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HomeMy WebLinkAbout11259 —�-- CITY OF DIAMOND BAR � COMMUNTTY DEVELOPIv1ENT 1�EPA72TIviENT � 21660 E.Copley Drive Suite 190 y PRESS (909)860-3195 Fax(909)86[-3117 "',w Bt_TII.AING PERMIT APPLICATION , � � FIRMLY � JOBSITE � " "+ APPLICATION �^" t � PERMIT � P/C ¢ ADDRESS ��� rn • • DATE � NUMBER�I �i o ISSUE TYPE -*�� OCC °-° APN LOT TRACT °' DATE CONST. GROUP p OWNER �p� 12 P (fF� : ADDRESS G7 YY) � ZONWG SETBACKS Z C1TY Gti��-- Z,IP TEL REART RW � o APPLICANT �ICc�[�-�-1 7EL. SIDE/51DESTREET RV�R ❑ ¢ CONTRACT�R !�-� �7 SIDE ❑ � ADDR S� � CITY ��- ZIP�t l CX�(c TEL.�'"-� PROPOSED USE � ARCH/ENG/ w DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDFi00MS � CI7Y ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � - � -�� . OWNER-BCILDER DECLARATION SFR/ADD/REM � Q p I HEREBV AFFIRM UN�ER PENALTV OF PER IIJRV THAT 1 AM El(EMPT FqOM THE CONTflACTORS LI- G9ffl92JC8f(JOf� - W CENSELAWFORTHEFOLLOWINGREASON(SEQ7031.56USINESSANOPFOFESSIONSCODE:ANYqTYOR (n U COUN7VNhiICHREDUIqESAPERMI7TOCONSTRUCT,AL'ER,�MPR�VF,DEMOLISH,ORFEPAIRANYS'RUG W PdtiO/D2Ck w TURE,Pfl10R 70 ITS ISSUANCE,ALSO REOUIRES THE APPLICANT FOR SUCH PERfv11T TO FILE'A SIGNED w � STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO TNE PROVISIONS OF THE CONTPACTOF75 ll- . � CENSE LPW(CHAPTER 9(COMMENCING PJITH'SECTION 7000)OF DIVISION 30F7FIE�BU'$INES5AYJD F�Flb- � POOVSPB FESSIONSCODE)ORTHATH=ORSHEISExEMPTTHEflEFROMANDTHEBA515FORTHEAILEGEOEXEMP- � TION.ANYVIOLATION,OFSECTION7031.5BYAN�APPLICANTPoRpPERMITSUBJECTSTHEAPPi_ICANTTO Z, RB-RDOf � A qVll PENALTY OF NOT 410F�THAN FNE Hl1NORE�OOLLAFS;$'S00�.): ������� ��� - � � � ❑I,ASOWNEROFTHEPROPERTY,ORMVEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, >L CoffIf1181C171 Z WILI DO THE WORK,AN�THE STRUCTURE IS NOT INTF_NDED OR OFFEREO fOR SALE(SEC.7044,BU51� J NE55 AND PROFESSIONS CODE:THE CONTRACTOaS LICENSE LAW DOES NOT APPLY TO AN OWNER OF � PROPERNWHOBUILDSOFIMPROVESTHERE-0N,ANDWHODOESSUCHWORKHIMSELFORHERSELFOR m � THROUGNHISORHEqOWNEM?LOVEES,PROVI�E�iHAiSUCHIMPROVEMENTSARENOTINTEND��OR W OFFEREOFORSALE.IF,HOWEVER,THEBUILDINGORIMPROVENENTISSOLOWITHI�ONEVFAROFCOFAPI.E � TION,THE OWNER-BUILAER WILL HAVE THE BUROEN OF'PqOVI�'G THAT HE OR SHE DID NOT QUILD OR Z IMPROVEFORTHEPURPOSEOFSALE�. - � UI,ASOWNEROFTH'ePROPER7Y,RME%CWSIVEIYCONTFACTINGWITHLICENSEDCONTRACTORS � TO CONSTRUC7'.'HE PROJECT(SEC,tad4,BUSINESS AND PROFESSIONS CODE:T4E CONTRACTORS LI- VBllldilOfl ADJ.AREA W CENSE:AWDOESNOTAPPLYTOANCWNEROFAPROPERTYWHOBUILDSORIMPROVESTH'cRE4N,AND � WHOCONTRACTSFORSUCHPRO.IECTSWITH.4CON7RAC70R(S)CICEN5EDPUfISU�ANTTOTHECO!JTRAC- QUANTITY DESCRIPTION FEE � TORSUCENSELAW.j. � J O rl I AM EXEMPT,UN�ER SEC.f__._._. B.8 P.C.FOR7NIS REASON � � Q � CATE oWNER. __.___ U W � LICENSED GONTRACTORS QECLARATION �y � I HEREBY AFFIRM UN�ER PENALTV OF PERJURY THAT I AM L�GENSEO UNDER PROVISIONS OF CHAPTEP � � 9(COMMENCINGWITHSECTI0�7o00)OFOIVISION30FTHE6USINESSANOPROFESSIONSCOJE,AND Z X MV LICENSE IS IN FULL FORCE AN�EFFECT. �I � e � LICENSE CLASS ��� LIC.NO. `�//��� J f1� � DATE � CONTRACTO� 0- �J CJ -- .. W � WORKERS'COMPENSATION DECLARATION ��I-1 Q � I U � 1 HEREBV AFFIRM UNOER PENALTV OF PERJURV ONE OF7ryE FOLLUWING DECIARATIONS: � Q L) IHAVEAND�"11LLMAIN7AINACERTIFICATEOFCDNSENTTOSELFINSUREFORWOqKERS' Z COMPENS0.TION,ASPFOVI�E�BYSECTION3�ooOFTHELABORCODE,FOF7HEPERFORMANGE U Q OF THE WOFK FOR WH�CH THIS PERMIT IS ISSUED. � 0 W I NA✓E ANO WILLMAINTAIN WOqKERS'COMPENSFTION INSURANCE,AS REQUIRED B'(SECTION Q 37Do OF TH�LABOR CODE,FOR?HE PERFORMANCE OF THE WORK FOR WHICHTHIS PERMI715 ISSUED.MY KERS' OMPF�SATION INSURANCE CAFifiIER AN�POLICYtJUMBERARE:�� CONSTRUGT�ON Q / �., � CARRIER �` �-� 4—l�V_ /1�7P / '� PLAN flEVIEW � POLICY NUMBER W�1�l�f� U�� _ /� � ; E�E . .. . . ...... . . . .�_ Q � ) � (THISSEC7I�NNE�Pl070EO�MPLEfEDOFTNEPERMRISFOFIXJEHJNDREDCKY.LMS�S'����RLESS). LUMBI �. �1 W MECHANICAL Z �GERTIFYTHAT IN THE PERFORMANCEOFTHE WORK FOR WHICH THIS PEPMITIS ISSUED,I (� SNALL NOT EAAPIOV ANY PERSON IN ANY MANNER 50 AS TO BECOME StJBJEC�TO THE � WORKERS'LOMPENSATIOVLAWSOFCALIFOFNIA,ANOAGREETHpTIFISHOULDBECOME INSPECT70NFEE = SUBJECTTOTHEWORKERSCOMP�l.'SATIONPROVIS�:ONSOFSEC7ION37000FTHELABOR CtlDE,I SHALL FORTHWITN COMPLV WITH 7HOSE PROVISIONS. ISSUANCE t p SMIP q DATE: APPLICANT: __ _ W ENERGY P/C � � J WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALC HE� �� LL, SUBJeCTANEMPLOYERTOCRIMINAIPENALTIESANDqVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT DOLLARS I=���000),INADD:TION TO THE COSTOF COMPENSATION,DAMAGES AS PROVIDE�FOF IN � SECTION 37ae Of THE LA80R CO�E,INTEREST,ANO ATTORNEV'S fEES. - RETENTION FEE: - � CONSTRUCTfON LENDING AGENCY PFE-ALT FEE: CL IHEREBYAFFIRMUN�ERPENALTYOFPERJURYTHATTHEREISACONSTRi1CTIONIENDINGAGENCY d FORTHEPERFORMANCEOFTNEIYORKWRWHICHiHISPEFMITISISSUED(SEC.309�,CIV.GJ. Z W � LENOER'S NAME_ --'' . .... . .d: �,.,, F- LENDER'SADDRESS .. . . . . � I CERTIFY THAT I HAVE READ THIS APPLICATION AN�SiATE THATTHE ABOYE INFORMATION IS CORREG7. TOTf'1L FG GS L/3' (-f w IAGREETOCOMPLYWITHALLCITYANDCOUNiYOPDINANCESANDSTATEl.4WSRELATINGTOBUI�DING " � � CONSTRl1CTiON,AN�HEPEBYAUTHORIZEfiEPRESENTATIVESOFTHISGOUNTVTOENTEftUPONTHE � � Z ABOVEMENTIONED PROPERTY FOR INSP CTION PURPOSES. COMMENTS o v;.. , � � — m PERMI AME(PRIN) ` �� � . � ,�..� �/IZ/� �' ,- .: . � SIGNATUREOFPERMITTEE DATE y � = RECPT.NO. _ PAID BY � VALIDATI � ..., . . ..,. . . WHITE—Department Copy,VELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROO—File Copy,GREEN—Applicant's Copy�� �� „r .;:,n. .� �'�'�'� ” �-::-. ,,,::....:, , � ...,....:� ��', .,._.-:,.. .e: r�;:k+b" .'^:,6iR+�rr +P��'�: .a� 'A�.kLd��� R, �'s.;-•;.7:;°�.'z+aat��'k�':as5t��*' .s,�-i*�dyf.i�--�#� ,t r. - .. . .,. ..�.� :y. .._ r..., , . . . . o-x ��'1�'s. . . . . � . ^�,.��;:t B��. � 4 . :� � . � � -- - .... . . . � . .. 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