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HomeMy WebLinkAbout12780 (13) !� CITY OF DIAMOND BAR DEPARTMEN'�OF COMMUIVITY&DEVELOPMENT SERVICES °' 21660 E.Copley Drive Suite 190 ° - � PRESS ;pM„ (909)860-3195 Fax(909)861-3117 BUILDING PER1ViIT APPLICATYON ' '` . , �..---.. , ::. . :. . ,.. . _. ... :,,... .. ; ,:<�. ;. ,,.: o DDRiESS� � �--1!.C.. W�I.���. ..^,...,. . _... •• DATE CATION�..,j f " C�' �4 NUMB R � .#/C a�^�Z� c� ISSUE TYPE OCC APN LOT�_ TRACT_ 1 �'T'TfT DATE CONST. GROUP p OWNER j�ls4 fU 4 fi!'j'�-��-� �S(�1� � o ADDRESS__`�C''�j_�'• ���R 1� �Q,,_-t� t G,7� ZdNING SETBACKS w � ->'�� FRONT RW J- CITY ZiP�'P�,I CC1'! TEL.R .� � APPLICANT G` ICL:K�1. TEL.��� ' REAR �' 51DE1SICE STREET FIW_ L'I � CONTFiACTOR�t�� 3 y C' � '- SIDE __ C'I � _���Ss'�, p� ADDRESS �Sir�tit ����7 —� (•:'a.� - � CITY ��C���1-�' ZIP��� TEL.��,��_��� PROPOSED USE t�ia ARCH/ENG! � . z DESIGNER � ` %h/ 't' �}�C.���_��'� NO.DWEL. NO. . NO. � ADDRESS . ��` r7L�1�-l� i��2 •�- l�� UNITS STORIES BEDROQMS � CI il' /�O:Ci�(�� ZIP O Cv TEL.�y,�:_Q��� � D CRIPTION SQ.FT. FACTOR PSF ADJ.AREANAIUATION OOWNER-SUILDER DF_CLAP.ATION SF DDlREM L��`.�Cy �j � 3Q��(,9(3 � I HERE6V AFFIflM UNDEfl PENALIV OF PERJURV THAT 1 AM EXEMPT FROM THE CONTRACTORS LI- G3faJB 2f{10f1 �� '�� �[S(,9 ��j W CENSEUWFORTHEFOLLOWINGREASON(SEC.7a31.58USINESSANDPROFES510NSCOdE-ANYCITYOR (n � COUNTYWHICMREOUIRESAPERMITTOCONSTRUCT,/LLTER.IAIPROVE,DEMOLISM,ORREPAIRANYSTRUG �J,J QdtIC/DOCI( W TUPE.PRIOR TO ITS ISSUANCE.ILLSO REQUIRES THE APPLICANT FOR SUCM PERPl.IT TO FILE A SIGNED w STATEMENT'fHAT HE Ofl SHE IS LICENSED PURSUANT TO THE PflOVISIONS OF THE CONTRACTORS ll� � CENSELAW�CHAPTER9(COMMENCINGWITHSECTION7oao�OFDIYISION30FTHE8:151NESSAN�PPD� V' PooUSpa � ' J FESSIONSCODE�ORTHATHEORSHEISEX:MPTTHEREFROMAN�INEBASISFORhiEALLEGEDE%EMP- (� V TION.ANYVIOLATIONOFSECTION7031.58YANYAPPLICAMFOR.4PERMITSU&I[CTSTHEAPpIICAMTO � pe-Roof � ACIVIL FENALTY OF NOT MORE 7NRN FIVE HUNDFED�OLLARS(S`�W).): ' ' ' � ❑I.ASOWNEROFTHEPROPEFTY.ORMVEMPLOYEESWITHWAGF.SASTHEIq50!.ECAMPENSATION, � COmfn01'Ci81 MVILL DO THE WORK,AND THE STRUCTURE IS NOT INTENOE�OR OFFERED FOR SALE�SEC 7044,61J51� J � NES£AND PROFESSIONS COOE:THE CCNTFACTORS LICENSE LAW DOES NOT APPLY 70 AN OWNER OF = _ PSiOPERTV WIiO BUILDS OR IMPROVFS THEREON.ANO WHO DOES Sl1CH NK)RN HI AISFLF OR HERSELF OR � TH110UGH HIS OR HER OWN EMPLOVEES,PROVIOED THAT SUCH IIAPROVEMENTS ARE�OT INTFNOED OR � QOFFEREOFORSALEIF,HOWEVER7HEBNlDINGORINPROVEMENTISSOLDWIIHINONEYEAROFCAMPLE� _ � TION,TME OWNEfiAUIIDEfl NALL HAYE THE BURDEN OF PROVINO THAT HF.OH SHE DID NOT�UILD OR � IMPROVEFORTHEPURPOSEOFSALE�. : : GI,ASOWNEROFTHEPflOPERTY,AMEXCLUSNELYCON7flRCTINGWITHLICENSEDCONTRACTOqS ���� „ � TO CONSTRUCT THE PR0.IECT(SEC.7044.BUSINE55 AND PROFESSI(NVS CADE:hIE CONTRACTORS LI� Valuallon D���f� ADJ.AREA LlA CENSEUWDOESNOTAPPIVTOANONMEROFAPROPERTYWHOBUILDSORIMPROVE5�T11FRFON.AN� � WF/OCOMRACTSFORSUCHPpQIECTSWRHACANTPl1C?OF(5)LICENSEDPIJRSUP.4TTOTHECONTqAC- QUANTITY DESCRIPTION FEE � TORSLICENSELAWJ. ______ ❑I AM E%EMPT UNOER 3EC.________,_,.__0.8 F.C.FOR'HIS REASON Q � _ U s+- � � -- DRTE _ OWNER__________'____— U Z p W a � LICENSED CONTRACTORS DECf�RATION W — 5Y � 1 MEREBV AFFIRM UN�ER PENALTY OF PERJUFY TMAT I AM LiCENSF�UNDEN PFOVISIONS OF CHAPTER Lry �I— d 9(CAMMENpNGWITXSECT�ON70D0)OF�IYISION30FTFIEDUS�NESSANDPROFCSSIONSCO�E,AN:] Z_ � AIV IICENSE IS IN FULL FORCEAND EFFECL �I I � LfCENSE CLA�S�S� � LIC.NO.� �� J I V DATE_J,.�—_i o�4�_ GONTPACTOR___ _ _""... � Q.i I � WOfdKERS'COMPENSATION DECLAHATION � . -��: ���'�F�TA�1rTC�N13 T3A� � ;�.:?�,.=�, c��' II—��i.�.l>dC� ;^:RT'`� — � IHEREBYAFFIRM�NOERPEhAL1YOFPERJUHYONEOFTH'cFOILOWINGDECLARATIONS: �� '� 0 _�IHAVEANOWILLM.AINTAINACEIRIFICATEOFCONSENTTOSEIF-INSUfiEFOflYlORK[RS' =i �I � COMPENSATION,AS PHOVIDED BV SECTION 3700 OF7HE LABOR CODE.f04 TH[PEPFORMhYCE �,___—_—J OF TNE WORK FOR WHICH THIS PF.RMIT IS ISSUE�. I 0 �� __ W _IHAVEANOWILIMA:NTAINWORKERS'COMPENSAT!oNINSURAYCF,nSRFGUIRE�I3Y5ECTION ' '� — � 37000F THE LA90R CODE,FOR 7HE PERFORMANCF OF'HE WORK FOR WHICH 7HIS P�P.MI?�S ' 0 ISSUEO.MVWORKERS'COMPENSATIONINSURANCECAPRIERANDP�LICYHUMBERARE. � CONSTRUCTION ` _ �C?{��C� ¢ � �'���q t� > c,wAiea -------.._.._..-—,------- ; PLAN REVIEW /y, � POLICYNUM9ER � ELECTRIC �r�l_V</ � __—' ___""_"' r,J- (fH�S5ECf10NNEmNOTBECORQLEfE�OFTfPEPoWTISFORONEHUI�REDIXAIARS(St00;ORLESSI. I PLUMBING �`_��f�o _ _ !�J � �r- �y � l CEH7IFY iHAT IN THE PERFORMANCE OF THE Y�ORK FOR WHICH TH15 PERMIT IS I55UF.D,l i MECHANICAL _I 7 dc��v (3 SHALLNOT EMPLOYANY PERSOM IN ANY MANNER 50/1„TO BECAME SUBJECT TO'HE ; t � WORKERS'COMPENSATIONIAWSOFCALIFOFlNIA.ANDAGREETHATIFISHOULDBECOME �I � INSPECTfONFEE ______.___ __. = SUBJECTTOTHEWORKEftS'COMPENSATqNPROVISIOM50FSEC?IONJ7000FTH'cLpBOR -- — --- � /9� fADE,i SHALLFOHiHWITM CAMPLV WIhITHOSE P OVISpNS � I �SSUAPICE 7 a✓ � 1,_ ry������Q � SMIP ��/ � p DATE:L��APPLICAN7: __-��,�C7rn�y�i._._.___.'— _ � � � WARNING:FAIIURE TO SECURE WORKERS'COMPENSAT:ON COVERAGE 1511NLAK�UL,AND SHA.LL BE � ENEFGY P/C ��( � L______,_ /� ` /-�, �y SUBJECTANEMPLOYERTOCRIMINALPENALTIESANOCJVI�FINESUPTOONFHUNOREOTHOl1SAN0 � ! ENERGYPERMIT /�01 Sv DOLLARS�51eo.o0o),INADDITIONTOTHECOSiOFCOMPENSATION,OAMAGESASnqOV!DEDFORIN —�----�--�---- �— C� q[�, � SECTION 37a00f THE LAEOR CODE,INTEREST,ANDATTORNEV'S FF.ES. ___ � RETEN I IOPI FEE: , �+f�`,t./ a CONSTRUCTIONLENDWGiGENCY j PRE-a'_TFEE� � � —"'� O i /� .._ J'� � IHEREBVAFFIRMUNDEPPENALTVOFPERJURVTHATT:aEREISACONSTRUCT10NLeN01NGAGENCV _"�Z��.�".!. 7 ___ FORTHE PERFORMANCE OF TNE WORK FOF WHICH TNIS PERMI`.IS ISSUED�SEC.309],CIV C.�. �, /� y�y p(� � _�'_'_"_""'Y_�.L'�,` 10 � LENDER'SNMIE __.____ � � � �y� __ "__"""'__"'_'__ '__�'�•Y -----�-J...�c—i�� v F— LENDER'SAD�7RESS __ _,_,__ .__ — � ICERTIFVTMATIHAVE�R�A�TiISAPPLICATIONANDSTATETHA7THEABOVEINFORMATIONISCORRECT. TOTAL FE�S /��� � f 6� � IAGREE TO COMiLV WITHAI.LCITY AND COUNTY ORD�NANCES AYD STATE IAWS flF.UTINC TO BUILDING / ) J � � CANSTRUCTION,AND HEREBY AUTFIORIZE HEPRESENTATIVES OFTIIIS COIRJTYTO ENTER UPON THE / � � A80VE-MENTWDIm VROPERTY FOR INSPECTION PURPOSES. 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