HomeMy WebLinkAbout16400 (22) : ` ' �� CITY OF DIAMOND BAR �
� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
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'4 (909)86Q3195 Fax(909)861-3117 PRESS
� ��'"�"� BUILDING PERMIT APPLICATION FIRMLY
N JOBSITE
a ADDRESS 22518 LARK SPRING TER aPP�icar�pry PERMIT ��n(� P/C
o DATE U�10712001 NUMBER 9J�� #
$ ISSUE ,�� iJITYPE OCC
APN LOT TRACT__ DATE CONST. GROUP
0 owNeR _TALBOT.NORMAN
p ADDRESS 22518 LARK SPRING TERRACE ZONING SETBACKS
gCI7v DIAMOND B ziP 91765 TE�. 909-860-653 FRONT Rw n
APPLICANT �etClerk InC TEL. 8S�'�TT� REAR U_
� SIDE/SIDE STREET RW ❑___
� CONTRACTOR �nquest management group SIDE �
ADDRESS 26741 orto a arkwa suite e- —
� CITY foothill ranch ZIP 926'�� TEL. ��B PROPOSED USE
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W DESIGNER_ NO.DWEL. NO. NO.
a ADDRESS
= CITY Z�p �� UNITS STORIES BEDROOMS
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� DESCFiIPTIf�N SQ.FT. FACTOR PSF ADJ.AREANALUATION
O OWNER•BUILDER DECLARATION SFR/ADD/REM <AP68> <V8IU8�
� 1 HEREHY AfFIRM UNDER PEN/LLTY OF PERIURV THAT i AM EXEMPT FROM THE CONfflACTORS LI� G2f09B/C8f{10ft �YM e�',�� �V'a�(J8�
W CENSEUWFOHTHEFOLLOWINGRFASON(SEC.7037.SBUSINESSANOPROFESSIONSCOOE:ANYCITYOR (n A,,
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TURE,PqIOR TO ITS ISSUANCE,ALSO HEOUIRES THE APPIICANT FOR SUCH PERMIT TO FILE A SIGNE� W
� STATEMENT THA7 HE OR SHE IS LICENSED PUIi5UAN7 70 THE PROYISIONS OF TIfE CONiFlACTORS LI� ^. `r
� CENSE UlW(CHAFTEfl e(COMMENCIN�WITH SECTION 7a00)OF DIVISION 3 0F THE BUSMESSAND PRO� � POOUSPB �tV Aay <Y�IUA�
fESSbNSCODE�OR7HATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTNEALL[GEDE%EMP- � A,,
TION.ANVVKKATIONOFSECTION7031.5BYANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO Z Re-Roof <HiBa� SVaIUA�
� A CMl PENALTY OF NOT MORE THAN FIVE HUN�RED DOLLARS(SSCO)J: p� �f
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WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDEU OR OFFEHED FOR Sf�LE(SEC.7o4s,BUSI� J
� NESS AND PqOFESSIOIVS CO�E:7HE CON7RAC70F5 LICENSE LAW OOES NOT APPLY'f0 AN owNER oF C�('Qa� GV'L�lle�
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� 'TION,YHE OWNER�BUILOER WILL HAVE THE BURDEN OF 7HOVING THAT HE OR SHE 01�NOT BUILD OR /�,. y`dlUe
IMPROVE FOR THE PURPOSE OF SAL�. [ri Aa�j S �
❑I,AS ONT7ER OF 7HE PflOPF.HTY,AM E%CLUSIVEIY CANTRACTING WfTH LICENSE�CONTRACTORS
� TO CONSTRUC7 THE PR0.IECT(SEC.701i,@USINESS AND PFOFESSIONS CA�e:7NE CONTRAC70R5 Lb Velualion 198.00 ADJ.AREA__
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� LICENSED CONTRACTORS DECLARATION W
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I HEREBY AFFINAI UNDER PENALTY OF PEFUURY THAf I AM LICENSED UNDER PROVISIOYS OF C4ipp7EH x
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d LICENSE CLArSS��r76 _-- uc.No. 529482 � � • ��� .�' `� ��� `�..��'.
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� COAIPENSATION,AS PROVIDED 8V SECTION 3�0o OF THF LABOFl CO�E.FOR TNE PERFOPMANCE U
O OFTHEWORKFORWHICHTHISPERMITISISSUED. �
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Q J7000FTXELA�RCODE,FORTNEPERWRMMICEOFTHEWORKFOFWHICHTHISPERMITIS
_ ISSUE�.MV WORKERS'CAMPENSATION INSURANCE CARFIEH AND PO!ICV NUMBER ARE: CONSTRUCTION ______..,._. _
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Z 1 CERTIFY TNAT IN THE PF.RFORMANCE OF THF WOPY,FOR WHICH T'IS PERMIT IS ISSl1E0,1 MECHANICAL _,...,__.__ � � Y.
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CJ� SHALE.NOT EMFLOV ANY PEfl50N INANY MANNER SO TO ECO E SUBJECTTO TH[ �
(n WOFKERS'COMPENSATIONLAWSOFCALIFORNIA,AN G ET TIFISh10ULDBECYME INSPECTIONFEE .__ ��...5_�.�'�.S
� SU&IECTTDTHE WORKEflS'CAMPENSATION PP,OVI N F . FTHE L4BOP �� _-. ----' - �
� CADE,ISHALLFOHTHWITHCOMVIYWIT4/THO, __ ISSUANCE _
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p DATE:_O�'�7rzon� APPLICAN2 _.._"'_.____ SMIP � ! k"�•�� /-� '�r,- ��`
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-'� WARNING:FAIWHETUSECUREWOflKEHS'COMPENSATIONC VERAG[1541NLl�WFUL.ANOSHALL6E ENERGYP/C _•...____.,,___„ _
J SUBJECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFIh ONEHUNORED7HOUSANU � �l�J�
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LL DOLLARS(S1oo.000),INADDITIONTOTHECOSTOFCOMPENSATION,DAMAGESASPROV;bEDFORIli ENERGYPERMIT 1.=!P..j� _�' ( �����-�}���}
J SECTION3708 Of hIE LABOR CODE,IN7ERESL ANDATTOHNEY'S FEES. �' �� � -� "'
¢ RETENTION FEE: __ . _. .. ..--,------...- -
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O CONSTRLICTIONLENDINGAGENCY PRE-ALTFEE: �-- . �
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� � I XEREBV AFFIFlM UND[P PENALTY OF PERJUflV THATTHEFE IS ACANSTItUCTION LENOING AGENCY �vu'AC� �--•% . ���' �
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z FOR THE PEFFORMANCE OFTHE WORK FOR WHICHTHIS PERMITIS ISSUED(SEC.3�57,CIV.CJ. ��Ar> � —��
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� LCNDER'SNAME__..._-'—_"'".,.__"—_____'_'_- �O{f1AY�
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� I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFOPMATION IS�HRECT.
W I AGREE TO COMPLV WITH P1L CITY AND COUNTV ORDINANCES AND STATE LAWS RELATING TO BUIL�ING
� CONSTRUCTION,ANU HERE6YAl1THOR12E PEPR[SENTATIVFS OFTHIS COUNTY TO FNTEH UPON THE
Z ABUVEMENTIONED PROPERTV FOR INSPECTION PUHPOSES. ,
� COMMENTS..___ __..__,___ __
� NetClerk In ' ._._ — ------ ----
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