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HomeMy WebLinkAbout10139 (5) . .. _,._ , . �� � ��� —1-'"� CITY OF DIAMOND BAR COMMUNITY DEVELOPMENT DEPARTMfiNT ;,,W 21660 E.Copley Drive Suite 190 PRESS (909)860-3195 Fax(909)86t-3117 '""' BUILDING PERMIT APPLICATION FI RM LY � JOBSITE 6 APPLICATION PERMIT P/C o ADDRESS���7 ��/�� DATE NUMBER J�/�� # � ISSUE �ONE T OCC � � APN LOT T CT DATE ( p OWNER � (�% S GROUP � LL ADDRESS � i f�`rS ZONING SETBACKS o ; Z CITY ZIP C' � � TEL. G�` %' r� FRONT RW ❑ � g APPLICANT �'C.;�.�r Yi^�--� TEL. REAR (J ;i SIDE/SIDE STREET RW f'.I � CONTRACTO �� �G'�/�"iJ SIDE fl ? a ADDRESS " -c' J' �" � CITY �' ZIP �i'7Gv. TEL. �'�7,�%�' PROPOSED USE � W ARCWENG/ �� �`�'`� � z DESIGNER 5 a ADDRESS NO.DWEL. NO. NO. UNITS STORIES BEDROOMS � �. CITY _ ZIP TEL.— --� uNi DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � p� OWNER•BI:ILDER DECLARATION SFR/ADD/HEM O �p I HEREBY AFFIRM UNOER PENALN OF PERJURY THAT I AM EXEMPT FROM TNE CONTRACTORS Li� � Garage/Carport ( W CENSELAWFON7HEFOLLOWINGREASON(SEC.7o31.5BUSINESSANDPROFESSION3CODE:MIVCITVOR U CWNTVWHICHREWIRESAPERMITTOCANSTRUCT,ALTER,IMPROVE,DEMOIISH,ORREPAIRANVSTRUF W d Z TURE,PRIOR 70ITS ISSUANCE,ALSO HE�UIRES THE APPLICANT FOR SUCH PERMIT TO FlLE A SIGNED PatiO/DBCk � w STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO 7HE PROVISIONS OF THE CONTRACTOHS ll- W � CENSE LAW(CHAPTER B(COMMENCWG WITH SEC710N 70D0)OF�IVISION 30F iHE 6USINESS AND PRO- � POOUSpB FESSIONSCADE)OHTMATMEORSHEISEXEMP7TiEfiEFflOMANDTNEBA313FORTHEALIEGEDE%EMP• (� � TION.ANYVIOLATIONOFSECTION7031.58YANYAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANTTO Z REROOf p CIYII PENALT/OF NOT MORE TWVJ FIVE HUNDRED DOLLARS(f500).�: � � ❑I,ASOWNEROFTHEPROPERTY,ORMYEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, � C0111111BfCi81 Z WILL DO THE WORK.ARD THE STRUCTURE IS NO7IN7ENUE�OR OFGEREO FOR SA�E(SEG.7014 6U51- J k NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DDES NOT APPLY TO AN OWNER OF � PROPERTYWHOBUILA90RIMVpOVE9THEREON,ANDWHO00E55UCHWOflKHIMSELFORY.EflSELFOR m � � THROUGHHISORHEflON7VEMPLOYEES,PROVIOEDTHATSUCHIMPROVEMENTSRfiENOTINTHJDEOOR � QOFFEREDFORSALE.IF,HOWEVER,7HEBUILAINGORIEAVROVEMEN7ISSOIDWITHINONEYEAROFCOAI7LE- TION,THE OWNER�BUILDEfl WILL HAVE THE BUflDEN OF PRWING THAT HE OR SHE OID NOT BUILD OR � � IMPROVE FOR THE PURPOSEaF SALE). �` w ❑I,ASOWNEROFTHEGROPERTY.AME%CLUSNELVCONTqACTINGWITHUCENSEDCANT1iACTOqS Q TO CONSTRUCT THE PRQIECT(SEC.)0�4,BUSINESS AND PROFESSIONS CODE:THE CONTflqCTORS LI- V2IUdUOl1 ADJ.AREA W CENSELAW�OESNOTAPPLY7oANOWNEflOFAPROPER7YWMOBUILOSORIMPROVESTFIEREON,AND - � WHOCONTFACTSFORSUCHPROJEC7SWI7HACANTRACTOR(5)LICENSEDPURSUANTlOTMECANTRAC- �UANTITY DESCRIPTION FEE Y TORS LICENSE LAW.). � �-�.AM EREMPT UNOER SEC. B.6 P.G FOR THIS REASON U � '� � � �i.� � ..._.__.._'....._ _. ..._. _—.""__ ¢ f � � �.��.� � " y�i LL DATE - OWNER_______ F t Z � LICENSED CONTRACTORS�ECLARATION w � 2 1 HEREBV AFFlRM UNDER PENpLN OF PERJURY THAi IAM UCENSED UN�EFl PROVISIONS OF CHAPTER � � d 9(COMMENCING WRH SECTION 7000�OF DNISION 3 0F THE BUSINE5S PND PROFESSIONS CODE,AND Z `X AIV LICENSE IS W FULL FORCE AND EFFECT. m � LICENSE CUSS `�'� LIC.NO. 7 � j V DATE GONTRACTOR_.� a W � WORKERS'COMPENSATIONDECLARATION � � J �' ''� � . �� � � IHEREBYRFFIRMUNDERPENALNOFPERJURYONEOFTHEWLlO`MNGDECLAMTIONS����� Z ��� �� ' � 0 I HAVf AND WILL AIAINTAIN ACERTIFICATE OF CONSEM TO SELF-INSl1RE FOR WORKER' � COMPENSATION,RSPqOYIDEDBYSECT10N37000FTHElABOHCODE,FORTHEPERFORMANCE �U OF THE WORK FOR WHICH THIS PERMIi IS ISSUED. � 0 W 1 HAVE AND WILL MAINTAIN WOfiNERS'COMPENSATION INSURANCE,AS REOUIREO BY SEC710N Q 37000FTHELABORCODE,FOHTFiEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS ISSUED.MY WORKERS'COMPENSATION INSURANCE CAHPIERAND POL�GY NUMBERARE: CONSTRUCTION ____,__ _ J j cnRAien--.------- PL4NREVIEW -- 0 PouCYNUMeEfl__.___ ELECTRIC - � -=t"' ' � (i}iI55EGTK)NNEmNOTOEOJMpLEfEDOFiIiEPEW�YTISFORONEM1WFiED00LLAR5(S100JqiLESS). PLUMBING _ ��'1 � ���F� w Z 1 CERTIFY TMAT IN THF.PEfiFORMANCE OF THE WOPK FOR WHlpi THIS PERMIT IS ISSUED,I MECHANICAL __ � (3 SHALL NOT EMPLOYANY PERSON IN ANY MANNER SOAS TO BECOME SUBJECTTO THE � WORNERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGREE7HATIFISHOULUBF/COME INSPECTIONFEE ____ SU&IECT TO THE WORKERS'COMPENSATION GflOVISIONS OF SECT�N 9700 OF TNE LABOR j / ISSUANCE __ �D• CADE,ISHAIL�FO)RTHW%ITHCOMPLVWI7HTH ROVISIONS. � A„J��/ 1__��,.�•�`I/ SMIP p DATE:=f_ APPLICANT: ��-------�--- W ENERGY P/C J WARNING:FAILURETO SECUHE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,M1D SHALL BE � -- � SU&lEC7 AN EMPLOVEH TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDREO THOUSAND ENERGY PERMIT UOLLARS(51 a0.G00).IN ADDI710N 70 THE COS70F CAMPENSATION,DAMAGES AS PROVIDED FOR IN �-------� � SECTION 370d OFTNE LABOR CO�E,INTEREST,AND ATTOHNEYS FEES. RETENTION FEE: � CONSTRUCTION LENDING AGENCY PRE•ALT FEE: O � I HEPEBV PFFIRM l/NDER PENALTYOF PERIURY THAT THENE IS ACONSTRUCTION LENDING AGENCY ___ __ FOR THE�ERFORMANCE OF THE WORK W R WHICN THIS PERMIT IS ISSUEO(SEC.3097,CN.C.). Z w ' � LENDER'SNAME _ __ / I— LENDEFYSADORESS„ .._ —_— � ICERTIFYTHATIHAVEflEADTHI3APPLICATIONPNDSTATETHATTHEABOVEINFORMATIDNISCONRECL TOTAL FEES � IAGREETOCOMPLYWITHALLCITYANDCOUNTYORDINANCES/WDSTATELAWSflEIATINGTOBU1L01NG � CONSTFUC ON,AND HER�`LJ�U7IiORIZE REPRESENTA7IVES OF THIS COUNTV TO ENTEH UPON THE ABOVE E IONEOPRO �F qINSPECTIONPURPOSES. COMMENTS o ����� � _ _ N PE M{�TE AME IPRINT) ,. �, j/ � �J."J _' __ / ( �� � r'/�._ y�. S NANREOFPEHMITTEE DATE _ � RECPT.NO. 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