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HomeMy WebLinkAbout10078 CITY OF DIAMOND BAR � COMMUNITY DEVELOPMENT DEPARTMENT � _,,,,w . 21660 E.Copley Drive Suite 190 PRESS (909)86Q3195 Fax(909)8613117 �'„�'f BUILBING PERMTT APPLiCATION FIRMLY � JOBSITE �� f,, �� y APPLICATION PERMIT P/C ' o ADDRESS �r`� �' DATE NUMBER '�� # � ISSUE TYPE OCC APN—y�y LOT. TRACT DATE CONST._ GROUP p OWNER fi'1�� �'��' — o ADDR SS � j�' �`� ZONING SETBACKS ^ g CITY�` • ZIP • TEI�'�� �'�' ' �* FRONT RW " APPLICANT TEL. REAR _ ❑ SIDE/SIDE STREET RW C � CONTRACTOR �' °L /� �."+c � � F'� - t�"�• SIDE C � ADDR��SS " ` � PROPOSED USE � c�Tv�J�� • ;ZIP� TEL` C•, � ,.' i� w ARCH/ENG! ' z DESIGNER NO.DWEL. NO. NO. a ADDRESS — UNITS STOfiIES BEDROOMS = CITY ZIP TEL. __ � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER•BI:ILDER DECLARATION SFRlADD/RERA O � 1 HEREBV AFFIRM UNDER PENNLTY OF PERJURV THAT 1 AM EXEMPT FROM THE CANTRACTORS LI� � Garaga/Carport W CENSEUWFORTHEFOLLOWINGREASON(SEC.7o31.59USINESSANDPROFE5510N5CODE:ANVCI7VOR U CWNTYWHIpiREOUiRESAPERMI7TOCONSTRUC7,ALTER,IMPROYE,DEMOLISH,IXiREMIRANYSTRUG w patio/Deck Z TURE,PRIOR TO ITS ISSUANCE.ALSO REOUIRES THE APPLILANT FOR SUCH PERMIT TO FILE�SIGNED W STATEMENT THA7 HE OR SHE IS UCENSED PUHSUANT TO THE FRDVISIONS OF THE CONTRACTORS ll- — � CEhSE UW fCHAPTER B(CAMMENCING WI7H SECTION 7000)OF DIVISION 3 0f 7FiE 6U5INE5S AND PRo- U' �aoVSpd OFESSIONSCODE)ORTHATHEORSHEISIXEWPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXEMP- U TION.ANY VIOLATION OF SECTION 7031.5 BVANY APPLICANT FOR A PERMIT SUBJECT5 THE APPLICANi TO Z Re-Roof � A CIVIL PENAlTV OF NOT MORE THAN FNE HUNDRED DOIU �S5W).): ' � ❑I,ASOWNEROFTHEPflOPERTY,OHMYEMPLOVE ITHWAGESASTHEIRSOLECOMPENSATION, � COmm8fC181 Z WILL DO THE WORK,AND THE STRUCTURE IS NOT I DED OR OFFERED FOR S0.LE(SEC�Oa1,BUSI- J NE55 ANO PROFESSIONS CODE:TME CONTRACT LICENSE LAW OOES NOT APPLY TO AN OWNER OF � 7ROPERTYWHOBUILOSORIMPROVEShIER ANDWHODOESSUCHWORKHIMSELFORIiERSELFOR � � THROUGH HISON HER OWN EMPIOYEES NDED THAT SUCH IIAPROVEMENTS ARE NOT INTENDEOOR m WQ oFFEREDFORSALE-IF,HOWEVERTM ILUINGORIMPHOVEMENTISSOtDWITHINONEYEAROFCOMPLE- Z TION,7HE OWNER-BUIL�ER WIL E TNE 9UROEN OF PROVING THAT HE OR SXE DID NOT BUILD OR � IMPqOVE FORTHE PURPOSE &ALE). � :.'I,ASOWNEROFT ROPEHN,AME%CLUSiVEL�CONTRACTINGWITHLICENSEOCANTRACTORS Q TO CONSTRUCT THE 7 JECT(SEC.7ala,BUSINES3 PND PROFESSIONS CODE:THE CONTMCTORS LI� VelU81iIX1 ___ ADJ.AREA W CENSELAWDOES APPIVTOANONRJEROFA7ROPERTYWHCBUILD50RIMPHOVE5Tf1EHEON.AND F WNOCONTRACj ORSUCNFROJECTSWITHACANTRACTOR(5)iICENSEUPUPSUANTTOTHECONTRRG QUANTITY DESCRIPTION FEE TORS LICENSE LKW.). .�//�� � / ¢ ']I AM E%EMPT UNDER SEC.__ 2.8 P G FOR THIS REASON � L"3J�'L� ..rjc �� C-'' � _ — �e�.�'"L:. .: f , 1� - ► � DATE OWNER_ _____— ./''�4," .-- Z �. s � LICENSED CONTRACTORS DECLARATION � � ••�•� • • ¢ � 1 HEREBV AFFIRM UNDER PENALTY OF PERJURV THAT I AA1�ICENSm UNOER PROVISIONS OF CHAPTER d B(COMMENCING WITH SECTiON 7000)OF DIVISION 3 OF THE 9USINESS AND PROFESSIONS COOE,MID 'X MY LICENSE IS IN FULL FORCE AND EFFECT. � LICENSF,F S ��"* LIC.NO, �.�" ��� _ � /P "'''`� V DATE CONTRA�+�"- W � WORKERS'COMPENSATION DECLARATION �� a �� ,� �, n.����y�4�`� ��! :. �t- _ �•`� „� � � 1 HENEBY AFFIRM UNOEH PENAL7Y OF PERJURY ONE OF THE FOLIOWING DECLARA7ION , U � q � � y�� Z f+: � � �fHAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF�INSURE FOR WOqKERS � Y �� • - � � COMPENSATION,AS PROVIDED BV SECTION 3'1000F THE UBOR CODE.FOR THE PERFORMANCE W ° G �, OF THE WORK FOR WHICH THIS PERAIIT IS ISSUED. � w 1 HAVE AND WILL MAINTAIN WORKERS CAMPENSATION INSURANC�AS RE�UIqED BV SECTION Q 3700 OF TME LABO E,FOR THE PERFORM E OF THE WORK F�R WHICH THIS PERNMT IS � ISSUED.MY WORKI�P NSA I�yN INSUH�E CARRIEP AND POLICY NUMBEfl APE: CONSTRUCTION � CARRIER_ Y PLAN REVIEW ZPOLICY NUMBEH� �� � " ELECTRIC Q � �a Q (TT1155EG710NNEmNOTBECOAAPLEfEDOFTI-EPERMfi15FOF10NEFYRDfiED �ttaoOFiLE551 4 PLUMBING ��' W � Z I CERTIFV TMAT IN THE PERFORMANCE OF THE WOflK FOR WHICH 7HIS P[RMIT IS ISSUED,I MECHANICAL ` � � (�} SHALLNOTEMPLOYANVPERSONINANVMANNERSOASTOBECOMESUBJECTTOTHE � W00.NERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGREETHATIFISHOl1LDBECOME INSPECTIONFEE pg j SU&IECT TO THE WORKERS'CO +�OVISIONS OF ECTION 37 THE LABOR , �SSUANCE }y l�S C� 1�l.793� I� GO IS LLFORTMWITMCO PLYWiT D PROVI910N ��5�� `� Q �re i�' `p DATE:1��— APPLICANT: ' �'�R. l.� ^" � •/ '— SMIP J � ENERGY P/C _y WARNING:FFILURE TO SECURE WORKEFiS'COMPENSATION COVERAGE IS UNUIWFUL,AND SHALL BE � SU&IECTANEMPLOVEPTOCRIMINALPENPLTIESANDCIVILFINESUPTOONENUNDRE�THOUSAN� { ENERGYPERMI7 DOLLARS�f�OD,000),IN AODITION i�THE COSTOF COMPENSATION,DAMAGES RS PROVIDED FOR IN J SECTION37080FTHELABORCADE,�NTEREST,ANOATTORNEYSFEES. RETENTIONFEE: Q a CONS7flUCTION LENDING AGENCY PRE-ALT FEE: O CC I HEREBV AFFIRM UNDER PENALTV OF PERIURY TFIAT THEftE IS A GONSTRUCTION LENDING AGENCY � FOR THE PERGORMANCE OF 7HE WORK FOR WHICH 7FN5 PERMIT IS ISSUED(SEC.3oe7,CIV.C.). � -- � Z W � IENDER'SNFME___ _ -- Z F— LENDER'SADDRESS — — , Q ICERTIFVTHA7IHAVEREADTHISAPPLICATIONANDSTATETHATTHEABOVEWFOFIAATIONISCORRECT. TOTAL FELS W IAGREETOCOAAPLYWITHILLLCITVAN�COUNTVORDINANCESANDSTATEIAWSREI.ATINGTOBUILDING � CONSTPUCTION,PND HEREBV AUTHORIZE REPRESENTATIVES OF THIS CDUNTYTO ENTER UPON THE ZABOVE-MENTIONEDPNOPERTV FOR INSPECTION PUR, SES. 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