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HomeMy WebLinkAbout14248 (20) ��,� CITY OF DIAMOND BAR ��� � DBPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � � 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS � �"9�'�� BUII.DING PERMIT APPLICATION FIRMLY � ADDRIESS � ` �� ���I/'�M� L�J"�� �� � DATE CATIO r � NUMBER_1��'�'�`_L #lC c� ISSUE TYPE OCC APN LOT TRACT DATE � CONST. GROUP g OWNER �',rv� La Q_ LL ADDRESS �� � ZONING SETBACKS � CITY ZIP TEL REORT RW O APPLICANT__ TEL. SIDE/SIDE STREET RW ❑ � CONTRAC7 R � .T�-. SIDE ❑ � ADDRESS� ' '_�.�t � PROPOSED USE o cirv �t�1rna`C' IP /7�1" TEL.�.�zG' 33''-^�S� o ARCWENG/ � DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION OOWNER-BUILDER DECLARATION SFR/ADD/FEM � 1 HEREBY AFFlRM UNDER PENALTY OF PENURY TMAT t AM E%EMPT FROM TNE CONTRACTORS LI- G8f09B/C3fpOtt W CENSEUWFORTHEFOLLOWINGREASON(SEG703f.5BUSINESSANDPROfE5510NSfADE:ANVC�?YOR (/� ZCOUNTYWHICHqEIX1iRE5APERMYTTOCONS7RUCT,AI.TER,IMPROVE,DEMOLISH,ORREPAIRANYSTRUG W patlo/DBCk TURE,PRIOR 70 ITS ISSUMICE,ALSO REa11RES THE APPUCANT FOR SUCH PERFAI7 TO FILE A SIGNED � STATEMEN7 THAT NE OR SHE IS I.ICENSED PURSUANT 707HE PROVISIONS OF hiE CONTRACTORS LI� W � CENSE UW�CHAPTER 9(COMMENCINa VJITH SECTION 7000�OF DIVISION 30F THE BI151NESS AND PAO� � PoDUSpd FES5qN5CODE)ORTFlATHEORSHEISEXEMPT7HEflEFFOMANDTHEBA5ISFORTHEALLEOEDEXEMP� C7 U TION.MIVVIOI.AIIONOfSEC710N7031.58�ANYAPPLICAN7FORAFERMi75L1flIECTSTHEAPPLICRNTTO Z RB-ROOf � A CIVIL VENALTY OF NOT MORE THAN FlVE HUNDRED DULIAAS(S5a0).): � ❑I,ASOWNEROFTHEPROPERT/,ORMYEMPLOYLESWITHWAGESASTHEIfl50lECOMPENSATION, � Commercial - WILI.DO THE WORK,AND THE STRUC7URE IS NOT INTENOED OR OFFEREO FOR SALE(SEC.�044,BUSI� J � NESS AND 7ROFESSIONS COOE:TME CONTRACTORS LICENSE lAW�OES NOT APPLYTO AN OWNER OF = PROPEFtTYNAiOBU1tDSORIMPROVESTHEREON,ANDNM1IODOESSUCHWORKHIAISELFORHERSELFOR m � 1Hfi7UOMMI50HHEflOWNEMP�OYEES,PROVIDEOTH�TSUCMIMPROVEMEN?SAHENOTINTENDEOOR QOFFEREDFONSALEIF,HOWEVER'rHEBUILDINGOAlA1PROVEMENTISSOLDWRHINONEVEAROFCOMPIE ' � TION,THE OWNER•BUILDEfl VALL.HAVE THF BURDEN OF PROHMG TfiAT HE OR SNE OIO N07 BUILD OR � IMPROVEFOATHEPURPOSEOFSQE�. ❑(AS OVMFROF?HE PROPEfiTY,AM E%CLUSNELYCANTRAC'fINO WRN LICENuED CONTRACTORg � TO CONSTRUCT THE VRC7JECT(SEC.70U,BUSINESS PNO PROFESSiONS C!7UE:THE CONTflACTDflS U- V81U8t1017 {iDJAFIEA_ W CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPFRTYWH09UILbSORMPROVESTHEREON,AND � WFIOCONTRACTSFOflSUCHPRQIECTSWITHACO1�liflACTOR�S)LICENSEDPUftSUANTTOTHECON7RAG QUANTITY DESCRIPTIQN FEE � TORSIJCENS[Uw.). J O ❑I AM EXEMPT UNDER SEC,____ _ 8,&P.C.FOR TNIS REASON � � _� _ _ � � OATE _ _ OwNER_�_ � W -- � �ICENSED CONTRACTORS DECLAFlATION �j � tHEREOYAFFIRMl1NDERPENALNOFPEFJURYTHATIAMLICeNSEDUfJ�ERPROVISION50FCHAPTER �, � f�COMMENCiNQWRHSECTION7000)OFDIYISiON30FhIEBUSINE55ANDPROFES510NSCADE,AND � L X W LICENSE IS IN FlR.I FORCE AN�EFFECT. m lU L� � UCENSE�CpL�ASS��.� T��L� UC.NO._ � � � "�+ j V DATE /�.):_`�:_„(_.� ._ CONTRAC70R_,�� �L._;�r" d W � YJOA6(ERS COMPENSATION DECLARATIO'V 1/`�y,e� „—�� � /l/`fC7 V N I HEFiEBY AFFIRM UNDEH PENAILTY OF PERJURY O�E OF THF FOLLOWING DEl`LARATIONS� f � . �n a ,' •.-- .,. — : a _ . , .,.�: � __,IHAVEAMDWILIMA�PA�N�10EliTIR1CATEOF�Ok5ENY709ELF-��NSURE�FOR'bVO�iNERS' t Z � '��- : -��' ". �' ��..:�` ," _=�'*„� -':...,�,� CpL19ENSATION,AS pHOVIDED BV SECTION 37000F THE LAHOF CODE,FOR THE PEflW RMANCE `U OF THE WORK FGR FVHICH THI's PERMIT IS ISSUED. � O - U"� �IHAVEAMDriIILMAINTAINWORKERS'C�JMPENSA?ION'�NSURAMCE,ASREOUIREDBYSEC710N n 9]0o OF TME�PAOq CCDF..FOR THE PERFCRfAANCE OF THE WORK FOR WHICH TNIS PEFMIT IS ISSUED.MY RKFA�S'COMREN5.4CNJN INSURANCE CARRIERAN�POUCV HUMBERARE: CONSTRUCTION �J PLAN REVIEW CARFtEfl -_ � -� � � coucv nuMeEa (t 4 ���"���� ` _--���' EIECTRIC Q ' Q �GssEcnoraner�r�?sea�.FreooFn-�aera,sn'+srarjaaE�+i�t�a�uaas�Eioo) � �. < PLUMRING _ � I C[RYIFY THAT tN THE PERFOfiMANCE OF 7N[H"ORK FOR WHICH THiS PERMIT ISSUED,I MECHANICAL (!} SHALL NOT EMPLOYANY VERSON IN ANY�1ANNER SO AS TO BFCOIAE SUAJEC 'O T�1E � WOHKEHS'COMPENSATIONIAYVSCF IA,ANDAGREF.THATIFISN L08ECOME INSPECTION FEE � SU&IECT 70 TNE WORKERS' NSATION P ISIONS OF SECTION 370 OF THE LABOR �SSUANCE __��U � '� � CO�E,f SHA-LLy fONTNWi7N G P.Y W�THTHOSE ROVISIONS. Cy DATE:J�� �!'71 APPLI _ -�� _ SMIP . . u� ENERGY P!C �� ` J WARNINO�FAILl1RETO5ECUFEN�ORKERS'GOMPENSAT!ONGOVERAGEISUNIAWFIJL,ANDS LLBE ����.�T'j�ry�'('7'6 + a I LL SUES.�ECTANEMP�OVERTOCRIMINALPENALTIESANOCNILPINESUPTOONEHUNDREUTH SAN� ENERGYPERMIT Ik�it�r,i•iv OOLLARS(5700.000).IN ADDITION TO iNE GOST OF COMPENSATION,DAMAGES AS PROYI�ED FOR IN � SECTION 37oe OF 7HE LABOft CODE,INTEREST,AND ATTORNEV'S FEES. RETENTION FEE: � CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � IHEREBYAFFIqMUNOEFPENAL7YOFPEFlJURYTHATTHEflEISACONSTRUCTIONI.ENDINGAGENCV d FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PEflMiT IS ISSUED(SEG.309],CIV.C.�. � Z W � LEN�ER'SNAME_ ____ 1y- LEN�ER'SAODRESS . - � I CcRTIFY THAT I HAVE READ THIS APPLICATION RND STATE THATTH'c ABOVE INFORMATION IS COPRECT. TOTAL FE ES � � I AGREE TO COMPLY WITM ALL CIiV AND COUNTY ORDINANCES AND STATE LANS REI.ATING TO BUILDING � CONSTRUCTION,ANDHEREBVAUTHORIZEREPRESENTATIVESOFTHISCAUNTY70ENiERUPONTHE Z ABOVE�MENTKKJE�PROPEF7V FOfl INSPECTION PURVOSES. COMMENTS � �G�3()�"t' �'C�-- �E AME(PRINT �, �- 7 � � SIG RE OF PFRMITTEE DATE = RECPT.NO. PAI�BY VALI�ATION ~ WHITE—Department Copy.YELLOW—Finence Copy.PINK—Assas�or Copy,GO ENROD—File Copy,GREEN—ApplicanYs Copy < . .:.�, ...�. . . . � „ . . . . . .�.�..r. ...... ,.:.„�. y .... . . . . ,. :6#e�>�m* ���� ���' ^3�'����u �:.s� i- � ��.. �.,�'��°�F�rb��,� ?^� � �- � ��� �����, . ������ ,. _... ' .;�«r; -. �' ..��,��w.. �" e;.a'"r�` ' ��,.. � �.�� �`��. �"�� -�•� ��'T��� '. � ..- ..�, �,�,, . � �,g.� :a'���g-� ���,�,���� �,� � �:��, �m � :.�. � � '� . � _ � � �� ��, ��:.4 ���.;�. : � a .. ���� � ����.�'�.�s . � s,..-�:�" �""��x ,,.., �.::. � �m�;,",�{�� "� � �� � �:�e��-�.. ,�..�..�� ,,�- ��.����;.� �-�.� �_� �- �, . � -'C SR, '�.y � . . '�, , . . . 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