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HomeMy WebLinkAbout16995 (25) CITY OF DIAMOND BAR ''F r ----��`'`---� DEPAR'TMENT OF COMMUNITY&DEVELOPMENT SERVICES � � 21825 E.Copley Drive � �+ �"�" (909)860-3195 Fax(409)861-3117 PRESS °%.vrir'' $UILDINGPERMITAPPLICATION FIRMLY � JOBSITE APPLICATfON l PERMIT �C��{ P/C I o ADDRESS SQ� /�.. 1-� L�iSS G�• DATE 7JIZ-IvI NUMBER � l N �i ! � APN g d L � �--'�� TRAC � _�'_�� DATEE ��CT��r CONST. ��'r`�' GROUP� V °� OWNER _�.-_�1� —/"?p , _�S o — ADDRESS � °g /Vr �-� � L � ZONING SETBACKS oCITY I � �,� ZIP TEL.� � �I FRONT RW ❑ o APPLICANT T �S/LTR�� TEL. O � ' SIDE/SIQE STREET RW ❑ z ¢ CONTRACTOR GU, SIDE O o ADDRESS PROPOSED USE r�l1T�I�II L��T �/ '2� ��.I2 �/� CITY ZIP TEL. w ARCHlENGJ ^ , / �/ s z DESIGNER � *+ N S ��" A NO.DWEL. NO. NO. a ADDRESS G 16► b. UNITS � STORIES +2 BEDROOMS � CITY I�J/l�UT ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OOWNHR-BUILOER DECLARATION SFR/ADDIREM p I HERE9Y AFFIRM LINOER PENAL7Y OF PERJUqY TNAT I AM EXEMPT FROM THE CONTRACTORS LI- G8f2J6/Cd/POR W CENSEIAWFORTHEFOLLOWIN6REASON(SEC.7�31.SB115MES5ANDPROFESSIONSCCDE:ANYCITYOF (n ZCOUNNWHICHRE�UIRESAPERMITTOCONSTRUCT,ALiER.IM7ROVE.�EMOLISH,ORREPAIRANV5TRl1G W palio/DeCk w TURE.PRIOR 70 ITS ISSUANCE,ALSO REQl11RE5 7HE APPUCANT fOR SUCH?ERMIT TO FILE A SIGNED W .� STATEMENT THAT HE OR SHE IS LICENSED P�RSUAVT TO THE PROVISIONS OF THE CONTRACTORS U- � CENSE LAW(CHAPTER 9(COMMENCING WITH SEC710N 7000)OF ONIS'ON 3 OF TME BUSINESSAND PRO� � F'QOVSpe FESSIONSCADE�ORTHATHEORSHEISEXEMPTTHEREFROMANDTHE�ASISFORTHEALLEGEDEXEMP� (� 0 TION.ANYNOLATIONOFSECTION7031,5BYANVAPPLICANTFORAVERA7ITSUBJECTSTHEA.PPLICANTTO Z Re•Roof � A CIVIL PENALTV OF NOT MOflE THAN FIVE HUNDPED D011AR5(E5C01.7: � pI,ASOWNEROFTHEPROPERTY,ORMVEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, � CORIfi1BfC18I Z WILL DO THE WORN.AND THE STRUCTURE IS N071NTEN�E�OR OFFEREO FOR SALE(SEC.7D44,BUSI� J NE55 AND PROFESSIONS CO�E:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF A � PROPERTYWFIOBUILDSOFIMPROVESTHEREON,ANDWHODOESSUCHWOtiKHIAASELFORHERSELFOR m �Lr�> CC THROUGHI1150RNEROWNEMPLOYEES,PROVIDEDTHATSUCMIMPPOYEMEN75ARENOTIMEN0E00R W OFFEREDFORSALE.IF,HOWEVEfl,TH'cBUILDINGORIMPfiDVEMENTI550LDWITHINONEVEAROFCOMPLE ZTION,THE OWNER-BUIL�ER WILL HAYE THE BURDEN OF PROVING THA7 HE OR SHE 01�NOT BUILD Ofl = IMPROVE FOR THE PURPOSE OF SALE). ❑I,AS OWNER OF THE PROPEPTV.AM E%C'.USIVELV CONTRACTING W,TH LICENSEO CANTFACTOfiS � TO CONSTPUCT THE PROJECT(SEC.704<,BUSINE55 AND PPOFESSIONS CODE:7HE CON'RACTORS LI- V8IUd110 ��Q ADJ.AfiEA W CENSELAWOOESNOTAPPLVTOANOYJNEROFAPROP'eRT'WHOBU�DS091MPROVESTHEREON,AND � WHOCONTFACTSFORSt1CHPROJECTSWITHACONTRACTOR(5)LICENSEDPUFSUANTTOTNECON'�'RAG QUANTITY DESCRIPTION FEE TORS UCENSE LAW.). J �` � C�I AM E%EMPT UNDER SEC. B.8 P.C.FOR THIS REASON U • � ��'�+ � � � DATE OVlNEfl � . Z W � LICENSED CONTRACTORS DECLARAT70N W 4 � I HEREBYAFFIRM UNDER PENALTY OF PEFJURY THAT I AM 410ENSEO UN�ER PROVISIONS OF CHAPTER � � 9(COMMENCING WITH SECTION 7000)OF D'.VISION 30FTHE BUSINESSANO PROFESSIONS CODE.AN� Z X MY LICENSE IS IN FULL FOPCEAND EFFECT. r� � � LICENSE CLA S LIC.NO. !�a�!/����.�� � J; U DATE��� D „� CONTRACTOFl�(,�/aZ�L� d W � � WORKERS'COMPENSATION DECLARATION -� = a � IHEREBVAFFIRMUN�ERPENALNOFPERJURVONEOFTHEFOLIOWINGDECL4RATIONS: U C!J a 0 _IHAVEAN�WILLMAINTAIYACERTIFICATEOFCONSENTTOSELFINSUFEFORWORKER3' 2 Z COMPENSATION,ASPfiOYI�EDBYSECTION370oOFTHEIABORCOOE,FORTHEPERFOPMANCE U Q qFTHE WOPK FOR WHICHTHIS PERMIT IS ISSUED. � � �MPVE ANO WILL MAINTAIN WORKERS'GOMPENSATION INSURANCE,AS REQUIRED BV SECTION � Q37000FTHELABORGO�E,FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS ISSl1ED.MY WOnRK`ERS'CO�MP^E,N�SAT70N INSURANCE CARRIER AND POL'�CV NU.�MjBE�R�ARE CONSTRUCTION j cnaaiea F!�[+ ��1��1�1Q�/I�.P.ryIs�V�d���� �'y-G• PLAN REqV�IE`W . _. . . ... . . e , Z voucvNUMeEa-i��-�-7p-�a`�a---- ELECTRIC � �"'� �'^'.,\ ± I � I-- ..?J �^�t� ,J r�-.' Q 0 (iHISSECTpNNEmNOTBEODMPLEfEDOFTHE?ERMRISFORONEHUNDREOOOLLARSI'�7W)ORLESSI. PLUMBI G w �ur� 700� � z ICERTIFYTHATINTHEPERFORMANCEOFTHEWOiiKFORWHICHTHISGERlAITISISSUED,I MECHANCAL 1 � ('} SF1A�L NOT EMPLOV ANY PERSON IN ANY MANNER SO AS TO 6ECOME SUBJECTTOTHE � WOFKERS'COMPENSATIONLAWSOFCAL�FORNIA,ANDAGREETHATIFISHOULDBECOAAE INSPECTONFEE � SL1&1EC_�RKERS'COMPENS ROVISIONSOFS/Ep7 ION37000FTHELABOR ISSUANCE ..L-.. �, V � CODE, HA FORTHWITH COMPLY W H T 5 �ION��' ' �'�,v---- � • SMIP �;.._! a. .__ .__...__.__..-'-. p DATE: � APPLICAN7: - ��"'" w ENERGY P/C � --� WAPNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFtIL,AND SHALL 8E J SUBJECTANEMPLOVERTOCRIMINALPENALiIESANOCIVILFWESUPTOONEHUNDReOTHOU5AN0 W ENEflGY PERMIT � DOLLARS(El 00,00oj.IN ADD(TION TO THE COST OF COM PENSATION,DAMAGES AS PROVIDED fOR IN t�' �y � SECTION37oe OF'HE LABOR CODE,IN7ERE5T,ANDATTORNEV'S FEES. RETENTION FEE: J V d CONSTFIUCTION LENDING AGENCY PRE-AL7 FEE: O Q IHEREBVAFFIRMUNDERPENALTYOFPERJURVTHATTHEREISACONSTRUCTIONIEN�INGAGENCY n- FOR THE PEHFORMANCE OFTHE WORK FOR WHICH THIS PERM171S ISSUED(SEC.3o97,CIV.C.j. Z W � LENDER'SNAME____ H LEN�EF1'SADDRESS A /�'/ • � ICERTIFVTHATIHAVEREADTHISAPPLICATIONANOSTATE7HATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES��(���/7 �1 � IAGREETOCOMPLYWIhIAIICITVANOCOUNTYORDLVANCLSANDSTATELAWSRELATINGT08'JILDING � CONSTRUCTION.ANDHEREBI'AUTHOR�ZEREPRESEN:ATIVESOFTHISCOl1NTYTOENTEftUPONTHE � ABOVEMENTIONEDPROPERTYFORMSPECTIONPURPOSES. COMMENTS � ��� _"____ J � --r�-�/ -. p m ENA (PHINT �p J . � ���'��� p��;�� - = RECPT.NO. 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