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HomeMy WebLinkAbout14821 (17) ������� � . �_ _�� CITY OF DIAMOND BAR G O���`�� DEPARTMENT OF COMMUNITY 8i DEVELOPMENT SERVICES w 21660 E.Copley Drive Suite 190 (909)860-3195 Fae(909)861-3117 ���� PRESS ���'�'�� BUILDING PERMIT APPLICATION FIRMLY _ __ - N JOBSITE .�� �� APPUCATION - (�PERMIT � ' P/C o ADDRESS � ��� �'�'���� DATE '�� NUMBER # � ISSUE TYPE OCC -- APN LOT TRACT DATE CONST. GROUP p OWNER ���1h1 ��5�`'aB � ADDR SS`�' `�-- ZONING SETBACKS Z CITY �:'�AJ-t�7 . ZIP �7 I TEL3��S'"..(.�, FRONT RHI ❑ g APPLICANT TEL. REAR ❑ � SIDE/SIQE STREET RW ❑ � CONTRACTOR �+�.r 'S7!\+_4...�i1! SIDE ❑ � ADDRESS L'�v.�i.� � CITY �,���•Ct.�a ZIP �M�-- TEL S '—�i-�� PROPOSED USE a ARCH/ENG/ � DESIGNER NO.DWEL. NO. NO. a ADDRESS � CITY ZIP TEL. UNITS STOfliES BEOROOMS � sn DESCHIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILOER DECLARAT�ON SFR/ADDlREM O 1 HEPEBV AFFlRAI UNDER PENAL7Y OF PERJURY THAT I AM EXEMPT FROA/THE CONTFACTORS LI- G8f8[J8/C31pOfI W CENSEUWFOHTHEFIX.LOW9JGREASON�SEC.7031.SBUSINESSANDPROFESSIONSCOOE:ANVCITIOR (n COUNT'/VMICHREGUIRE9APERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOL'SH,ORREPNRANV3TRUP W PatiO/�BCk W TURE,PRIOR TO RS ISSUANCE,A150 REQUIflES THE APPLICANT FOR SUCM PERMI7 TO FILE A SIGNED W STATEMEPIr THA7 HE OR SNE IS LICENS�PURSUANT TO THE PROVISIONS OF iHE CONTRRCTORS LI- � CENSE LAW(CHAPTER Y(COMMENCINO WRH SECTION 7o00)OF DIVISION 30F THE BUSINE55 AND PRO- � PooUSpa FESSpNS CODE)OR THAT HE OR SHE IS E1(EMPT THEREFROM AND THE BASIS FOR THE ALLEQED EXEMP- TION.ANYVIOLATK7NOFSECTION709t.6BYANVAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO Z RB-ROOf � A CML PENALTYOF NOT MORE THAN FNE HUNDflED DOLLARS(5500).): � ❑I.ASOWNEROFTHEPROPER'T'/,ORMYEMPLOYEESWITHWAGESASTHEIFSOLECOM7ENSATION, � COR1fI18fC18I � WILL DO THE WORIC,AND THE STRUCTUPE IS NO7 INTENpEO OR OFFERED FOR SALE�SEC.7044,BU51- J � NESS AND PpOFES&ION&CODE:THE CONTMCTOR6 LICENSE LAW DOES NOT APPLY TO AN oWNEH OF � PflOPEHiY VhiO8U1lAS OR IMPROVES THEREON,AND WHO DDES SUCH WORK HIMSELF OR HERSELF OR Q THROUQHHISORHEROWNEMPIOYEES,PROVIDE�hiRTSUCHIMPROYEMENTSARENO71N7ENDEDOR m 0 OfFEREDFORSALEIF,HOWEVER,7HEBUIIDINGORIMPROVEMENTI550LDWITHINONEYE4ROFCOMPLE� � TION,THE OWNEH-6UILOER WILL HAVE THE BURDEN OF PROVIN�THAT HE oR SHE OID NOT BUIID OR � MAPROVE PoRTHE PURPOSE OF SALE�. W ❑I,ASOWNEHOFiHEPROPEFRY.AMEXCLUSNELYCANTRACTINGWITHUCENSEDCONTRACTORS � TO CON5TRUCT THE PRQIECT(SEC.)OM.BUSINESS AND PROFESSIONS CO�E:THE CONTRqCTORS Ll- V21UetlOn ADJ.AREA � CENSELAWDOESNOTAPPLYTOANONMEHOFAPROPERTVWHOBl1!LDSORIMPROVESTHERC-0µAND W1IDCONTMCTSFOPSUCHPRQJECTSWITHpCOMRACTOF(S)LICENSEDPURSUANTTOTNECONTRAP pUANTITY DESCRIPTION FEE � TORS LICENSE LAW.). ❑I AM E%EMPT UN�ER S�C. B.&P.C.FOR THIS REASON Q U � � DATE ONRJER v � LICENSED CONTRACTORS�ECLARATION W � IHEREBYAFFIRMUNDERPENALTVOFPE0.IUHYTHATIAMLICENSEOUN�EPPPOVISIONSOFCHAPTER � p. 9(COMMENCINO WITN SECTION 7000)OF DIVtSION 3 OFTHE BUSINESS AND PROFESSIONS CODE,AND Z _ X MV LICENSE IS IN FUTA FORCE AND EFFECT. � F2�.� 0 �.� `��iS"Z..`c�.➢� � b.., �.i.�C..i.-. UCENSE CLAS/S' � LIC.NO. � V DATE �t'���'�� CONTRACTOR d W � WORKERS'GOMPEN5ATION DECL4RATION Q � U � 1 HEflEBY AFFIRM UNOER PENMTY OF PERAIRV ONE OFTHE FOLLOWINO DECLAflATIONS: Z a � _IHAVEANDWILLMMNTAiNACERTIFlCATEOFCON5EN7TOSELF-INSUREFOPWORKERS' _ CdJPENSATION.AS PROVIDED BY SECTION 97a0 OF YHE UBOR CODE,f-0R THE PERFORMANCE U � OF THE WORK FOR WHICH THIS PF.RMIT IS ISSUED. � � W _I HAVE AND Wlll MAIMAW WORKERS'GOMPENSATION INSURANCE,AS REWIRED BV SECTION Q 37000FTHELABOflCO�E,FORTHEPERFORMANCEOFTHEWOflKFOftWHICHTMSPERMR15 ISSUm.MY WORKEFS'COMPENSA710N INSURANCE CARRIER AND POLICY NUMBER ARE: CONSTRUCTION � CARRIER �'�'� = 1 L��� ����,�-���'j PLAN REVIEW � POUCY NUMBER �k� ��`1�G�C)" E�ECTRIC __�� 0 (IHISSE(."IpNNE�NDTBE�MR.EfEDOFhEPEPoMl4FOR�NEMX�DRED00LlPR5(5100)OFiLESS). PLUMBING �" �� � �� Z I CERTIFV THAT IN THE PERfORMANCE OF THE WORK FOR WHICH THIS PEPMIT 45 ISSUE�,I MECHANICAL (.�J SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECTTO THE � WORKERS'COMPENSATIONLAWSOFCALIFOFNIA,AN�AGREETMATIFISHDULDBECAME INSPECTIONFEE -��}�{ Su&IECTTO7HE WOPKEHS'CQMPEN T10AFRRQYISLp 5 OF SEC710N a7oo OF 7HE LA9oR / j � �j �CADE.,tI�SHALLFORTHWITHCOMPIY ITH�OSEPfiOVi51 � ISSUANCE � L.—Y.l�L � `� ���`�� APPLICANT: --_..__,..�""�`� SMIP ��O p OATE: J WRHNIN�:FAILURE TO SECIIRE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE ENERGY P/C ����„ _ SUBJECTAN EMPLOYER 70 CRIMINAL PENALTIES AND CIVIL FINES 11P TD ONE HUNDREO THOUSAND �d LL DOLLARS�S7a0.Da0),INAD�ITIONTOTHECOSTOFCOMPENSATION,DAMAGESASPROVIDEDFORIN ENERGYPERM�T '�T� � SECTION 3�oe Of TrIE LABOR CODE,INTEAEST,AND ATTORNEY'S FEES. {3ETENTION FEE: g S d CONSTRUCTION LENDING AGENCY PRE•ALT FEE: O � IHEREBVAFFIRMUNDERPENALTYOFPERJl1RYTHATTNEREISACONSTRUCTIDNLENDINGAGENCY FOR THE PEFFORMANCE OF THE WOPN GOR WHICH THIS PEFMIT IS ISSl1ED(SEG 3097,CIV.CJ. Z W � LENDEH'S NAME F— LENDER'SADDRE55 W ICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETHATTMEABOVEINFORMATIONISCORRECT. TOTAL FEES ��r�1�' � I AGREE TO COMPLV WRH ALL CITV AND COUNTY ORDINANCESAND STATE LAWS RELATING TO BUILO�NG CONSTRUCTION,AND HEREBV AUTIiORIZE REPRESENTATIVES OF THIS CW NTY TO EMER 11PON THE � ABOVE-MENT'ANEO PROVERTV FOR INSPECTION PURPOSES. COMMENTS � ��..���_��...�`-� � ¢ PERMITTEENAM�NT� ' � �.._��..�__.-��- �~13�� � SIQtUTUREOFPERMITfEE D/TE � REGPT.NO. PAI�BY VALIDATION WHITE—DepaRment Copy,YELLOW—Financa Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy ... ,..c.., ca,.,���..� .;�.n.,. �w...:........ ..,�,..,.. . . ..t...,�.::.. �... :.y:... .:. . . . .... , �., .. .,i^ .. . „ ,.�, � �i t , .��•� , , vx,.K. . �f _,.. . �., . , ����� � �� ���� . ,.._ ... ,��. � .� .�_ . i. . 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