAINACERTIFICATEOFCONSENTTOSELF-WSUREFORWORKERS' Q CAMPENSATION,AS PROVIDED BYSECTION 37000F THE LABOR CODE.FORTHE PERFORMANCE OFTHEWOFKFORWHICHTHISPERMITISISSUEO. � � � _IHAVEANDWILLMAIN?AINWORKEFS'COMPENSATIONINSURANCE,ASREOUIFEDBYSECTION Q 37000F TN.E LA00R CD�E,FOR THE PERFORMANCE OFTHE WORK FOR WHICHTHIS PERMIT IS ISSUED.MY WORKERS'COMPENSATION INSURANCE CARRI R AND POLICV NUMBERARE: CONSTF9UCTION � NwG 4�15 n �j—oo . � CARRIER PLAN REVIEW Z POLICYNUMBER_ , � QI ____ ELECTRIC �� � Q �/ 'v! � (I}iISSECTN7NNEmNOTBECOMPLEfEDOFh1EPERMfT�SFORIXJEHUNDPE�00LLAFlS($IOO�ORLESSj. PLUMBING _ W Z I CER7IFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH7HIS PEFiMi71S ISSUE�.l MECHANICAL C7 SHALLNOTEMPLOVANYPERSONINANYMANNEFSOASTOBECOMESUBJECTTOTHE � WORKERS'COVAPENSATION�AWS DF CALIFORNIA,AND AGREE TNAT IF 1 SHOULD BECOME INSPECTION FEE = SUBJECTTOTHEWORKERS'COVAPENSATIONPROVISIONSOFSECTION37000FTHELABOR ^ CODE,I SHALL fORTHWITH COMPLY WITH Tj105E PROVI510NS. � ISSUANCE 3![/, O� p OATE:_}[_'7p//(X y APPLICANT� __v{�V✓I.�/� S'7V� SMIP W ( 7�T'�- � � WARNWG�FAIUJRETOSECUqEWORKERSCOMPENSAT.ONCOVERAGEISUNL4NIFUL,ANDSHALLBE ENERGYPiC �y SUBJECTANEMPLOYERTOCRIMINALPENAlTIESANDCNiLFINESUPTOONEHUNOREDTHOUSAND ENERGYPERMIT DOLIARS(S�D0,006),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN � SECTION 37oB OF THE IABOR CODE,INTEREST,AND ATTORNEV'S FEES. RETENTION FEE: � OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: �~��'� � � I HEREBV AFFIRM INDEP PENALTV OF PERJURV THAT THERE IS A CONSTRUCTION LENDING AGENCY ��.���� ` FOR THEPERFORMAYCE OFTNE WOFK FOR WHICH THIS PERMIT IS ISSUED(SEC.30fl],CIV.C.J. �"„ , Z ��i 1 ��._q ? LENDER'S NPME ' ' �f±J�;% . � '1 F— LENDER'SADDflE55 W ICERTIFVTHATIHAVEREADTNISAPGLICATIONANDSTA7ETHATTHEA60VEINFORMA710NISCORRECT TOTAL FEES Z�J p � I AGREE TO COMPLY WITH AlL CITV AND COUNTV ORDINANCES AND STATE IAWS RELATING TO BUILDING � CONSTRUCTION,ANDHEREBYAUTHORIZEREPRESENTAiNESOFTHISCWNTVTOENTERUPONTHE Z A80VEMENTIONED PPOPERTY FOR INSPECTION PURPOSES. COMMENTS o •� �,y� m PERMITf E NAME(PRINT) � Q O �. Cl� � SIGNATUREOFPERMI OA E = AECPT.NO. 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