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HomeMy WebLinkAbout16181 (22) ���c�� _j��_ CITY OF DIAMOND BAR ��F/3 d�0� � DEPARTMENT OF COMMUNITY&DEVBLOPMENT SERVICES 21660 E.Copley Drive 3uite 190 (909)$60-3195 Fax(909)861-3117 PRESS �^�9N"�`w BUILDING PERMIT APPLIGATION �(`; l � � FIRMLY o DDRIESS � � ��� G��� " DATECATION" �-' V � NUMBER �� #/C � ISSUE TYPE OCC APN-�-�LOT TRAC DATE CONST. GROUP � OWNER �d� � a �` ADDRESS ZONING SETBACKS Z CITY E ZIP���.��'�TEL. REART RW p g APPLICANT EL. SIDEJSIDE STREET RW � � CONTRACT SIDE ❑ ¢ AODRESS PROPOSED USE � CITY ZIP�.�,�fEL. oARCWENG! 4 Z� DESIGNER NO.DWEL. NO. NO. n. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OOWNEH-BUILDER�ECLARATION SFR/ADD/REM � I HEREBY AFFIRM UN�ER PENALTY OF PERJURY THAT I I1M EXEMPT FROM THE CONTRAGTORS LI� GdfB$JB/CBfPOlI IJJ CENSEUWFORiHEFOLIOWINaflEA50N(SEC.7031.50USINESSANDPROFESSIONSCODE:ANYCIT'OR (n � CIXINTYWHICHREOUIRESAPERMITTOCpJSTRUCT,QTER.IMPROVE,DEMOfJSH,OBREPAIRANYSTfiUG W patio/DBCk NRE PRqR TO ITS ISSUANCE.ALSO REQUIRES THE APPLICANT FOR Sl1CH PERMIT TO FILE A SIGNED w � STATEMENT THAT HE OR SHE IS LICENSED PUfiSUANT TO THE PROVISIONS OF THE CONTRACTORS L4 � CENSE LAW(CFIAPTER 9(COMMENCINO WITN SECTION 70�0)OF DIVISION 30F THE BUSINESS ANO PR0- � PooUSpa FESSpNS OOOE)OR THAT HE OR SHE IS EXEMIPT THEREFROM AND TNE BASIS FOR THE ALLEGED EXEM P- v TKKJ.ANVVIOLATIONOFSECTION7031.68YANVAPPLICANTFORAPERMITSU&IECTSTNEAPPLICANTTO Z Re-Roof � ACMIPENALTY OF NOT MORE THAN FIVE HUNDRED DOLLAHS�t500).�: � ❑I,ASONTIEROFTh1EPFiOPERTY,ORMVEMPLOYEESWITHWAGESASTHEIRSOLECAMPENSA710N, G COflllf18fC181 ' WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENOED OR OFFEHED fOR SALE(SEC.7os�,BUSI� J NE55 PND PROFESSIONS COUE:TME CANTRACTORS LICE�YSE UW OOES NOT APPLV TO AN OWNER OF � PROPERTYWFIDBUILD50HIMPqOYE51}1EREON,ANOWHODOESSUCHWORKHIMSELFORHERSEIFOR � � THROUGH HIS Ofl NEROWN EMPLOYEES,PROVIDED THAT SUCl1 IMPROVEMENTS ARE NOT INTENDED OR m 0 OFFEREDWRSN.EIF,HOWEVER.THEBUIIDINGORIMPROVEMENTISS�tDWRHINONEVEAROFCOMPLE- Z 710N,TNE OWNER�Bl11LDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR � IMPipVEFORTHEPURPOSEOFSALE). W ❑I,ASOMMEROF'iHEPqOVERTV,0.M5X0.USNElVCONTRACTIN6WITH!ICENSEDCONTRACTORS [= TO CONSTRUCT THE PRQIECT(SEC.70�t,BUSMESS AND PROFESSIONS COOE:THE CONTRACTORS L!- VHIU2l10l1 ADJ.AREA IlJ CENSEUWDOESNO4MPLVTOANOWNEROFAPflOPERTVWNOBUILO50RIMPROVF.STHEfiEON,AND , � WFqCONTMCTSFORSUCHPFQIECTSWITHACONTRACiOfl�S�UCENSEDPURSUANTTOTHECONTMP pUANTITY DESCFjIPTlON FEE Y TORSIICENSELAW.). 0 ❑!AM EKEMPT UNDER SEC.__ _. _B.&P.C.FOR i HIS REASON U 3 — _ � � DATE OWNEft �" Z W � LICENSED CONTRACTORS DECIARATI�N W � I HEHEBY AFFIflM UNDER PENALTY Of PERIURYTHAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER � � a, 9(COMMENCING WITF1 SECTION 7000)Of OIVISION a OF THE BUSINE59 AND PROFESSIONS CODE,�JD � X MY LICENSE IS IN FULL FORCE AND FFECT. P � m lll � � LICENSE CLASS LIC.NO,� � J � DATE � CONTRACTOR_� �- W � WORKERS'COMPGNSATION DECLARATION Q � U � 1 HEREBV AFFIqM UNDER PEkALTY OF PERJURY ONE OF 7HE FOLLOWING DEIXARATIONS: z Q O _IHAVEANDWILLlAAINTAMACERTIFICATEOFCONSENTTOSELF-INSURF.FORWORKERS' S � COAIFENSATION,AS PGWVIDED BY SECTION 3�0o OF 7HE LAHOR CODE,FOR THE f�EiiFOAMANCE � OF hIE WORK FOfl MlHICN THIS 7ERMIT IS ISSUED. � a W �I HAVE AND Yfl1.1 MNNTAIN WORKERS'COMPENSATION INSIIRANCE,AS REQUIRED BY SECTION Q 37aa OFTHE UAOR CODE.FOqTHE PERFORh9ANCE OF THE W4RK FOR WHICHTHIS PERMiT 15 ISEUED.i.1YWOkKERS'COMpENSATIONIN URANCECARRI'�R�AN`.D,(?OLCYNUMBEFARE: CONSTRUCTION � CARRIER �� �� ^t91�_ ' `�-'���-��/ PLAN REVIEW ZPOLICV tiUMBER ��- �� ��_�a,t_�___ ELECTRIC 4 0 (niSsecT�NE�rarBEo�FrIDeFh,�r�raxrsr�or+EHur�o�.�,.aas!sioo�ora�Ess� PLUMBING ,� Z ICERTIFVTNATINTHEPEiiFORNANCEOFTHEWORKFORWHICHTF115PERMITI5ISSUEO,I MECHANICAL (f- SHAL4 NOT EMPIOV PNY P£RSON IN ANY MANNER 50 AS TO BECAMF 5U9JECTTO TNE � WORKERS'COMPENSATIONlAWSOFCALIFORNIA,ANDAGREETNATIFISHOULDBECOME INSPECTION FEE � SUB.IE TO TH- HKERS'COMPC:NS $QVISIONS OF SECTION 370D OF THE LABOR . , 1 � COOE, 'MA4Lf THWITHGOMPLYW HTH�SE� �SioN�� ISSUANCE _. _ 0 p DATE ` ' �, APPLICANT: _� SMIP � _ . J ENERGY P/C a ____, J WARNING:FAILURETOSECUREWORKERS'GOMP[NSATIONCAVERAGEISUNLAWFUL,ANDSHALIBE � 9U&IECTANEMPLOYEftTOCRIMINALPENALTIESANOCIVILFlNESUPTOONEHUNDREOTHOUSANp ENEqGYPERMiT DOLLARS(5100,D00).IN ADOITION TO THE COSTOF COMPENS�TION,DAMAGES AS PROVIDEO FOq IN � SECTION 370e OF THE LABOP CODE,INTEREST,ANO ATTOANE'f5 FEES._ RETENTION FEE: � a CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � I HEREBYAFFIRM UNDER PENALTV OF PERJURV THAT THERE IS ACONSTRUCTION LENDING AGENCY n- FOR THE PERFORMANCE OF THE WORN FOR WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.C.). Z W � LENDER'S NAME _ t— IENDER'SADDRESS_ /� w I CEPiIFV THAT I HAUE FlEAD 7HIS APPLICATION AND STATE THAT THEABOVE INFORMATION IS CO17RECT. TOTAL FEES � I A6FEE TO CAMPLY WITrI ALl CIT'AND COUYTV ORDINANCE ND STATE IAWS RELATING TO BUILDING CONSTftUCTiON,ANDHEREBYAUTHOPoZEflEPRESENTATIVE FTHISCDUh'TYTOENTERUPONTHE /� �ry ZABOVE-MENTIONEO PPOPERTV FOR INSPECTfON PURPOSE COMMENTS B v 0 J � _ m PERMITTEE INT� �C — G� � SIGNATUHE ERMITTEE OAT �,, = RECPT.NO. 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