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HomeMy WebLinkAbout17387 (26) CITY OF DIAMOND BAR �/� --�--� -- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � r,r 21825 E.Copley Drive �rs� � (909)860-3I95 Fax(909)861-3117 ,,,.-` PRE$$ '��°%v»�'�' ' BUILI2INGPERMITAPPLICATION FIRM ', o� JOBSITE � APPLICATION �� `� b` PERMIT ��sj�� P/C ADDRESS �^ DATE � � NUMBER r,J p � � ISSUE y TYPE OCC � APN LOT TRACT DATE � � O 1 CONST. GROUP °C OWNER I��Ib � �--� �' ZONING SETBACKS p ADDRES Z CI ZIP TEL. � FRONT RW ❑ o APPLICANT TEL. S DE/SIDE STREET RW ❑ Q� '' � SIDE ❑ CONTRACTO. � ADORESS PROPOS U ' o CI ZI TEL� S�� � o ARCH/ENG/ W 'qESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� - OWNER-BUILDER DECLARATION SFR/ADD/REM � O 'p I HEREBY AFFIRM UNDER PENALi1'OF PERJUPY THAT 1 AM EXEMPT FROM THE COMRACTORS LI- Gef29B/C21POff '�W� CENSELAWFORT'�EFOLL�WINGREASON(SEC_7037.5811SINESSAt�PROFE5510N5CODE:ANYCITVOR (n �V GOUNNWHICHRE�UIRESAPERMI?TOCONSTFUCT,AL7Efl,IMPROVE,OEMOLISH,ORflEPAIRANYSTRUC- W patio/Deck �,,w TURE,PRIDR TO ITS ISSUANCE,ALSO RE�UIRES THE APPUCANT FOR SUCH PERMIT TO FILE A SIGNED W �� ,STATEMENT THAT HE OR SHE IS UCENSEO PUflSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- i� CENSE LAW(CHAPTER 9(COVAMENCMG WItH SECTION�000�OF�IVISION 3 OF THE BUSINESS AND PRO- V' P401/SP8 'FESSIONSCOOE)ORiHATHEOR5HEI5EXEMPTTMEREFROMANDTHEBA515FDRTHEALLEGE7EXEMP- (� � TION.ANVVIOLATIONOFSECTION7o91.5BYANVAPPLICANiFORAPERMITSUBJECTSTH'cAPPUCANTTO Z Re-Roof 'p CIVIL PENALTV OF NOT MOfiE THAN FIVE HUNDRE�DOLLARS�5500).): - Z� . ❑I,ASOWNEftOFTHEPROPERN.ORMYEMPLOYEESWIiHiNA3ESA3THEIRSOLECOMPENSATION, � Commercial -� WILL DO THE WORN,AND 7HE STRUCTURE IS NOT INTEN�ED OR OFFERE�FOR SALE(SEC.7044,BU51- J '�NESSAND PROFESSIDNS CODE:7HE CONTRACiORS LICENSE LAY�DOES NOi APPLY TO AN OWNER OF �'� PflOPERTYWHOBUILDSOFIMPROVESTHEREON,ANOWHODOESSUCHWORKHIMSELFORHeRSELFOR � '�' 'THROUGHHISORHEROWNEMPlOVEES.PROVI�FDTHATSUCH�IMPROVcMENTSARENOTINTEN�EDOfl m Q .OFFEREDFORSALEIF,HOWEVER,iHEBUILDINGOflIMPROVEMENTISSOLDN'ITHINONEYEAROFCOMPLE- i Z; .,TION,THE OWNER-BUILDER WILL HAVE THE BURDcN OF PR(7VING iHAT HE OR SHE�ID NOT BUILD OR ��.i ,W�,,, '.,IMPROVE FOR THE PUflP09E OF SALE).� ❑�,AS OWNER OF iHE PROPERTY,AM EXCWSIVELV CONTFACTING WITH LICENSED CONT,4ACTORS '�. �'' TO CONSTRUCTTHE PROJECT(SEC.�040,BUSINESSAND PPOFESSIONS CO�E:THE CONTRACiORS LI- V81U3f1011 _ADJ.AREA W� CENSELAWDOESNOTAPPLVTOANOWNEROFAPROPERNWHDBUILDSORIMPROVESTHERE�N,AN� � 'WHOCONTRACTSFORSUGHPROJECTSWITHACON?RACTOR�S)LICENSEDPURSUANTTOTHECON7RAC- QUANTITY �ESCRIPTION FEE x TORS LICENSE LAW.). �� ❑IAM EXEMPTUNDERSEC. B.&P.C.FORTHIS riEA50N � � � �' DATE .OWNEfl � W � LICENSED 60NTRACTORS DECLARATION �j �' IHEREBYAFFIRMUNDERPENAITVOFPEAJURY7HATIAM�IGENSEDUNDEFPFOVi510N5OFCHAPTEfl � � ('L , 9(COMMENdNG WITH SECTION 7000)OF DIVISION 3 OFTHE BUSINE55 AND PROFESSIONS CODE,AND Z �X MY LICENSE IS M FULL FORCEANQ EFFECT. m b LICENSE CLASS��LIC.NO. j h � DATE���a"'�_CONTRACTOR d W � � WORKERS'COMPENSATION DECLARATION -� ¢ � IHEREBVAFFIRMUIJ�ERPENALT/OFPERIURYONEOFTHEFOLLOWINGDECLARAilONS: U � Q �, _IHAYEANDWILLMAINTAINACERTIFICATEOFCONSEN'TOSELFINSUREFOflWORKEPS' _ CDMPENSATION,ASPROVIDEDBVSECTION3�oaOFTHELABORCO�E,FORTHEPEFFOFMANCE �U OF THE WORK FOR WHICH;THIS PEFMIT IS ISSUED. � �. w'� �I HAVE ANO WILL MAIMAIN WORNERS'COMPENSATION MSURANCE,AS REOUIRED BY SECTION ' L'� K 3]OOOFTHELABORCD�E;FORTHEPERFORMANCEOFTHEWOftKFORWNICHTHISPERM1T15 � L� �5� A� ISSUED.MYWOqKFAS'CO�IPENSATIONINSURANCECAfiqIERANDPOLICYNUMBERARE: CONSTRUCTION �. a'' C,�-������J� �. cnaaiEA�,. ry � PLANREVIEW 2, POLICYNUMBER I, I 7�C°�D y ELECTRtC ¢ (MISSECTIONNEmNOTBE�MPLEfEDOFTHEPERMffISWRIXJEHUPDRE�U0LLAR5($100)ORLE557. PLUMBING b w� ICERTIFYTHATIN7HEPERRORMANCEOFTHEYlORKFOPWH�CFiTHISPERMITISISSUED,I MECHANICAL Z C� SHALL NOT EMPLOV ANY P€RSON IN ANY MANNER 50 AS TO BECOME SUBJECT TO THE � WOPKERS'COMPENSATIONLAWSOfCALIFORNIA,AN�AGREETHATIFISHOULOBECOME INSPECTIONFEE � SUBJECTTOTHEWORKERS'COMPENSATIONPROVISIONSOFSECTION37D6DFTHELABOR � � s'� CODE,I SNPLL FORThIWITH COMpLY WITHTHOSE PftOVI5KKJ5. ISSUANCE � SMIP �_ p DATE: APPLICANP, � ENERGY P/C � WARNINGFAILURETOSECUflEWORKERS'COMPENSATIONCOVERAGEISUNL4WFUL,ANOSHALLBE 4y. SUBJECTANEMPLOYERTOCRIAfINALPENALTiESAN�CIVILFlNESUPTOONEHUNDREDTtiOVSAND ENERGYPERMIT ' OOLLARS(5100,000),IN ADOffIO�Tb THE'COST Of'COMPENSATION,DAMAGES AS PROVIDEO FOR IN ' �. SECTION37080FTHELABORCOOE,INTEFEST,AN�ATTORNEV'SFEES. FlETENTIONFEE: � Q CONSTqUCTION LENDING AGENCY PRE-ALT FEE: ��, lHEFiEeVAFFIPMUNDERPENALTY.OFPERJURYTHRTTHEREISACDNSTRUCTIONLENDINGAGENCY _ __ . fOfiTHEPERFOflMANCEOFTHE\YORKFORWHICHTHISPERMITISISSUED�SEC.3oB�,CIV.C.�. 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