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HomeMy WebLinkAbout15889 (22) � :� _1� CITY OF DIAMOND BAR �� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � 21660 E.Copley Drive Suite 190 ��� � (409);860-3195 Faac(909)861-3117 PR E$$ �'��°� BUILDING PERNIIT APPLICATION FIRMLY ; -.- , � JOBSITE � { APPLICATION���L 1 �_`'��PERMIT PIC o ADDRESS ��-� DATE � � NUMBER� # � ISSUE NPE OCC APN LaT T T ° DATE CONST. GROUP °C OWNER Y1 o r o ADD SS. O ZONWG SETBACKS W CI Ol. � ZI TEL. FRONT RW ❑ � APPLICANT m� ���ja. �iv-/lr�l n+t TEL. REAR ❑ � SIDE/SIQE STREEf RW ❑ CON7RACT SIDE ❑ ADDR S � � PROPOSED USE � C ZIP L. - z� ARCH/ENG/ DESIGNER � ADDRESS NO.DWEL. NO. NO. tn UNITS STORIES BEDROOMS � CITY ZIP TEL. v� DESCRIPTION 5�.FL FACTOR PSF ADJ.AREANAI.UATION p� - OWNER-6WLDER DECLARAT�ON SFR/ADD/REM O 1 HEREBV AFFlRM UNDER PENALN OF PERJURY THAT I AM EXEMPT FROM THE COMRACTORS U� Gflt89B/C81pOh �W CENSEUWFORTHEfOILOWINOfiEASONi5EC.7031.58USINESSANDPROPESSIONSCODE:ANYqTVOR � (n �} -COUNT`lWHICHREOUIRESAPEAMITTOOONSTRUCT,ALTER,IMPRDVE,OEMOLISH,ORREPAIRANYS7RUG �W�� TURE,PNIOH TO ITS ISSUANCE,A150 REWIRES THE APPLICPNT FOR 3UCH PEHMIi TO FILE A SIGNE� W Patio/Oeck �� STATEMENf iNAT HE OR SHE IS IJCB�lSED PUflSUANT TO THE PROYISIONS OF THE CONiqACTORS LI- � '�. CEN$E LAW(CHAPTER 9(COMMFNCIN�WITH SECTION 7000)OF�NISION 9 OFTHE BUSINESSAND PRO- POOVSP2 °� FF.SSIONSCODE�ORTHATHEOflSHE15EXEMPTTHEREFROMANDTHEBA5ISFORTHEALLEGEOEXEMP- (� . V- TpN.ANYVIOUTIONOFSECTION7o3t.58VANYAPPUCANTFORqPERM17SU&IECTSTHEAPPLICANTTO Z Re-ROOf r, ACMLPEN�L7YOFNOTMORETHANFIVEHUNDREODOLURS(SSoo).): �� ❑I,ASO4MEROFTHEPROPERTY,ORMYEMPLOYEE64ATNWAGESASTHEIflSOLECAMPENSATION, COfi1f118fG81 - WILL OO iHE MIOflI(AND TME S7qUCiURE IS NOT INTENDED OR OFFEflEO FOR SALE(SEC.7oM,BUSI� � � NESS AND PROfE5510NS CODE:AiE CONTRAC70RS LICENSE LAW 60ES NO7 APPLY T�AN OWNER oF � . . PROPEAfYWF108UILDSORIMPROVESTHEHEON,ANDWHO00ESSUCHWOflKHIMSELFORHEflSELFOR �2 THROU6HHISORHEROWNEMPLOYEES,PNDYIDEDTHATSUCNMIPROVEMENTSARENOTINTENDEDOR m 0 ,OFFEREDWRSAIE.IFHOWEVER,iHEBUNAINQORIMPHOVEMENTISSOIDWITHINONEVEAROFCOMPLE� Z `�TION,THE 6WNER-6UILDEH WILL HAVE 7HE BURDEN OF PROVING TNAT HE OR SHE�ID NOT BUILD OR �:. IMPROVE FOA THE PURVOSE OF BAI.E). W ❑I.ASONMEROFTHEPROPEflTY,AMEXCLU5IVELYCONTRACTWGWfTNLICENSEDCONiAAC70HS �. TO WNSTRUCTTHE PROJECT(SEC.70M,8U31NESSAN�PPOFESSIONS CODE:THE CONTRACTORS LI- V3IUdIl0I1 ADJ.AREA W..-CENSEIAWDOESNOtAPPIYTOANOKRiEflOFAPROPEflTYWHOBUILA50RIMPHWE9THEftEON,ANO -F- WMOWMMCTSFOPSUCHPROJECTSWI7HACONTflACTOR(S)LICEN5�PUPSUANiT07HECINJTMC pUANTlTY DESCRIPTION FEE . �'. TORSt10ENSELAW.). 'Q. DIAMIXEMPTUNDERS�C. 8.8P.C.FORTHISREASON Q U � ¢ �'=' OATE OWNEF � � UCENSED CONTRACTORS DECLARATION W J � IHEREBVAFFIRAIUNOENPENAITYOFPERJURVTNATIAAILICENSEDUNDERPROVISION30FCHAPTER � _p.� S(COMMENCINQ WIiH SECTION 7000j Of DIVISION 3 OF THE BUSINESS AND PROFE3310N3 CODE,AND Z X� MY�ICENSE IS It7 FUL �j AN" EF,A�fECT. �''�`"'� 0� LiC E LAS�S/ d�/'�' —`� IIC.N � • s 6y �.�� j �U. DATE � 79 CONTMCTOR �. d W � WORKERS'COMPENSATION DECIARATION ¢ �; IHEflEBYAFFIRMUNDERPENpLTYOFPER1lIRYONEOFTHEFOLLOWING�ECLARATIONS: z _L]-. _IHAYEAtdDWILIMAMTAINACERT�FlCATEOFCONSENTTOSEIHNSUREFORWORKEflS' ¢ G COMPBi51,TION,ASPROVIDEOBY5ECT10N370oOFTHELA80PCODE,FORTHEPERFOflMANCE U Q OFTHE WOflK FOR WHICH THIS PERMIT IS ISSUED. W Q; �2 �- _I WNEAND WILL MAItitA1N WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION �0_ 37000FTHE LABOR CODE,FORTME PERFOFMANCE Of THE WOPK FOR WHICH 7HI5 PERMIT IS ISSUED.M�,WOR�K RSp'C,O�M,P�ENS,�/.�IN�SURAN�.CARRIERANDPOI.ICYNl1M6ERA`9�,� CONSTRUCTION � cnnqirtq,����1{.y�+4�/r�A�!Tul r,�1 S�i�,�.Y��. �G/ PLAN REVIEW Z-: aa�cvnuueEa;s�����' j(� � � � . ELECTRIC ---_— a .� �: (fWSBECf'ANNE�NOTBEaf.ffl.EfIDOFTF£PER�MISR7RIXJEHUNDREDOq.LNiS(Si00)ORLESS� PLUMBING W '�Z. I CERTI%THAT INT}iE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,l MECHANICAL .;('J- SWU.LNOTEMPLOYANVPERSONINPNYMANNERSOASTOBECOMESU&IECTTOTHE �y gC �q C) -pq[ygq ' - ��(n��- WORKERS'COMPENSA7IONUWSOFC FOflN1A,ANDAGREETHAiIFISNOULDBEGOME -�NSPECTIONFEE 9$�9. 7 .-S 9IIA1'� _._,,,___ - - ;�' Sll&IECT OTHEWORKEHS'COMPEN5A PROVISIONSOFSECTION37000FTHELABOR "' �„�/�, �� � fADE,l S ALL FORTFiWITN CAMPLY OSE PflOVISIONS. ISSUANCE _ i �c r p �,.'t�.,.a____r� �_----� kaL,z .�p PA7E: APaLlcn �SMIP _ 'J_ WARNIN6:FAILU ETO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWfUL,ANO SHALLBE ENERGY P/C 5 -�� SU&IECTANEMPLOYERTOCPIMINALPENALTIESANOCIVILFlNESUATOONEHUNDREDTHOUSAND ENERGYPERMIT DOLUflS�5700.000),IN ADDRIINJ TO THE COST OF COMPENSPTION,DAMAGES AS PflOVIDED FOR IN -,�. SECTION370BOFTHELABORCODE,INTEREST,ANOAiTOqNEI"SFEES � RETENTIONFEE: ____.__ -;d CONSTRUCTION LENDING AGENCY PREALT FEE: O _:Q- I HEREBY AFFIRM UNDER PENRLTY OP PEliNNY THATTHEfiE IS ACONSTRUC710N LENDING AGENCY � FORTHE PERLORAIANCE OF 7HE WOFK FOR WHICH THIS GERMIT IS ISSUED(SEC.3097,CIV.C.). Z: W: .�-, LENDER'S NAME . - - �F—' LENDEH'SADOHE55 :w� TOTAL FEES _;,� 1 CERTIFY TMAT I HAVE flEAG THISAPPLICATIONANO 3TATETMATTHEABOVE INFORMRTION IS CARRECT. �' ;�; IAGFEETOCOMPLYWITHALLCITYAND NOfl01NANCESANOSTATELAWSRELATINGTOBUILDING , :_�.. CONSTPUCTION,ANDHEREBYAUTHORI RE ESENTATIVESOFTHI�UNTVTOENTERUPONTHE � . •MENTIONED PflOP£fl7V FOP INS ECTIO PURPOSES. � - � COMMENTS ' ¢ E N (PNN1� � � si w� ITfEE oa e RECPT.NO. �S"!� PAID BY 'U� VALIDATION 2 "v. ~ WHITE—Department Copy,YELLOW�inance Copy,PINK—Assessor Copy,60lDENRO�File Copy,GREEN—ApplicanYs Copy �� 9 �i��{ � ��� ' � � � � ,� � S � i�� ' —�'"-' � y��� ,�''`�, .... ��� ;....,..�..�.__,>� �__'""r.,,.� � � 6 �;�4 ri r^�m i-� y .,.� �j UJ k'r�� ..J�f !S3 t..���€et�"i.� �!"R i GJ�f7? � 1 r I � 3 ! "' ."� r`i S �� � �� � I C � � ,.�t�� e� -t � � S_}� . � r � 3 .� � ��s �"" � I -' n�� �" � �� � G'� �� s r� e�t � G i r!�, `E � + I A.� f � � -r c 3� i .� -t'� � ( . 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