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HomeMy WebLinkAbout10724 - CITY OF DIAMOND BAR �� e�'�D ,� COMMUNITY DEVELOPMENT DEPARTMENT �:; 21660 E.Copiey Drive Suitc 190 (909)66o-3195 Fax(909)861-31(7 PRESS �'"'"� BUILDING PERM[T APPLICATiON FIRMLY `.•o', ADORES � � �'` DATE CATION "� a. PERMIT /� NUMBER O� q � APN LO TRAC �SSUE TyPE OCC ; DATE CONST. GROUP g'. OWNER o ADDR S ' ZONING SETBACKS z CI ZIP TEL. ' FRONT RW ❑ i p' APPLICANT TEL. REAR U SIDFJSIDE STREET RW ❑ � � CONTRACTOR ' � SIDE ¢ ApDRESS @, V . u �' o � : PROPOSED USE CIN 1lUslniit��l�A17 � TEL o ARCH/EN(i/ z DESIGNER �. ADDRESS NO.DWEL. NO. NO. � � CiTY ZIP TEL. UNITS STORIES BEDRpOIyS �n.. — -- - `n DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANAIUATION � OWNER•6t;IL�ER DECLARATION O SFR/ADD/REM W CENSELAWFOHTHEfOLLOWNOR ASON(SECR7]R58USINF56ANOPROFESSIONS DEANYcl7ypp `� GaragelCarport �, CWHTYWHICHREQU(RESAPEFM7TTOCON57qUCT,ALTER,IMPROVE,DEMOLISN,OqRE?qIflANYSiflUG ' TURE,PRIOR TO 1T5 ISSUANCE,AL50 REO�IHES hIE APPLICANT FOR SUCH PEHMIT TO FILE A gIGNED �,W P8110/DBCk � STATEMENT THA7 NE Oq SHE IS IICENSED PURSUANT TO 7ME PROVISIDNS OF THE CONTMCTORS LI• �. CENSE LAW(CNAPTEq 9(COMMENGINC W1TM SECTION 7000�OF DIYISION 30F THE BUSINESS AND PflO� �u' POOUSpB 8 FESSIONSCWE�ORTHATHEORSHEISE%EMPTTHEREFROMANDTHE6ASISFORTHEALLEGEDEXEMP- �� � TION.ANYyIpUTIONOF6ECilON7o31.5BVANVAPPlICM1TFORAPERMITSUBJGCT5IN[APPLICAN7T0 - Z Re.qpp� � AqVILPENALT'OFNOTMOPE7HANFIVEHUNOREDOolLARS(SSoo�.); � ❑I,ASOWNEROFTHEPROPERTY,ORMYEMVLOYEESWITHWMESASTHEIRSOLECOMPENSATION. ��� Commercial Z WILL DD 7HE WORN,ANO THF STRVC7URE IS NDi INTENDED OR OFFEAED FOR SA�E(SEC.)Oa1,B1151� �J � NE55 AN[1 GROFESSIONS COOE:THE CONTRACTOflS LIGENSE lAW OOES NOTA7PLV i0 AN OWNER OF �� PR�PER7Y YYMO BU�LOS OR IMPROVES THEflEON.AND NMO DOES 5UCH WORK HIMSELF OR NERSELF OR �w 7HROUGHHISORHEROWNEMPLOYEES,PROVIDEDTrIRTSUCM'fAPhOYEM�N7SARENOTW7EN0EDOq C� � OFFEREOFORSALEIF,HOWEVERTFIEBUIIDINGORIMPpOVEMEMI550lDW1THINONEYEAROFCOMPI,E� �Z TION,THE OWNER-BUI�DER Wlll HAVE THE BURDEN OF PROVING THAT HE Oq SNE DI�NOT BUILD OR � IMPAOI'E FOA TNE PURpOSE OF SAIE). ��yJ ❑�.ASOWNEROFTHEPpOPEN7Y,AMEXCLU5IVELYCONTRACTINGWITMUCENSEDCONTpqCTOHS � TO CANSTRl1CT THE PqOJECT(SEC.7046.BUSINESS AND PflOFESSIpNS CODE:THE CONTMCTORS U- VelU2Yl�r1____ ADJ.AREA = CENSEUWi)bESNOTAPPLYTOANOWNEROFhPFOPERTI'WMOBUILDSORIMPqOVESTHEflEON,ANO � NRIOCOMFACTSFORSUCHvqq1ECTSWITHACONTPACTOR�SJLICEN&EDPIIRSUANTTOTHECONTpAC pUANTI7Y DESCRIPTION Y TORSLICENSELAW.). FEE -o tJ I AM E%EA1PT 4N�ER SEC,,.__._ ,__.,B.B P.C.Fop THI5 REASON Q ,'a �'S U LL OATE OWNEq,_ � i . a Z -' — () �¢ LICENSED CONTRACTORS DECLARATIDN �W 2 1 HEREBY AFFINM UNDER PENn�TY OF VEHJURY THAT I AM LICENSED 11NDER PRO�ISIONS DF CHAPTER �. 9(COMMENCINpWITNSECTIOry7a0o)pFDIVI510N30F7HEBUSINESSANDPROFES510NSCODE,AND ; Z ` � �X MY LICENSE IS IN FULL FORC�AND EFFECT. ' !n- m t � UCENSE CLAS l-. LIC.NO.� � F�-� �/ 7 w �ATE—�J CONTRACTOR � � d � WORKERS'GOMPENSATION DECLARATION Q � I HEREBV AFFIq1A UNDEfi PENAL7V OF PERIl1RV ONE OFiHE FOLLOWING DFCLARATION3; V C�J Z � _I NAVEAND WIIL MAINTAIN A CENTIFlCATE OF COYSENT TO SELF�INSURE FOR WOqHEFS' _ � CAMPFNSATION,AS PROVIDED BY SECTION 3]W OF TNE�ABOq GODE,iOR TME PERFORMANCE U OF THE WORK FOR WHICH TMIS VERMIT IS ISSllEO. W � � w __�NAVEANDWILLMA'NTAMIWORKERS'COMPEMSA710NINSVRANCE.ASflEQVIREDBYSEC?ION O 370o Of THE LAAOR CODE,FOR TH�PERFOqMANCE OF 7HE WORK fDR WHICH TMIS PEqM1T IS $ ISSUED.MV WORKERS'COMPENSATION INSURANCE CqRiiIER AND POLICY NUMBEflARE: CONSTRUCTION J j CAaRIER __._ PLAN REVIEW s ZPOUCV NUM3Eq_'_�.______ _'' ^ E�CTRI ^ d � � (IHIS3ECJICWNE@ND78EIXM4Y.EfEDOFTNEPEWMLSPoHONEMIN7RED00l1/1R5�51CU)OHIESS} C MBI - Z 1 CERTIFYTHAT IN TH[PEAFORMANCE OF THE WOHK FOR WNICH THIS PERAl1T IS I55UE0,I MECHANICAL (7 SHAILNOTEMP(,OYANYPERSO,UINANVMANNERSOASTOBECAMESU&IECi70THE -- � P� ((7 WORKERS'COMPENSATIONLAWSOFCALIFOHNIp,ANDpGREETHATIFI5MIXILOBECOME INSPECTIONFEE = SUBJECTTOTHEWOqKEHS'COMPENSATIONPPOVISIONSOFSECTION37000FTHELABOR � CODE,I SHALI.FOflTHW�TH CO'nP�v WiiH THOSE P ISI Se. �SSUANCE t `p pA7E:`�� AVPUCANC_...,_L�L��f'�.�i _ SMIP — _ r � WAHNING FAILURE TO SECUqE WORKEHS'COMPFNSATION CAVERqGE IS UNLAWFUL,AN�SHALLBE ENERGY P!C _ LL SUBJECTANEMPIOYERTOCqiMINALPENALTIESANDCIVILflNESUPTOONEHl1NOREDTHWSANO ENERGYPERMIT 5�..'a ��i1 ,�^'1 �OILARS(S10D,000�.IN AO�ITIpN TO THE COST OF COMPENSATION.DAMRGF.S AS PROVIDE�FOH IN �y; ..'d: J SECTIONJ70BOLTHEIqBORCOOE,INTEREST.ANDATTORNEY'SFEES. �—^�-�t._'�Sh,.' ��! '— � � RETENTION FEE: OCONS7RUCTION LENDING AGENCY pR�•ALT FEE: � 1 H�REBY AFFIRM UNOER PENALTY OF PEFUURV THATTHERE IS ACONSTRUCTION LENDING AGENCY � FOq THE FERFOFMANCEOF TNF WORK FOR WHICH THIS VERMIT I5155UE�(SEC.3087,CIy.C.). '--"—--- ;",�.`� " �� �.�p:'b`�y W � i �.. � LENOER'SNAME""'_ ______'�_ —, —'_— J "— F" LENDER'SPDORESS W ICERTIFYTHATIHAVEqEADTNISAPPUCATIONANDSTATETHATTHEABOVEINFOqMATIONISCoqqECT. TOTAL FEES a�/� d IAOREETOCAMCLYWITHALLCITVANpCOUNTVOi701NANCESM10STpTELAWSRELATINGTOBUILDING �. 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