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HomeMy WebLinkAbout10280 � - - CITY OF DIAMOND BAR � F COMMUNITY DEVELOPMENT DEPARTMENT $ ;,.W 21660 E.Copley Drive Suite 190 PRESS (909)86(�3195 Fax(909)861-3117 � ��'""°~ BUILDING PERMITAPPLICATION FIRMLY � JOBSITE '//� d1 APPLICATION � PERMIT P!C � o ADDRES�V���G������� �� DATE - I NUMBER�- ti c� ISSUE TYPE OCC APN LOT T ACT_ pATE CONST. GROUP � °C OWNER ' O ADDR S ZONING SETBACKS �' z CITY ZIP TEL - FRONT RW__ ❑ � APPLICANT TEL. REAR ❑_ � SIDE/SIDE STREET RW ❑ � SIDE CI_. � m CONTRACTOR �.B.i. lnc a ADDRESS � CITY '' TEL. PROPOSED USE �; w ARCWENG/ � gr�� !' wDESIGNER t a ADDRESS NO.DWEL. NO. NO. E UNITS STORIES BEDROOMS F; = CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION ;{{{ � OWNER-BI;ILDER DECLARATION SFR/ADD/REM � O p I HEREBY AFFIHM UNDER PENALTY OF PERJURY THAT I AM EXEMP7 FROM THE CONTRACTOHS LI• G2I8g8/CBIpOft W CENSF.LAWFORTHEFOILOWINGREASONI5EC.7o37.59U51NE55ANDPROFE55lON5CWE:ANYCITYOR (n U �pUNTVVh11CHREWIRESAPERMITTOCONSTRUCT,AI.TER,IMDROVE,DEMOLI5F7,ORREPAIRANYSTRUC� W pa�io/Deck r' W TURE,PRIOR TO ITS IS9UANCE.ALSO HEQUIflES THE APPUCANT FOR SUCN PERMIT TO FIIE A SIGNED W rL STATEMENT THA7 ME OR SME IS IICENSED Pt1RSUANT TO THE PflOVI510N5 OF THE CONTqACTORS LI• � � CENSE L4W(CHAPTEH 9(COMMENCING WITH SECTION 7a0o)OF�IVISIDN 9 OF 7HE B1151NES5AND PflO� � POOVSpB ; FLSSIONSCADE�OR7HATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEDE%EMP- (� { � TION,ANYYIOLATIONOFSECTION�o31.58YANYAPPLICANTFORAPERMITSU&lECTSTHEAPPUCANTTO Z Re-Roof t � A CIVIL PENALTV OF NOT A10RE THAN FIVE Hl1N�RED�OLUfiS(f500).): 6 � C11,ASOWNEROFIHEPROPERTV,ORMVEMPLOVEESWITHWAGESASTHEIRSOI.ECOMPENSATION, O C0111ff1BlC18I ; Z WILL DD THE WORK,AND TME STflUCTUflE IS NO71N7'ENDED Ofi OFFERED FOR SALE�SEC.7044,fiU51� J P � NE55 AND PNOFESSIONS CO�E THE CANTRACTORS LICENSE LAW OOES NOT APPLY TO AN OWNER OF � -• PROPERTY WHO BUIlD50R IMPROVES THEPEON,ANO WHO DOES SUCH WORK HIMSELF OR HEHSELF OR ! [L 7HRWGHHISOftNEflOWNEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTENDEDOR m � W� OfFEREDFOR5ALEIF,HDWEVER,THEBUILDINGORIMPROVEMENTIS50LDWITNINONEYEAROFCOMRF �. Z TION,THE OWNER-BUILDEF WILL HAVE THE OURDEN OF PROVING 7HAT HE OR SHE DID NOT BUILD OR � IMVROYE FOR TME PURPOSE OF SALE). j ❑I.AS OWNER OF THE PHOPERT',AM EXCLUSIVELV CON7PAC71NG WITH LICENSE�CON7FFCTORS � Q TO CONSTRUCT THE PRQIECT(SEC.7044,BUSINESS AND PROFESSIONS CODE:THE CONfflACTORS LI� V2N811D11 _ADJ.AREA f W CENS[LAWDOESNOTAPPLVTOANOWNEROFAPROPERTYWHDBUILOSORIMPflOVESTiEflEON,AND ? � WHOCON7RRCTSFORSUCHPROJECTSWITHACANTRACTOF(5)LICENSEDPUFSUANTTOTHECONTflAC- QUANTITY �ESCRIPTION FEE � TORS LICENSE LAW.). Y Qf I I AM EXEMPT UNDER SEC._______._,_._ B.d P.Q FORTHIS REASON U _ � '} ___ _...__ _.___- � i: LL" DATE OWNER v �' � LICENSED CONTRACTORS DECLARATION i j � ¢ � I HEREBV AFFIRM UNDER PENALTV OF PERJURV THAT I AM IICENSED UNDER PROVISIONS OF CHAPTER � p. 9�ODMMENCINGWITHSELTION7000)OFDIVISION30FTHEBUSINESSANDPROFESSIONSCADE,MO Z �:; X AIV LICENSE IS IN FULL FORCE AND EFFECT. � _.I �1.7 i� LLJ L, O lif/ //K� I 0 LICENSE CU1S5__ � LIC.NO.�� � � � J U DATE �� __ CONTRACTOR __ n- I 4'' W , � WORKERS'COMPENSATION DECLARATION � r _ ¢ t. N 1 HEREBV AFFIRM UN�ER PENALTV OF PERJURV ONE OF THE FOLLOWINC DECLARATIONS: � �� � z � Q 0 I HAVEAND WILI AIAINTAIN A CERTIFICATE OF CANSENT TO SELF�INSURE FOF WOFKERS' 2 �'� COMPENSATION,AS PPOVI�ED BY SECTION 37000F THE IABOR CADE,fOR THE PERFORMANCE U ` � oF THE WOHK FOR WHICH THIS PERMIT IS ISSUEO. � Ft � 4 W __I HAVEAND WILL MAINTAIN WOfliCEFS'COMPENSATION MSURAh'CE,AS PE�l11RED BV SECTION Q 37000F THE LABOR CODE.!OR 7HE PERFORMPNCE OF THE WORK FOR WHICH THIS PERMIT IS - -- F� IS5UED.MY WORKERS'COMPENSATION IN5URANCE CARRIER AND POLICY NUMBER ARE: CONSTRUCT�ON F j caaaiEa --.-- -.-.– PLAN REVIEW _ �. zPOI.ICY NUM�ER_ ___. ELE � k� a Q (fNISSEG7qNNE�NOTBE�tAFtEfEDOFTHEPEfUNTSFORQVEFRR�FiE�00lL�F75(570D)OFiIESS). ' BING,�.>� � - � i. Z I CERTIFYTHAT IN THE PERFORMANCE OF THE WOHK FOR WHICH THIS PERAIIT IS ISSUED,I MECHANICAL s� C'� SHAILNOTEMPLOYANYPERSONINANYMANNER50A5TOBECOMESU&IECTTOTHE )ji`fi yR�' q Rh='':;�w, � Vj WORKEAS'CAMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT lf'I SHOUI.O BECOMF. INSPECTION FEE _ _ -(�' � �. SU&IECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 37000F THE LA90R ���;t5���+1�;��� � ✓ � CA�E.I SMALL FORTHWITH COMPLY WITM TH ao�vJisiorrs. ISSUANCE __..__ � � ��-.7._ ,/���� SMIP .---- -- � - � `p �ATE: / � APPLICANT: ��iS � � ENERGY P/C _. � —_ WARNINO:FAILUFETO ECUREWOflKFAS'COMPENSATIONWVERAGEISUNIAWFUL,ANDSHALL6E LLSU&IECTANF.MPLOYERTOCRIMINAIPENALTIESANDCIVILFINE5UPTOONEHUN�PEDTHOUSAND ENERGYPERMIT , __ � � � DOLLARS(5100.000),IN ADDI7ION 707HE COS70F fAMPENSATION,DAMAGES AS PROVIDEO FOR IN � ¢ SECTION37080FTMELABORCODE,INTEREST,ANDATTORNEYSFEES. RETENTIONFEE: . 6 OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: ¢ � 1 HEREBV AFFIRM UNDER PENALTY OF PERJURV THAT THERE IS ACANSTRUCTION LENDING AGENCV 4 d FOFiTHE PEflFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEO(SEC.3097,CIV.C.). � W �� LENDEF'SNM7E_.__ '___. _"'__"__ {_ LENDER'SAU�HESS ._ --------- /J . � wICEHTIFYTHATIHAVEREPUTHISAPPLICATIONAN�STATETHATTHEA80VEINFORMATIONISCARHECT. TOTAL FEES ��" / � IA�REE TO COMPLY WITH ALL CIN AND COUN7V ORDINANCES AND STATE LAWS RELATING TO BUIL�INC CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTV TO ENTER UPON THE 4 Z pBOVE-MENTIONEDPROPEHTVFORINSPECTIONPUHPOSES. COMMENTS i 4 � J � "___ m PERMITfEE NAME(PRIM) Q N ' � � SIGNATURE OF PERMITTEE DA E /� � � � RECPT.N0. 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