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HomeMy WebLinkAbout10225 (5) — - CITY OF DIAMOND BAR COMMUNITY DEVELOPMENT DEPARTMENT � 21660 E.Copley Drive Suite 190 PRESS � (909)860-3195 f ax(909)861-3117 ""'Y BUILDING PERMIT PPLICATIO[V FIRMLY ,,�;}s JOBSITE ' � � '�' APPLICATION/j"�,°�,,_')_�G�i"1 PERMIT �` •r, �-"P/C "`o^. ADDRESS -� �� S� ` �^� DATE u � a^=,a,1 NUMBER l+�,s'�:��� # �' APN---��kQ T , TflACT ' � ' ISSUE ' 7 TYPE OCC p: OWNER EPfM..�_�,±�;�. � DATE CONST. GROUP " ADDRESS��� ZONING SETBACKS w �- a , FRONT RW ❑ z cirv zip r��. �9 p' APPUCANT TEL. / SI�SIDE STREET RW ❑ m CONTRACTOR �'"��'�'s'' f.�U� �-A i�:.'� SIDE ❑_ Q ADDRESS ' '.'r•, • �.;; i "' PROPOSED USE �� CITY ZIP TEL t� "�- � ,, ` O:, f F�,:� wo;, ARCWENG! W; DESIGNER , NO.DWEL. NO. ' NO. a ADDRESS ' UNITS STORIES BEDROOMS � CITY ZIP TEL. c�n DESCRIP710N SQ.FT. FACTOR PSF ADJ.AREANALUATION O. OWNER-BL'ILDER DECLARATION SFR/ADD/REM 1 NEREBV AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM 7HE CONTRACTORS ll� ('jgf892/C8fF70(t W CENSELAWFORTHEFOLLOWINGREASON(SEC.7037.SBUSINESSANOPflOFES510N5CDDE:ANYCITYOR ..,(n U COUNTYWHICHREOUIRESAPERMITTOOONSTqUG7,Al7ER.IMPqOVE,DEMOLISFI,ORREPAIRANYSTRUC• '� W P0ti0/DBCk �; TURE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES iHE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED '.,W STATEMEN!TMA7 ME OR SHE IS LICEN3E0 PURSUANT TO THE PROVISIONS OF THE CONTqACTORS LI- g:: CENSE LAW(CHAPTER B(COMMENCING'MTH SECTION]000)OF DIVISION 30F THE BUSINE55 AN�PRO� � Pool/Spa O FESSIONSCODE)ORTHATHEORSHEISEXEMPTTHEREFROAIAN�THEBhSISFORTNEALLEGEDE%EMP- V T�ON.ANYVIOLATIONOFSECTION7031.58YANYAPPI.ICANTFOqAPERMITSUBJEC79THEAPPUCANTTO ��. Z Re-Root ,.�..i! ��•��..� �� ' ACIVILPENAl,TVOFNOTMORETHANFIVEHUNDREDDOLLARS(S50a).): - 0� ❑I,ASOWNEROFTHEPROPERIY.ORMYEMPLOYEESWITHW�ESFSTHEIRSOLEfAMPENSATION. ':0 Commercial Z WILL DO THE WORK,AND THE STRUCTURE IS N07 INTENDEO OR OFFERED FOR SALE(SEC.70N,BUSI� �J NE55 AND PRDFESSIONS CA�E:THE CONTRACTORS LICENSE tAW��ES NOT APPLY TO AN OWNER OF � PROPERTYWr10BllILD50RIMPqOVESTHEREON,ANDVrti000E5SUCHWOFiKHIMSELFORHERSELFOR � ���' THROUGHHISORHEROWNEMPLOVEES,VROVIDEDTNATSUCHIMPROVEMENTSARENOTINTENDEDOR m W OFFEREDFORSALE.IF.HOWEVER.7HEBl11LDINGORIMPROVEMENTISSOLDWITHINONEYEAROFOOMPLE- 0 TION,TNE OWNER-BUILOER WILL HAVE THE BUROEN OF PROVINO THAT HE OH SHF.�ID NOT BUILD OR Z� IMPqOVEFORTHEPURPOSE�FSAIE). �Q_ ❑I,ASOWNEROFTHEPROPERTY,AMEXCLUSIVELVCONTRACTINGWITHLICENSEDWNTRAC70R5 � � TO CANSTRUCT TNE PRQIECT(SEC.70a4,BUSINESS AND PROFESSIONS CODE:7HE CONTqACTOPS LI� V8IU8IlOf1 _,___ A�J.AREA W� CENSELAW�OESNOTAPPLYTOANOWNEROFAPitOPERTVWHOBUILO50RIMPROVESTiEREON,AND F WHOCONTMCTSFORSUCHPRQIECTSWITHACONTRACTOR(5)LICENSEOPURSUAMTOTHECONTRAP QUANTITY DESCRIPTION FEE Y TORS LICENSE LAW.�. � f7 1 AM EXEMP7 UNDER SEC. B.8 P.C.FOR 7HIS qEASON � � � "__—'_""'_' ___ U LL � DATE_ ONMER ____ .. U . z W �. LICENSED CONTRACTORS DECLARATION ; W ' ��� 1 MENEBYAFFIRM UNDER PENNLTY OF PERIl1RV TMAT I AM LIGENSED UNOER PROVISIONS OF CHAPTER ' � �p„� B(COMMENCINGWITHSEC7ION7000)OF�IVISION30FTHEBU6INESSANOPNOFESSIONSCODE,AND Z �X AIY LICENSE IS IN FULL FORCE AND fFECT. . , • � A o � ...�� ��..� e��i`_.�.� � � LICENSE CLASS " -=�_LIC.NO__..� �-'�_=__ ;"u�� V DATE �` � � �S � CONTRACiOR � ' a ,, �i E� W' ..A"�--�'^ 'T ... . .. �� WORKERS�COMPENSATIONOECLARATI.N � � � � � � U � 1 MEflEBYAFFIFM UNDER PENALTY OF PERJURY ONE OF TME FOLIOWIN6 DECLARATIONS: z ���y @ 1 �� _IHAVEANDWILLMAINTAINACERTIFICATEOFCANSENTTOSELF-INSUREFOHWORKERS' = 1. y�,; COIAPENSATION,ASPROVIOE�BYSECTION3�OOOFTHEUIBORGODE,FORTHEPEflFOqMANCE U � OF THE WOflK FOfl WHICH THIS PERMIT tS ISSUED. � �' W _IHAVEANOWILLAAAINTRINWOPKFRS'(:OMPENSATIONINSURANCE,ASpE�UIHEDBYSECTION � p Q 37000FTHELR90FiCODE,FORTHEPERFORMANCEOFTHEWOqKfOflWMICHTHISPEM11T15 . 8..��g� ISSUED.MYWORKEflS'�; PENSATIONINSUMNCECARRIEF��DPO ICYNUMBERApE: CONSTRUC,TION , _ B '"ir�. L��*F- �j CARRIER��t�L�,�_---__. PLANREVIEW _ � __. o aa.icvNUMeEa____ ELECTRIC ¢ ' '.. .� (iHISSECTIONNE�NOTBENMPLErE0Cf7NEPEPNRISfORONEHIA�DFEDo0UN7S�S10JIORLLSS�. PLUMBING _ 'Z ' 1 CEflTIFY THAT IN TME PERfORMANCE OF THE WORK FOR WHICH THIS PEflMIT IS ISSUED,I� '� MECHANICAL � �'} SHALLNOTEMPLOVANYPERSONINANYMANNERSOASTOBECOMESUBJECTTOTHE Uj � WOqNERS'COMPENSATIONLAWSOFCALIFOflNIA,ANpAGREETHATIFISHOULDBECOME INSPEGTIONFEE _ � = SUBJECTT07HEWOHKERS'COMPENSAf10NPROVI510NSOFSECT10N37000FTHELABOR — CODE,1 SHALL FON7HWITH COMPLV WITN THOSE VqOVIS10N5. ISSUANCE �����'.�:�:�` � •.p DATE: _ ARPLIGANT: '_" SMIP ___ __ � '�-"�f�. �� ENERGY P/C _ _ J WARNING:FAILURE TO SECUfiE WORKERS'COMPENSATION COVEHAGE IS UNLAWFl1L,ANO SNALL9E LL SU&IECTANEMPLOVERTOCRMAINALPENlLLTIESANOCIVILFINESUPTOONEHUNDFEDTHOU9ANU ENERGYPERMIT �OLLAflS(S1 a0,0ao).IN ADDITION TO THE COST OF COMPENSATION,DMIAGES AS PROVIDEO FOR IN —�� --- J � SECTION 37oB OF THE LABOR CODE,INTEFEST,ANDATTORNEY5 FEES. RETENTION FEE: i �� OCONSTRUCTION LENDINGAGENCY PRE-ALTFEE: _ � '� �..It�ls" I � 1 HEHEBY AFFIRM UN�ER PENALTV OF PEFJURY THATTHEHE IS ACON5TRUCTION LENDINQ AQENCY � FOqTMEPERFORMANCEOF EWORKFO WHICH7HISPERMIT161SSUEO�SEC.3a97,�CIV.C.). - Z f[ j'�);� WTc� LENDEfl'S NAME_��.m ��� `*�f v ! . l 7 4 9 ,• A c F—, LENDER'SADDRESS _ � �_ ���.__ �' TOTAL FEES ¢ ICEFliIFYTHATIHAVEREADTHISAPPLICATKKJANDSTATETHATTHEABOVEINFORMATIONISCOHNECT � W 1 AGNEE TO CAMPLV WITiI RLL CITY AND CAUNTV ORpINPNCES AND STATE LAWS REUTMG TO BUILDING ^�p, y,., � CONSTflUCT10N,ANDHEREBYAUTHORIZEREPREbENTATIVESOFTHISCOUNTYTOENTERUPONTNE M F T r'�� Z PHOYE�MENTIONED PRODERTV FOR INSPECTION Pl1RPOSES. COMMENTS 'ef/ �' �" Y ' ��`�� Ry� ��'���3 c � .r" . . J -� �,� :�^�. ' �,��y� �'/ . � PERMITiEENAME(pFUNT� ; y'r ' � :� \6��L-f� -~�.�; . . � - Cn ;� F. r�F '�'e i� .s 15.. .f� � SIGNATUREOFPERMI E YlI ��J' DATE C . / , . . . . / .y _ ✓� ,f' ��"..� HECPT.N . 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