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HomeMy WebLinkAbout10771 (5) CITY OF DIAMOND BAR �XPl��D COMMUNITY DEVELOPNIENT DEPARTIv1ENT 7 �,�; . 21660 E.Copley Drive Suite 190 ' ��1 ,� O ,00/1 PRESS` (9(�)860-3195 Fau(909)861-31t7 u FIRMLY ����'� � BUILDING PERMTT APPLICATION , � JOBSITE i � APPGCATION --��y � ERMIT � Q � P/C p ADDRES � �� G C� DATE NUMBER� # $ ISSUE TYPE OCC APN LOT TRACT.�_�_ DATE CONST. GROUP. p OWNER CJ ADDRES �,7 /�1 � ZONING SETBACKS g cirr',�i�4-/d0�11A � ZIP � L � � .d9S�' FRONT RW ❑ APPLICANT TEL. REAR ❑ SIDElSIDE STREET RW ❑ � CONTRACTOR SIDE ❑ � ADDRESS PROPOSED USE � CITY ZIP TEL. — w ARCH/ENG/ � z DESIGNER NO.DWEL. NO. / NO. a ADDRESS UNITS STORIES ! BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � 'OWNER-B�ILDER DECLARATION SFR/ADD/REM � .� 0 1 HEREBV AFFIRM UNDER PENALN OF PERJURV THAT I AM E%EMPT FROM THE CONTRACTORS LI� (jg�y9g/C8f{WfS - W CENSEIAWFORTHEFOLLOWINGREA50N�SEC.7ai1.58U51NESSANDPPOFESSIONSCODE:ANYCITYOP (� U CWNNWHICHREOUIRESAPEHMITTOCONSTRUCT,AL7ER,IMPROYE,DEMOLISH,OAREPAIRANYSTRUG W PeIiO/DBCk wTURE.PRIOR TO IiS ISSU�INCE,ALSO REWIRE5 THE APPUCAN7 FOR SUCH PERMiT TO FILEA SIGNEO � STATEMEM THAY HE ORSHE IS IICENSEO PURSUANT TO THE PROVISIDNS OF THE COHiRAC70RS L4 � CENSE LAW(CHAV7ER 9(COMMENCiNfi WITH SECTION 7000)OF DIVISION 9 OF THE�BUSiNESSAND PF�O� � POOUSp2l FE6SIONS CODE)OR THAT HE OR SHE IS E%EMPT THEREFROM ANDTHE BASIS FORYHE ALLEGED EICEMP• V TION.ANYVKK.ATIONOFSECTION7o31.68YANYAPPLiCANTFORAPERMITSU&IECTSTHEAPPLiCANTTO Z g-R001 � � A CIVIL PENALTY OF NOT MOHETHAN FtVE HUNDIiED DOLLAhS(5Bo0�.�: � ��� ��� '-� ��� — � OI,ASOWNEROF7HEPROPER7Y,ORMYEMPLOYEESWITHWAOESASTHEIRSOLECOMPENSATION, COf11rt16fCi81 Z WILL DO 7HE WORK,ANO THE STRUCTURE IS NOT INTENOEO OR OFFERED FOR bALE(SEC.7044,BUSI� J NESS AN�PROFESSIONS CODE:THE CONTRACTORS LIbENSE LAW QOES NOT APPLY TO AN OWNER Of � OROPERTV WI�O BUILDS OR IMPROVESTHEREON,AND WHO DOES SUCH WORK HIMSELFOR HERSELF OR = � THROUGH HiS OR HER OWN EMPLOYEES,PpOVIDED THAT SUCH IMPHOVEMENTS ARE NOT INTENDED OR m QOFFEHEDFORSALE.IFHOWEVER,THEBULDINGORIMPROVEMENTISSOIDWITHINONEVEAFOFCO�dPIE• � TION,THE OWNER�BUILDEH WILL HpYE THE BURDEN OF PROVING 7HAT HE bR SHE Dlp NOYBUILD OR = IMPROVEFORTHEPURPOSEOFSALE). O I,AS OWNER OF THE PRDPEFttY.AM IXCLUSIVELY CONTRAC7ING WITH UCENSED CONTMC70RS � TO CONSTRUCT THE PROJECT(SEC.7049,BUSINE55 ANO PROFESSIONS CODE:THE CONTRACTORS U� V0W9IlOf1 i ADJ.AREA W CENSELAWOOE3NOTAPPLYTOANOWNEROFAPROPERTYWHOBUILDSORIMPflOVEStHEREON;ANO Z WHOCONTMCTSFORSUpiPROJECTSWITHACANTRACTOR(S)LICENSEOPURSUANTTOTNECONTRAC- QUANTITY DESCRIPTION FEE F— 7oR5LICENSELAW.). 0 O I AM EXEMPT UNDEii SEC. B.&P.0.FOR THIS REASON U � Q � OATE OWNER F Z W � LICENSED CONTR T RS DECLARATION -� � W 1 HEREBYAfFIFM UNOER PENALTV OF PERJURY ' IAM L�CENSEO UNDER PROVISION6 OF CHAPTER � � 9(COMMENCING WRH SECTION)000)OF DIVISION 30F 7HE BUS�NESS ANO PROFESSIONS CODE,AND Z � MV LICENSE IS IN FULL FOi7CEAND EFFECT. m O �` . �.,_, UGENSECtASS LIC.NO._ J V DATE GONTRACTOR � �- � W � WORKERS'COMPENSATION DECLARATION � �i � 1 HEREBVAFFIRM UNDER PENAL7V OF PERJURY ONE OfTNE FOLLANANG DECLARATWNS: N Z � _IHAVEANDWILLMAINTAINACERTIFICA7EOFCqNSEN7TOSELf�INSUREFORWJRKEHS' S � COMPENSATION,ASPROViDE�6VSECTION37000FTHElABORC00E,FORTHEPE`RFORGANCE W OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. � � � W _i HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTpN ' Q 370o OF 7HE U160R CO�E,FOR THE PERFOflMANCE OFTHE WORK FOR WHICH THIS VEFMI7IS J v` � ISSUED.MY WORKERS'COMPENSA710N INSURANCE CARRIER ANO POL�CY NUMBERAflE: CONSTRUCTION j CARRIER PLAN REVIEW I Z PaICY NUMBER ELECTRIC I ¢ � (iHISSEcmdNE�No7eEmMPLET�oFiHEPEW�1ftISFORONEFNWFEDDIX1ARs(Sta�l��ssl. PLUMBWG Z i CEHTIFY THAT IN THE PERFORMANCE OF THE WORK FOF WHICH THIS PERIAIT AS ISSUED,I MECHANICAL (} SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE Uj WORKERS'COMPENSA710NLAW50FCALIFOFNIA,ANDAGREETHA7IFISHOULDBECAME INSPECTIONFEE SUBJECT TO THE WOqKEflS'CDMPENSATION PROVISIONS OF SECTION a7000F THE LABOR = CODE,I SHALLFORTHWITH COAAPLV WITH THOSE PROVISIDNS. ISSUANCE � � SMIP v p OATE: APPLIGANT: � ENERGY P!C � WARNING:FAIWNE 70 SECURE WORKERS'COMPENSATION CAVERADE IS UNUWFUL,PND SHALL BE r � SUBJECTAN EMPIOYER 70 CqIMINAL PENALTIES AN�CIVtL FINES 11P TOONE HUNORED THOUSANO �NERGY PERMIT `�a�L.•L� f� � ���°t`Y -- OOLI.ARS(S1o0,o00).IN AbD�TiON TO THE CQST pf COMPENSATION,DAMAGES AS PROVIDED FOi11N —�� � SECTION37060FTHELABORCODE,INTEFEST,ANDATTORNEPSFEES. - � {�ET'ENTIONFEE: �� �� W CONSTRUCTION LENDING AGENCY PR6ALT FEE: C_. � I HEREBY AFFIRM UNDEfl PENALTY OF PERJURV THAT THEFiE IS A CONSTRUCTION LENOINp AGENCY FOR TME PERFORMANCE OFTHE WORK FOR WHICH TNIS PERMR IS ISSUED(SEC.3oB7,CN.C.�. Z W � LENDER'S NPME ' F— LENDER'SAOURESS �-- �� � IGERTIFYTHATIHAVEREADTH�SAPPLICATIONANDSTATETHATTHEABOVEWFORMATIONISCORPECT. TOTA�FEES , �. W 1 AOREE TO COMPLY WITH 11LL CITY MU CDUNTY OFDINRNCES AND STATE lAWS REUTINp TO BUIL�ING � �'� � � � . � CONSTHUCTION.AND HEREBVAUTHORIZE REPRESENTATIVES OF THIS COUNTYTO ENTEH UPON THE � � �� Z A00 M 710NEOPROPERTYFORINSPECTIONPURPOSES. p COMMENTS � ��N Ay� r/—"'.." ���"'"_ . : , m 4 R ITT NAME(PHINT� � �_� �° __-- � � TUR O P ITfEE DATE t;ii�„�1�k�� �I u' (,. _ - RECPT.N . 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