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HomeMy WebLinkAbout11286 (5) , �: �"•� CITY OF DIAMOND BAR COMMUNITY DEVELOPMENT DEPARTMENT �( - _ 21660 E.Copley Drive Suite 190 �REa�•�• n (909)860-3195 Fax(909)861-3117 '""� BUILDINGPERMITAPPLICATION FIRMLY � JOBSITE APFLICATION � PERMIT P/C �} o ADDRESS 2 I��� L.(�J�'T J'����'EL. D R. DATE Y � ._.__ NUMBER '�� # 4° o� ISSUE 1YPE OCC r APN LOT TRACT DATE CONST. GROUP � OWNER �IY�j� R. N��^T� O p ADDRESSZ��f)� L�ST IZ P��'R`y� ,,�piQ• ZONING SETBACKS oCITY�PHH7('3HJD l�➢°IR ZIP�ra� TEI��`�,�+'aZ�`_i�/' FRONT RW ❑ o APPLICANT �iVI7�L l2, 1°17f1 tY'� TEL REAft ❑ z SIDE/SIDE STREET RW ❑ ¢ CONTRACTOR Dn� /L � __ SIDE ❑ � A�DRESS PROPOSED USE R��%XI�N C� � C�-f3SEb P�i l� � CITY ZIP TEL. �w ARCH/ENG/ 4 � DESIGNER NO.DWEL. O. N0. a ADDRESS UNITS STORIES BEDROOMS = CITY ZIP TEL. � � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION -�. OWNER-61;ILDER DECLARATION SFR/ADD/REM O 0 I HEREBY RFFIRM UNDER PENALTY OF PEflJUflY TI�IAT I AM[X[MPT fROM THG CONTRACTORS LI- G8f'dJ8/C3f(70fI W CENSELAWFOHTHEFOLLOWINGREASON(SEC.7031.58USINESSANDPftOFES510NSCO�E:ANYCITYOR (n U COUNTYWNICHREQUIRESAPERMIT7000NSTRUCT,ALTER,IMPROVF,�EMOIISH,ORftFPAIRANYSTRUC- - ' W TURE,PRIOR TO IT:ISSUANCE,ALSO fiEQUIftES THE APPLICANT FOR SUCH PERMIT TO FlLE A SIGNED W a�10/DBCK STA1 EMENT IHAT NE OR SHE IS LICENSEO PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- .� CF.NSE LAW(CHAPTER 9(CAMMENCING WITH SECTION 700�)OF DIVISION 3 DF THE BUSINESS AN�Pfl0- �'j' PooUSpa . O FESSIONSCODE)OftTHATHEOflSHEISEXEMPTTHEREFROMANOTHEBlSISFORTNEALLEGEDEXEMP- U 710N:ANYVIOLATIONOFSECTION7o91.5BYANYAPPLICANTFOflAPERMITSUBJECTSTHEAPPLICANTTO A CIVIL PENAIN OF NOT MORE THAN FNE HUNDRED DOLLARS(55D0).j: � ❑4ASOWNEROFiHEPFOPERiV,ORMVEMPLOVEESWITHWAGESASTHEiRSOLECOMPENSATION, � COfIlf118fCIaI - WILL 00 THE WORK,AND THE STRl/GNHE IS NOT INTENDE�OR OFFERED FOR SALE(SEG.T094,BU51-. J NESS ANO PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF � PROPERTYNhiOBUILDSORIMPROVESTHEREON,ANDWHODOESSUCHWORNHIMSELFORHEFSELFOP � [L THflOUGHHI50flHEROWNEMPLOYEES,PROVIOEDTHATSUCHIMPRDVEMENTSARENOTINTEN�EDOR m .O OFFEREDFORSALEIP,HOWEVER,THEBUILDMGORIMPROVEMENTISSOtAWITHINONEYEAROPGOMPLE � � � � TION,THE OWNER�BUILOER WILL HAVE THE BUFDEN OF PROVMG THAT HE OP SHE DID NOT BUIlO OR . � IMPROVEFOR7HEPlRPOSEOFSAIE). . W �I.ASOWNEROFTHEPROPERTY,AMEXCLUSNELYCONTflACTINGWITHLICENSEDCANTFACTORS � TO CONSTRUC7 THe 7ROJECT(SEC:7o60,BUSINESS AND PFOFESSIONS Cq�E�THE CONTRACTOAS LI- 3ltlfffiOfl ADJ.AREA - W CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUILDSOfiIMPf10V[STH[fi[ON,ANO - � WHOCONTRACTSFORSUCHPHOJECTSWITHACONTflACTOR(SJLICENSE�PUflSUANTTOTHECANTRAC� - QUANTITY DESCRIPTION FEE � TORSLICENSELAW). - � �I AM EXEMPT UNDER SEC. B.8 P.C.FOR THIS REASON J � —# _ — � �Y' s � DATE��(�_=� OWNER � , - Z W �c[ UCENSED CONTRACTORS DECLARATION W CC I HEREBYAFFIRM UNDER PENALTY OF PEFJURY THAT I Aih LICENSED UN�JER PROVISIONS OF CHAPT'cR � � 9(COMMENCING 1VITH SECTIOIv 7o00)OF DIVISION 3 OF THE BUSINESS AND PflOFE5510N5 CODE.AN� z L1� MY UCENSE IS IN FULL FOflCEAND EFFECi m � LICENSECLASS LIC.NO. j � J U DATE CONTRACTOA -� d- W a� WORKERS'COMPENSATION DECLARATION ¢ � � I HEREBY AFFIRM UNDER PENAITY OF GERJl1RY ONF OFTHE FOLLOWMG�ECLARATIONS: z . 0 tHAVEANDWILLMAINTAINACERTIFICATE0FCq45EN7TOSElP-INSUREFORWORKERS' 2 '- Z COMP[NSATION,AS('ROVIDEDBVSECTIONa7000FTHEl.A80PCO�E,FORTHEPERFORMANCE U Q OF THE WOPK FOR WHICH THIS PEHMI I'IS ISSUEU. � 0 W _IHAVEANfIWILLMAINTAINWOflKERS'COMPENSA710NINSURANCE,PSREDUIREDBYSECTION ` � Q 3700 OF THE 1A00R CODE,FOft THE PEtiFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS � ISSUED.MYwoRKEF1S'COMPENSAT10NiNSURANCECARRiERANDPOLICYNUMBERARE: CONSTRUCTION C � �, CARRIER PLAN REVIEW .. � POLICVNUMBER ELECTRIC Z ¢ (MISSECTICtJNEmNOTBE�APLEfEDOFiHEPEW�IRISWFQVEHUNDREDCq1AAS(S1oo)OHLESS). PLUMBING 0 � -�Z- I CEFlTIFYTHAT IN TH[�EFFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEO,I MECHANICAL -"-- � SHAIL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE '� -- -- -- -� �� WORKEFS'COMPENSATbN4AWSQfCALIFORNIA,ANDAGREETHATiFISHOULOBECOME � ��NSPECTIONFEE . ._.. SUOJECT TO TIfE WOfiK[f1S'COMPENSA710N PROVISIONS OF SECTION 37000F THE NBOR � � CAUE,ISHAILFURTHWITHCOMPLYWITHTHOSEPftOVI510N5. ISSUANCE � �j � SMIP J " � p DATE: APPLIGANT: J- WAflNINGFAILURETOSECUflEWORKERS'COMPENSATIONCOVERAGEISUNLAWFUL,ANDSHAILBE ENERGYPlC � -�' SU&IECTAN EMPLOYER TO CRIMINFL PENAL7IES AND CIVIL FINES UP TOONE HUNDflED THOUSAND ENERGY PERMIT � DOLLARS(t100,oao),IN ADDITION TO THE COSTOF CAMPENSATION.DAMAGES AS PROVI�EO FOR IN - J SECTION370BOFTHEIABORCADE,INTEflEST,ANDATTORNEY'SFEES. RETENTIONFEE: � -oW„. CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O, � 1 HEPEBYAFFlRM UNDEF PENALTY DF PERJUAY THAT TNERE IS ACONSTRt1CTION LENDING AGENCY � FOH THE PERF-0RMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUE�(SEC.3a97,CIV.C.). Z. W �- LENDER'S NAME ' 'F'-� IENDER'SA��RESS - w. ICERTIFVTHATIHAVEREAD7HIS�PPUCATIONANDSTATETHATTHEABOVEINFORMATIONISCORFECT. TOTAL FEES _ -� IAGFEETOCOMPLYWITHALLCRYANDCOUNTYORDINANCESANDSTATELAWSRELATINGTOBUILDING CONSTRUCTION,AND HEREBYAUTHORRE REPRESENTATIVES OF THIS COUNTv TO ENTEH UPON 7HE ' OVEMENTIONED PROPEPTV FOR INSPECTION PURPOSES Z. COMMENTS - � � ���11 C. '� � �,,..�. -, � . .¢ P RMITT AME(�INT) � CJ] -� IGNA F EF DATE 4 .. = RECPT.NO. 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