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HomeMy WebLinkAbout15991 (20) -�,, _. ^ �� CITY OF DIAMOND BAR /""��"� - DEPARTMENT OF COMMiJNITY&DEVELOPMENT SERVICES w 21660 E.Copley Yhive Suite 190 � (909)860-3195 Fax(909)861-3117 PRESS ':;�'���� BUII,DING PERMIT APPLTCATION ; . - . , FIRMLY , :..... �� JOBSITE �/� �.iC� ADORESS 'J��'�ca�� l"-I FtC/C� �id��. �/'�� DATE CATION I !I ('S I NUMBER 1 ` #/� c� ISSUE � TYPE OCC APN LOT _ TRACT DATE Ir �x CONST. GROUP p OWNER �✓tesw.� t , o ADDRESS�k�23�1�i�-� �'� ZONING SETBACKS Z CITY _�(ALti�'� ZIP917f9 TEL��.��//`'F�3� FRONT RW ❑ g APPLICANT TEL. REAR ❑ � SIDE/SICE STREET^ RW ❑ � COM7RACTOR �,�frANr� 1.�-s��%�2s T rY� SIDE ❑ ADDRESS 2��3�tir�dE,�l�ry i4✓� � CITY Ls�-f5��e��✓c� ZIP G%i? / TEL..S7+Z-s��GGsST`�� PR�POSED USE n ARCH/ENG/ z DESIGNER NO.DVdEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. y DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER-BUILDER DECLARATION SFR/ADD/REM p I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I NA EXEMPT FROM THE CONTRACTORS LI- G8f8]B/CBfPOf[ W CENSELAWFORTHEWI.LOWMGNEASDN(SEC.)a31.5BUSINESSANDPROFES510NSCADE:ANVqTVOR (n , �J pOUNTVWNICHREGUIRESAPERMtTTOCONS7RUCT,ALTER,IMPROVE,DEMOLISH,OqREPAIRANYSIRUC- W PytiOl�6Ck � 7URE,VRqR TO ITS ISSUANCE,KSO REQUIRE5 TME APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W STATEMENT THAT HE OR SHE IS LICENSED PU0.SIlANT TO THE PqOVISIONS OF THE CANTfiACTORS LI- ! CENSE lAW(CNAPTER 9(COMMENCINO WITH SECTION 7000)OF DNISION 3 OF THE BUSINESSAND PRO- u' POOUSp3 S FESSIONSCOOE�ORTHATMEORSHEISEXEMPTTHEREFflDMAND111EBASISFORTHEALLEGEDEXEMP• V TION.ANYVIOLATIONOFSEC710N7031.50YANYAPPLICANTFOPAPERAIITSUBJECTSTHE0.PPUCANTTO Z Re-iiuot �, ACMLFENAL7YOFNOTMORETHANFNEMUN�REODOUARS��,500).): � ❑I,ASONMEHOFTHEPROPERTY,OPMYEM7LOYEESWITHWAGESASTHEIRSOLECAMPENSAtION, 0 Comm8fCi81 - WILL DO THE WORN,AND THE 5?RUCTURE 15 NOT INTEN�m Oq 4FFERED FOR SAL[(SEC.7044,BUSI- J NESS ANU VF�ESSIONS CODE:7HE CONiRACTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF y OHOPERTYWFIOBIIIL�SORIMPqOVESTHEREON.ANDWHODOESSUCHWORKHIMSEIFaRHEFSELFOq m Q TNROUGH HIS OR HEfl OMM EMPLOVEES,PROVIOED THAY SUCN IMGROVEMENTS APE NOT MTENDED OR QOFFEREDFORSAIE.IF,HOWEVERT'HEBUIIDINGCRIMPROVEMENTI3SOLDWITHINONEVEAROFCOMPLE- � TIDN.TNE ON�NER-BUIL�ER WILL HAVE THE BUROEN OF PqOVING THAT HE OR SHE DID NOT BUIL�OR IMPROVE FOR THE PURPOSE OF SALE). � ❑I,AS OWNEflOi THE PROPERTY,MI E%CLU57VELY CANTRACTING WITH LICE4SED CONTRAC'ORS � TO CON&TRUCTTHE GRQIECT(SEC.'Iod4,9U51NESSAND PROFESSIONS CODE:THE CONTRACTORS LI- V81Uetlon ADJ.AREA W CENSELAWDOESNOTAPPLY70ANOWNEROFAPROPERTYWHOBUILDSOFIMVROVESTHEREON,AN� - --- � WFqCONT'RACTSFORSUCHPR0.1ECi5WITHAQ�NTRACTOR(5)UCENSEDPURSUPNTTOTHECONTMG QUANTITY DESCRIPTION FEE Y TORSUCENSELAW.). � J a ❑IPM E%EMPT 11N0Efl SEC. _ 8.8 P.G FOR THIS REASON Q � U � LL DATE OWNER _ �' Z W �s( LICENSED CONTRACTORS DECLARATION W CC I HEREBYAFFIRM UNDER PENAITY OF PERJURY THAT IAM LICENSED UNDEH PROVISIONS OF CHAPTER � 1\ .-1 �.sl��,.�� Q 9(COAIMENCWOWITHSECTION7000JOFDIVIS�ON30FTHEBUSINESSANOPRCFESSIrJNSCOQE,AND Z u' «� (-PT x MV LICENSE IS IM FULL FORCE AND EFFECt m � LICENSEGU15fi C�� UG.NO.�,�'"�,S a- j --- N v onrE_ 3l 'L cornaacroa�p�r+���?a�li�/Y�-al.eLt a w � WORKERS'COMPENSATION DECLARATION � ¢ � I HERE6V AFFIRM UNDER PENAISY OF PERIURV ONE OF'THE FOLLOWING DEGLP.MTION3: U Cn Z Q O �IHAVEANDWILLMAINTP�NACERTIFIGATEOFCONSENT70SELF�INSUREFORWORKERS' $ � CbA/PENSRTION.AS PROVIOED BV SECT'ON 3'l0o OF THE LABOR CODE,FOR THE PERfORMANCE W OFTMF WORK FOR WHICH THIS PERMIT 191SSUED. � � W _I HAYE AND WILL MAINTAIN 1NORKERS'�AFAPEN9ATION INSURANCE,AS REQUIREP BY SECTION Q 370o OF THE LdBUq COOC,1=0R THE PERFOiiMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.MY WORKER5'COMPEN9A710N�HSURAIvCE CARRIER ANO POLICY NUM9Efl ARE: CONSTRUCTION � CARRIEq_._ ,E/1^✓�'Jt<t,6 C4�� _ PLAN REVIEW _.--__- � POLICYNUMBER_'y.+•��t�'r'���"�� ELECTRIC _ Q � (iHl55ECIl�NNE�NJTBECY7IAPLETEPOfTHEPEFYMA'+FOf1ONE1-'U1�DPED�OI.L1Ri(51C0)ORLESS} PLUMBING � Z I CEATIFY THAT IN THE PERFOflMANCE OF THE Y/ORK FOR WHiCN THIS PERMIT I5�SSUEp,l MECHANICAI. ����j� �I_��,p°��.�� (3 SHALLNOTEMPLDYqNYPERSONINNi`1YMqNNER50A5TOBECOMESUBJ[CTTOTHE N W4PHER5'COMPENSATIONL/WSOFCALIFORNI0.AN�A6PEETHATIFISHOULDBECOME INSPECTION FEE SU&IECTTOTNEWORKERS'COlAPFNSA710NPROVISIONSOFSEC710N3�ooOfTHEUBOR r� 'q�qT�$`p • � � ����yp yy CODE,I SHALL FORTHVATH COMPL�WITHTHDSE PROVISItlNS. ISSUANCE ����d�� A�',Y.7.C's�rg�4 � SMIP ^"✓xa..i.s��7�1VT�'.�',}�i���`+.� p DATE: APPLICANT: . � ENERGY P/C _ J WAflNINO�FAIW RE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,ANfJ SHAIL 8E � SUBJECTANEMPLOVERTOCRIMINALPENALTIESANOCIVILFINESUPTOONEHUNDiiEDTHOUSAND �NERGYPERMIT DOILARS(5����),IN ADDITION TOTHE COST OF COMPENSATION,OAMAPES AS PROYIDED FOf71N J SECTION 37aN OF THE lABOR CODE,INTEREST,AN�ATTORNEY'S FEES. RETENTION FEE: Q a CONSTAUCTION LENDING AGENCY PRE-ALT FEE: � IHEREBYAFFIRMUNDERPENA�TYOFPERJURYTNATTNEPEISAGONSTRUCTIONLENDWGAGENGV _. _ GOR THE PERFORMANCE OF THE WORK FOR WHICH iHIS PERMIT IS ISSUE�(SEC.3097.CIV.C.�. Z W - � LENDER'SNAME 1--' LEN�ER'SADDflESS � I CERTIFY iHAT I HAVE READ THIS APPLICATION ANO STATE THAT THEABOYE INFORMATpN IS COpqEGT, TOTAL FEES 1 � I AGREE TO CDIAPIY WITH AL�CITY ANO COUNTV OROINANCES ANO STATE LAWS RELP.TING TO Bl11LDING GONSTFiUCTION,AND HERE6Y AUTFIORIZE REPRESENTATNES OF THIS COUNTV TO ENTEF UPON THE � ABOVE-MENTIONEDPROPEFNFORINSPECTIONPURPOSES. COMMENTS � j J ���.j�SjE- l/ � Q PERMITTEE,!/MA�� � -' , I` ��_- � �1 � S NA RE�F PEFMUTTEE TE = RECPT.N0. PAID BY VALIDATION ~ WHITE-DepaAment Copy,YELLOW-Finance Copy.PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applica 's Gopy � _., �. . .. ..... . .... ,., i '.r�x�. � . , .' . ::.� .��-.e. t .-,,..,,s., ,. ,,'".... . ., , "� . 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