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HomeMy WebLinkAbout10592 (5) } ; � � I CTTY OF DTAMOND BAR I COMMUNITY DEVELOPMENT DEPARTMENT --',:/ ,,.,� 21660 E.Copley Drive Suite 190 . PRESS � �'""'� BUILDINGPERMITAPPL[CATION %� FIRMLY a ADDRESS ���� G����� C��� vs✓ S��`` APPLICATIblI_ s- �� PERMIT ��l��P/C f i`� / o r DATE NUMBE6!' # � $ ISSUE y,�' ,✓ �. TYPE OCC i APN LOT TRACT DATE �/" } f� CONST. GROUP ' p OWNER � � i ADDR SS I C;t�. , CC�/L'v[/Y1 f� ZONING SETBACKS � z CITY � d ZIP 4l 1 b�i T LE���FI FRONT RW__ f7 f � APPLICANT 7EL,��y y�� REAR ❑_ Z SIDE/SIDE STREET RW f7 r m CONTRACTOR � /' IG SIDE ❑ Y � ADDR S PROPOSED USE A�'0� �-p�''��`'y ��� � � CITY Y �/ .. ZIP TE . " :3� o ARCWENG/ y Z DESIGNER NO.DWEL. NO. NO. � a ADDRESS UNITS STORIES BEDROOMS � � CITY ZIP__ TEL. " N DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION ! � OWNER-BI:ILDER DECLARATION SFRIADD/REM O �. p I HEREBY AFFIRAI UNDER PENAL7V OF PERJURY THAT I AM EXEMP7 FROM THE CONTRACTORS LI� G8�899/C8/pOK W CEN6EUWFORTHEFOLLOWINGREASON�SEC.7031.5BUSINESSPNDPflOFE5510N5COOEANYCITVOH �� U CWNTYWMICHNEOUIRESAPERMITTOCONSTRUCT,qLTER,iMPROVE,DEMOL15N,ORflEPAIRANYSTRUC- � j� r .��j' Z TUHE,PRIOR TO RS ISSUANCE.ALSO REOL11RE3 THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W Patio/Dedc �� ��/�.' y� ;'�. � � STATFAIENT THAT HE OR SNE IS LICENSED DURSUANT TO 7HE PHOVISIONS OF THE CONTRACTORS LI� � S; � CENSE LAW(CFiFPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PHO- POOUS(Id � FESSIONSCODE)ORTNATHEORSNEISEXEMPTTHEREFROMAN�THEBASISFOflTHEALLEGEOEXEMP- TION.ANVVIOLATIDNOFSECTION7031.SBYANVAPPLICANTFORAPENI.IITSU6IECTSTHEAPPLICANTTO z Re-Roof � ACIVILPENALTYOFNOTIAORETHANFIVEHUNDREDDOLURS�f500).): 0 ❑I,ASOWNEROFTHEPROPEflTV,ORMYEMPLOYEESWITHWAGESASTHEIR50LECAMPEN5AT10N, � CpmmBfClal Z WILL DO THE WONK,AND THE STHUC7URE IS NOT INTENDE�OR�FfENEO FOR SALE ISEC.7o4a,BUSI• J NE33 AND PROFESSIONS CODE:THE CON7RACTORS LICENSE lAW DOES NOT APPLV TO AN OWNER Of � PflOPER7YWHOBUIL�50RIMPROYESTHEREON,A�DNT1oDOE55UCHWOftKNIMSELFORNEflSELFOR m � � THROUGHHISORHEROWNEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTENDE�ON �� W OFFEFlEDFOR3IILE.IF,HOWEVEfl,THEBIAL�INGORIMPROVEMEN71SSOtDWITHINONEYEAROFCOAIPLE� (' � TION,THE OWNEH-BUILDER WILL HAVE THE BUROEN OF PROVING THAT HE OR 9HE DID NOT BUIID DR r� Z IMPHOVE FOR THE PURPOSEOF SALE). S+ fl I,AS OWNER OF THE PROPERTY,AM E%CW SIVELY CONTRACTING WITH LICENSED CONTPACTORS F. Q TO CONSTflUCT THE PflOJECT(SEC.7o<a,BUSINE55 AND PROFESSIONS CO�E:THE CONTMCTOflS ll- V8IU011011 __,_„�� � �s ADJ.AREA W CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUILDSORIMPFiOVESTHEREON,ANO � WHOCONTRACTSFORSUCHPRQIECTSWITHACONTRACTOR(S)LICENSEDPLJRSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FEE , Y TORS LICENSE LAW.). �� � O I AM EXEMP7 UND[R SEC. __._B.8 V.C.FOR THIS PEASON U � � r. . _ _ , �"'......."'...._._.._.. Q � k � DA � ��r- OWNER U I;� Z �'_' ; W 1 � LICENSED CONTRACTORS DECLARATION W 2 I NEFiEOY RFFIRM UNDEfl PENALN OF PERJURY TliAT IAM LICENSED UNDER PflOVISIONSOF CHAPTER � �.' d 9(COMMENCING WITH SEC710N 7000)OF DIVISION 30F THE BUSINE55 AND PqOFE55qN5 CODE,Ml� Z X MY UCENSE IS IN FULL FORCE AND EFFECT. m � u� � O � LICENSE CLA55 LIC.NO.____.__ J V DATE -___'_' CDNTRACTOR_ a "� W � WORKERS'COMPENSATION DECIARATION Q �[[[ � IHEREBVAFFIflMUNDERPENALNOFPERJURYONEOFTHEFOLIOWINGDECLARATIONS: Z ' N Q � _I HAVE AND WILL MAINTAIN A CERTIFICATE OF CCNSENT TO SELF-INSUfiE FOR WORKERS' _ � a CAMPENSATION.ASPflOVIDE08Y5ECTIDN37000FiMElABORCOOE,FORTFIEPERFORMANCE W � OF THE WORK FOR WHICH THIS PERMI7IS ISSUED. � p 0 P W _IHAVEANDWILLMAINTAINWORKERS'COAIPENSATIONINSURANCE.ASREOUIREOBYSECTION ` ` { Q 310o OF TNE LABOF CODE,FOR THE PERFORMANCE OF THE WOfiK FOR WHICHTHIS PERMIi IS [.N'` "'�� ��«' € ISSUED.AIY WOFiKERS'CAAIPENSATIDN INSURANCE CARRIER ANU POLIGY NUMBEfi ARE: ONS N � --� ,�. ;.�.5 .r/9 `= .i 4 CARRIER PLAN RE q ] ___._ _. � POUCYNUMBER _ ELEC7RIC $ � (rr�ISSEcmaNE��voraEocMPtErEooFniEPEwxr6wr�aMEM.rnaEooauxs(E�oo)oaLFss7. PLUMBING a w MECHANICAL � Z i CERTIFY 7HAT IN THE PERfORMANCE OF THE WORK FOR WtI1GHTH15 PEFMIT IS ISSUED,I - � SHALL NOT EMDLOY ANY PEFSON IN ANY A7ANNER SOAS TO BEfAME 5U8JECT TO THE N WORKERS'COMPENSA710NLAWSOFCALIFORNIA.AN�AGREETHATIFISHOULOBECOME INSPECTIO�JFEE �� � SlIE1JECTTOTHEWORKERS'COMPENSPTIONPROVISIONSOFSEC710N3�aoOFTN[1A80R ;.,.a, � � � CODE,ISHALLFORTHWIThICOMPLVWITHTHQSEPROVI51ON5. SS �--.j-- � SMIP M` �� p DATE:_ APPLICANT: ___' —_—_— _ w ENERGY P/C �� �� � - J WpRNING FAILURE TO SEIX1flE WORKERS'COMPENSATION COVERPGE IS UNIAWFUL,AND SNALI BE � ` � � SU&IECTAN EMPLOVER TO CRIMINAL DENALTIES ANO CIVIL FINES UP TOONE Hl1NORED THOUSAN� ENERGY PERMIT I OOLlARS(5100,000),INAD�ITION TO TNE COST OF CAMPENSATION.DAMAGES AS PROVIDED FOR IN � SECTION37080FTHELABORCODE.INTEREST,ANDATTORNEY'SFEES. RETENTIONFEE: d CON5TRUCTION LENDING AGENCY pRE-ALT FEE: � I HEREBYAFFlFM UNDER PENALNOF PERJURY THAT THERE IS ACONSTRUCTIOY LENDINO A6ENCY FOR THE PERf-0RAIANCE OF THE WORK W R WHICH THIS PEFMI715155UED(SEC.3oel,CIV.G.). -- � � LENDEH'S NAME ._.— _ .J��' 1 .�. i,i `1:.e" �i� � � �..,:+iT, 'r'.�.r � :.^.� " n:,��. _ �.:: F- LENDEN'SA�OflE6S_" —..._. _ ....,.. �.J:'�;�...i.:1 � , . � ICERT�FYlHATIHAVEREADTMISAPPLICATIONAND57ATETHATTHEA60VEINFORMATIONISCAflflECT. TOTAL�FEES ��/..�' • •� � � W 1 AGREE TO CAWPLY WITH ALL CITY AND COUN7Y OROINANCES AND STATE LAN�S flELATING TO BUILDING • � CONS7RUC710N,M1D HEREBV AU7HOfiIZE REPRESENTA7IVES OFTHIS COUNTV TO EN7Ep UPON THE ZABOVE-MENTIONED PHOPERTY FON INSPECTIOn PURPOSES. 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