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HomeMy WebLinkAbout17280 � CITY OF DIAMOND BAR ,,..�-'"' '� ' DEPARTMENT OF COMMUNTI'Y&DEVELOPMENT SERVICES 21825 E.Copley Drive """��� (909)860-3195 Fax(909)861-3117 � PRESS �"���� BUILDING PERMIT APPLICATION FIRMLY � JOBSITE ^�!,/ I� �^ � / APPLICATION /' �} PERMIT �+P/C ADDRESS,C."11�0..+ -H'���,},a�Lt�. ��f 1`'�1i C� ���r p DATE NUMBER # � ISSUE TYPE OCC APN L T TRACT DATE �C� � � CONST. GROUP p OWNER _ �>. � �i(1A o ADD SS ^' _ ZONING SETBACKS z CITY `� ��r ZIP TEL. FRONT RW ❑ � APPLICANT �!�`�42r�. ' ti%�°� TEL. REAR ❑ Z SIDE/SIDE STREET RW ❑ ¢ CONTRACTOR �°'�J"W � �liG i;l�17r1f'v� SIDE ❑ ADDRESS- '1�. >:�.,�. � � CITY�'c r1u IP TEL � SY�r�`���4�j PROPOSED USE o ARCH/ENG/ z DESIGNER w NO.DWEL. NO. NO. a ADDRESS � CITY ZIP TEL. UNITS STORIES BEDROOMS cn cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFRJADDJREM O p 1 HEREBY AFFIRM UNDER PENALN OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- Gdf090/C3fPOfI W CENSEL4WFORTHEFOILOWINGREA50N�SEC.7o31.5BU51NE5SANDPROFESSIDNSCODE:ANVCITYOR (/� U CWN7VWHICHREOUIPESAPERMITTOCONSTflUCT,ALTER,IMPROVE,DEMDUSH,ORREPAIRANYSTRUC- W TURE,PiiIOR TO ITS ISSUANCE,ALSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FI�E A SIGNED w PatiolDeck � STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PpOVi510N5 OF TME CONTRACTOFS LI- CENSE LAW(CHAPTER 9�COMMENCING WITH SECTION 7oao)OF�IVISION 3 OF THE BUSINE55 ANO PRD- � POOVSPd � FESSIONSCODE)ORTNATHEOPSHEISE%EMPTTHEREFROMANOTHEBASISFORTHEALLE�EDEXEMP- (� U TION.ANVVIOLATIONOFSECTION7031.SBYANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO Z RQ-RoOf � A CIVIL PENALTV OF NOT MORE THAN FWE HUNDRED DOLLARS(35001.1: 0 C]I,ASOVJNEROFTHEPROPERT/.ORMVEMP��OYEESWITHWAGESASTNFIRSO�ECOMPENSATION. � Commercial Z WILL DO THE WORK,AND THE STRUCTURE IS NOT INiENDED OR OFFERED FOR SALE(SEC.7044,8U51- J � NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOTAPPLY TO AN OWNER OF � PROPERTV NhiO BV I�DS OR IMPROVES THEREON,AND WHO�OES SUCH WORK HIMSELF OR H[RSELF OR � THROU6H HIS Ofl HER OWN EMPLOYEES,PROVIOED THAT SUCH IMPROVEMENTS ARE NOT INTENDE�OR m Q OFFEHEOFORSALE.IF,HOWEVER,7HEBUILDINGORIMPROVEMENTISSOLDWITNINONEVEAROFCOMPLE- Z TpN,THE OWNER-BUILDER WP�L HAVE THE BUROEN OG PROVING TI�IAT ME OR SHE DID NOT BIJILD OR � IMPROVE FOfl THE PUFPOSEOF SALE). w ❑I,ASOWNEROFTHEPROPERTY,AMEXCLUSIV0.YCONTPACTMGWITHLICENSEDCONTRACTOPS � 70 CANSTRUCT THE PROJEC7(SEC.7o4a,BUSINESS AND PROFESSIONS CADE:THE CONiRAC70RS LI- Valuatl011 ADJ.AREA W CENSELAWOOESNOTAPPLYTOANOWNEROFAPROPERTVWHOBUIL�SORIMPROVESTHEREON,AND � WHOCOMRACTSFORSl1CHPROJECTSWITHACONTFACTOR(5)LICENSE�PURSUANTTpTHECONTRAC� QUANTITY DESCRIPTION FEE Y TORSLICENSELAW.). �� ❑I AM EXEMPT UNDEfl SEC. B.6 P.Q FOR THIS REASON Q U � �. �k OATE OIM1'NER U Z W � LICENSED CONTRACTORS DECLARATION W ¢ 2 IHEFEBYAFFIRMUNOEFPENALTVOFPERJUPYTHATIAMLICENSEDUNDERPROVISIONSOFCHAPTER � � 9(COAIMENCINGWITHSECTION7aoo�OFDIVISlO'J30FTHEBUSINESSANDPROFESSIONSGODE,AND Z X MY LICENSE IS M FVL ORCE AN�EFFECT. ���rrryyy 0 LICENSE CLASS( �/ LIQ N0.�_ � � WDATE ��,�Y�l��1� CONTRACTOR: � � d � WORKERS'COMPENSATION DECLARATION ¢ � IHEFEBVAFFIRMUNDERPENALT'OFPERJURYONEOFTHEFOLLOWINGDECLARATIONS: Z Z _I HAVE AND WILLMAIN7AIN ACERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS' _ ¢ CAMPENSATIDN,ASPROVI�EDBVSECTIDN�]OOOFTHELABORCD�E,FORTHEPERFORMANCE W OF TNE WORK FOR WH'CH THIS PERMIT IS ISSVED. � � � _IIIAVEANOWILLMAINTNINwORKEAS'CONPENSATIONINSURANCE,ASFEQUIREDBYSECTION Q 37000FTHELABOR OOE,FORTHEPERFORMANCEOFTHEWORHFORWHICHTHISPERMITIS ISSl1EO.MYWO E CAMPE TION NSUR NCECA IERANDPOLICY UMBERAR�: CONSTPUCTION ¢ �a > CAqqIER��-?.� 'W..n �� '�t.�" '�c��C�? � PLAN REVIEW 0 POUCVMIMBEa ELECTRIC ��� Z ¢ � (IHISSECTIONNEmNOTBEQ;MPLEfEDOFiHEPERMfiISFORpVEHUI`DREOOOlLAF5�5100�ORLE55). PLUMBING Z I CERTIFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PEflM1T IS ISSUED,I MECHANICAL C�'S SNALLNOTEMPLAYANVPERSONINANYMANNERSOASTOBECOMESUBJECTTOTHE � WORKERS'COMPENSATIONLAWSOFCA:JFORNIA,ANDAGREETHATIFISHOULDBECOME INSPECTIONFEE � SUBJECTTOTHEWORKERS'COMPENSATIONPROVISIONSOFSECTION3�ooOFTHELA80R i CO�E,I SHALL FOflTHWITH COMPLY WITH THOSE PROVISIONS. ISSUANCE � p OATE: APPLICANT: SMIP � WARNINGFAILURETOSEWREWORKEFS'COMPENSATIDNCOVERAGcISUNLAWFUL,AN�SHALLBE ENERGYP/C �y SUBJECTAN EMPLOYERTO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDREOTHOUSAND ENERGY PEflM1T �OLLARS(St W,0001.IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN J SECTION 97oe Of THE LABOR CODE,INTEREST,AND ATTORNEV'S FEES. RETENTION FEE: � � CONSTRUCTION LENDING AGENCY pRE-ALT FEE: O � I HEREBVAFFIRIA UNDER PENALTY OF PERJUfiV THATTHERE IS ACONSTRUCTION LENDING AGENCV FOR THEPERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.309�,CIV.C.�. Z W ,2� LENDER'S NAME � F— IENDER'SADORESS W ICERTIFYTHATIHAVE4iEA�THISAPPLICATIONANDSTATETHATTHEA80VEINFORMATIONISCARRECT. TOTAL FEES �/J� ��V � I AGREE TO COMPIV W;TH ALL CITY AND COUNTY ORD�NANCES AND STATE LAWS RELATING TO BUILOING U! t � � CONSTRUCTION,ANOHEREBYAUTHORIZEREPRESENTATIVESOFTHISCOUN7VTOENTERUPONTHE z ABOYE'�TIONEDPROPERTYFORIN PECTIONPURPOSES. COMMENTS � J '� � m PERMITT E(P ) ,� a � � SIGNATURE OF PE A f( DATE = RECPT.�O. � PAID 8Y VALIDATION_ ~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD--File Copy,GREEN—ApplicanTs Copy .. . . , Y ._ ,. , .�.: . � ,...��I".Y�Ik,:'��..ro v. .'.�;r':..... ��-.� .....,.�;.,y.:. -..r ..�. ...-�..i�� .. .,.i�1J C '.9;Axn. R!3�'4 n� �� . le V�i�Vu`C'�. "':�kb:s� t. �:aY4. ...A;�F ., ..':d' . . . .. . . . . .. . . . 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