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HomeMy WebLinkAbout12170 (11) � ��_ CITY OF DIAMOND BAR r...� DEPARTI",4ENT OF COMMUNITY&DEVELOPMENT SERVICES ; L , 21660 E.Copley Drive Suite 190 / I (909)860-3195 Fax(909)861-3117 �.� PRESS ���+� BUILDING PERMIT APPLICATION FIRMLY o. ADDRIESSZ 7 3I S �ND L-Ci��U�T. DATE CATION ��' Gy� NUMB R �l I'It� #�° � ��S � AP� LOT TRACT ISSUE ���+ �� TYPE OCC � . DATE CONST. GROUP p OWNER �IL• L(� k ADDRESSZ N�T� (�l.Cr �.E7U�� ZONING SETBACKS � w FRONT RW ❑ Y z CITY I'11�A�011+✓�/.♦f�' ZIP�/7 6�TEL.�� g APPLICANT 4N/�QoLS � REAR p_ � SIDE/SIDE STREEf RW ❑ i': � CONTRACTOR Wi� Q SIDE ❑_._�_ � ADDRESS�J�/ i�L 5 � y �� � CITY Gf�i//�Na ZIP9/ZZLTEL. _ PROPOSEDUSE � �S� O �N �-���.r 2-x2- '. r � � w ARCWENG/ � � � z DESIGNER�i�� �l�"� ��-�V ` --�-- NO.DWEL. NO. N0. e � ADDRESS UNITS STORIES BEDROOMS�_ � � CITY ZIP TEL. - �. N DESCRIPTION SQ.FL FACTOR PSF ADJ.AREANALUATION ;. � , OWNER-BUILDER DECLARATION SFWADD/REM y O I HEREBY AFFlRM UNDER PENA�TY OF PE0.IUHV THAT i AM EXENPT FPOM THE CONTRACTORS LI- Gdf8g0/CBfPOI[ � W .CENSEUWFORTHEFOLLOWINGREASON�SEC.7031.5BUSINESSANDPROFE9310NSCODE:ANYCINOR (n j; U �OUHTYWHICHpEQUIRESAVERAiITYOCONSTRUCT,ALTER,IMPROVE,OEMOLISH,ORREPAIRANVSTR�C• W PBIIO/�BCk T. W �NRE,PRIOR TO IT$ISSUANCE,AL50 pEWIRE3 THE APPLICANT FOF 9UCH PERMIT TO FILE A SIGNED W y�, S7ATEMENT T1AT HE OR 3HE 13 LICENSED PURSUAN7 TO THE VROVISIONS OF 7HE CAMNACTON9 LI� ^ti � CEN5E UW(CHAPTER e(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINE55 AND PRO- � PaOUSPfl � FESSIONS CODE)OR THAT HE OR SHB IS E%EMPT THEHEFROAI AND THE BA515 FOR iHE ALLEGED EXFMP� V TKKi.ANVVKKATIONOFSECTION7031.5BYANYAPPUCANTFOflAPERMIT5U8JECT5TMEAPPLICANTTO Z Re-Roof 4� - r, ACNIL PENALT'OF NOT MORE 7HAN FNE HIiNDRED OIX.IARS(f5ao).): j . � p1.ASOWNEROFTHEPflOPEflTY,ORMYEMPLOYEESwITHWAGE5A5THEIRSOLECOAIPENSATION, � Com1119fCial " " .V/ILL 00 THE WORK,AND THE STRUCiUR[IS NOT INTENOED OR OFfERED fOp SALE�SEC.7oa4,BUSI- J Y. � NE55 AND PROFESSIONS CODE:7HE CO:ITRACTORS LICENSE LAW�OES NO?APPLY TO AN OWNER OF = ' PRDPEFlTV VM10 BULOS OR IARPilOVE3 THEREON,M1D WHO UOES SUCH WORK HIMSELF ON HERSELF OR j� � 'TFIRWGHHISORHEFlOYMEMPIOYEES,PROVIDEDTIATSUCNIMPROVEMENTSAflENOTINTENDEDOR m ' 0 OFFEREDFOflSALE1F,FfOWEVERNEBUIIDINGORIMPi30VEMENTISSOIDWITHINONEYEAROFCOMP�E- k � TION,TME OV/NER$UILDEfl WILL MAVE THE BURDEN OF PRDYING THp7 ryE OR SHE DID NOT BUILD OR �; � IMPROVEWRiHEPURPOSEOFSALE). k: w ❑1,0.50VMEROFTHEPROPERlI;AMEX0.U51VELYCONTRACTINGWITHIICENSEDCONTPACTORS y. (,'L TO CONSTRUCT THE PROJECT(SEC.7041,BUSINESS AND PROFESSIONS CADE:THE CONTfiACTORS LI- !� VyIU8N011 � �' _,__,_.,,,_ADJ.AREA_,___._...____.,,.,___,__ W CENSELAWDOESNOTAPPLYTOANOWNEROFFPflOPERTYWHOBUILD50RIMPROYE5T11EPEON,AND ��� �L yy�pCpNTFiACTSFOHSUCHPROJECTSWITHACONTMCTOR(5)LICENSEDPLIRSUMfTTOTHECANTRAC QUANTITY DESCRIPTION FEE f � TORSLICENSEUW.1. � 0 ❑i AM EXF.MPT UNDER SEG. __.____B.8 P.C.FOR7HI5 REASON U � E. _ __...__... � : � DATE OWNER_ F' `� 2 ___._..._'_.__ U ^ W F� LICENSED CONTRACTORS�ECLARATION � W � IHEflEBYAFFIflMUNOERPENl1LTYOFPERJURYTHATIAMLICENSEDUNDERPROYISION50iGNAPT[p �' q 9(COMMENCINp W1TFi SECTION 7000)OF DIVISION e OFTHE 8U51NE55 AND DflOFESS1045 CODE,AND � �� x MY LICENSE IS IN NLL FOFCEPIlD EFFECT. ? W (r� m ii � LICENSECLAS��� LIC.NO. �c�� ��� • . � IF U DATE �� �� CONTRAc70R.7��__ d '� W 1' � WORKERS'COMPENSATION DECLARATION a . � IHEREBYAFFIRMUNDENPENALTI'OFVERJURYONEOFTHEFOLLOWINGDF.C�AFlATION3: U �' � Z E' � _IHAVEANDWILlA1AINTAINACERTIFICFTEOFCON&ENTTOSELF�INSUREFOFlWOflKERS' _ �h COMPENSRTION,ASPROVIDEDBYSEC770N37000FTHELABOACO�E,FORTHEPEflFORMANCE U �� � ! OF YHE WORK FOR WHICH 7HI5 PF.RIAIT IS ISSUED. � �; � v _I HAYE ANU WILL MAINTAIN WORKERS'COMPENSATION INSUPANCE,AS HEMIIRED 0Y&ECTION A �; q370U�FTHEI.PBORCODE,FORIHEPERiORMANCEOFTHEWORRFORWHiCH7lIISPERMITIS /�.�P J1!'Y � _ ISSUE�.MY WORK 5'COMPENSATION INSURANCE CARRIEfl AND POLIGY NUMBEHARE: CONSTRUCTION ___.___„__ �� r u'��' r(+, 4 ,,An '�-'—'--- y cnRRiER_ 'YL_. . PLANREVIEW �Ss � --.._..-,-------.---_ k� - � POLICY Ni1MBER� � `� � ELECTRIC H .._.__.._.._'"—""'_'____ 1, - �sEcrcNr��raTSEa�n�ermoFn��w�ar�srnaowe�eooainr�s�siw)at�Ess). PLUMBING t' � I CERTIFVTHAT IN THE PEFFORMANCE Of THE WORK FOR WHICH THIS PERMI715155UED.I MECHANICAL � ____... ,__ ___._ � SHRLLNOT EMPLOY I1NY PERSON IN ANY M/1NNEH SOAS TO BECOME SUBJECT i0 THE � � WORKERS'COMPENSATION LpWS OF CALIFORNI D A6H THAT IF I SHOUL�BECOME INSPECTION FEE _.___.._____.._, S SU&IECTTOTHEYIORKERS'COMPENSATIONP V ION SECTION37000FTHE�A90R �p�y � CADE.ISHALL ORTHWI PLVWITHT OVI S. ISSUANCE '____"_'___'..... ___"__ � /G/4{"�y !� p DATE:��� A�ANT: __ _'_-- SMIP _._._ —_— .__.�6s' � W ENERGY P/C � � WARNIN6:FAllURETOSECUFENNqKENS'COMPENSATIONCOVEFAGEISUNLAWFUI.,ANDSHALLBE J —.. ��� SU&IECTANEMPLOYERTOCRIMINALPENAlTIESANOCIVILFINESU7TOONEHUNtlFEOTHOl15AN0 ENERGYPERMIT DOLLANS(S10o.000),INADDITIONTOTHECOSTOFCOMPtFlSATION,DAMAGESASPHOVIDEDFORIN -- ------------ —�-------�--- � SECTWN3�oBOF7HELABOFCODE,INTEkEST,ANDATTORN[Y'SFF.ES. RETENTIONFEE: ___. _ _ __ _ � k; d CONSTRUCTION IENDING AGENCY PREALT FEE: ________ � �. I HEREBY AFFIRAA UNDER PENFLTY OF PERJURY THAT TNERE IS A COYSTRUGTION LENDING AGENCY __ _ _ FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEG?OB7,CIV.C.)- w � ----- ------- --- � IENDERSNAME_„_ -- '_--- --.._ _ _ � 1� LENOERSADDRE55 __ _—..._ __,._ �'y' w ICERTIFYTHATIHAVEREA�THISAPPUCATIONANDSTATETHATTHEPBOVEINFORMATpNISCOPqECT. TOIAL FEES � / '�`�� a � IAGREETOCOMPLYWITHALICITYANOCOUNTYORDINANCESANDSTATELAWSRELATINGTOBUIL0ING 1�- 4 CONSTRUC710N,AND HEREBYAUTNOHIZE REPRESENTATIVES OF THIS COUNTY TO ENTEfi UPON THE � zABOVE•MEMIONEOPPOPENTVFORINSPEGTIONPURPOSES. COMMENTS � _ � '—_ � "'_' _ � m ¢ PEHMI MIE(P, �� � __ � —"— � '`:.(n � � — '_ "'.--_. _ SKiNATUPEo MITTEE DATE � � � RECPT.N0. PAID BY ,t? VALIDATION � WHITE—DepaAmEfnt Copy,YELLpW--Finence Copy,PINK—Assassor Copy,GOLDENROD--Fils Copy,GREEN—ApplicanYs Copy �� ,.. I _._ ... _ .. 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