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HomeMy WebLinkAbout14729 (8) � , ,s 1� CITY OF DIAMOND BAR �"" F. DEPARTPJIENT OF COMIVIUNITY&DEVELOPMENT SERVICES ¢ 21660 E Copley Dnve Suite 190 .,...,._.,,..., 7 S � M»° BIIIr.,n1CI�G P��r7t8AP7P�,tC"A`TIbN ' � , ` _ FIRMLY _ . � .. �.�., � - �,��ni��� '.�� JOBSITE APPUCATI F � PERMIT L��� P/C �� ADDRESS � �, DATE • �` NUMBER � # ISSUE p' TYPE OCC '� APN LOT TRAGT DATE ! CONST. GROUP �i OWNER `�"Lr,���f' ����i°"—�,"eL%'���`-�"�"--�� �� ADDRE S�'� ' ZONING SETBACKS ��.'"+ CITY " ZIP TEL,,��-�2 ca C'"r FRONT RW ❑ �� APPLICANT TEL. S DE/SIDE STREET RW ❑ �"� '.'�q� CONTRACTOR SIDE ❑ � ADDRESS �j PROPOSED USE ` �t' /� d CITY ZIP TEL. i:u ARCH/ENG! � � �� DESIGNER NO.DWEL���� NO. NO. �1� ADDRESS UNITS STORIES BEDROOMS ,:� CITY ZIP TEL. an �cn DESCRIPTION SQ.FT. FACTOR PSF AOJ.AREANALUATION OWNER-BUILDEH DECLARATION SFR/ADDlFiEM I� I HEREBY AFFlRM UI�ER PENALiY OF PERJURY TH�T I AM EXEA7PT FROM THE CONTPACTORS U- G8f8g0/CBfPOf1 LL CENSEUWPoRTHEFOLLOWINOREASON(SEC.7091.58USINESSANOi+ROFESSIONSCODE:XNVCIT'OR (� ;� COUNTYWHICHRC-0UIHESAPERMITTOCONSTRUCT,ALTERIMPROVE,DEMOLSH,ORREPAIRANYSTRUC- (jJ patio/Deck IIL NRE,PflIOR TO 1T9ISSUANCE,AC50 RE4UIRE3 THE APPLICANT FOR 9UCH PERMIT TO FILE A SIGNED W STATEMENT THAT HE OR SHE IS IICENSED PURSUANT TO THE PFiOVISIONS DF TF1E CONTHACTORS l:l- . I� CENSE LAW(CHAPTER B(COMNIENCINO WiTH SECTION 700U)OF DIVISION 30F THE 6USINE551WD Pp4- � � POoVSpa FESSpNSCODE)ORTHATHE6�IS�iEISEXEMPTTHEREFROMAND7HEBASISFORTHEAILEGEDEXEMP• (� � � TqN.ANYYIOLATI0NOF5ECTION7a31.6BVANYAPPLICANTfORAPERMI7SUBJECTSTHEAPPIICANTYb Z R9-RoOT Q f ACM�PENAI.7YOFNO7AIORETHANFNEHUNOREDDOLLARS�Sstlb).j: �� � �"��' i,� Ot,ASOVMEROF7HEPFOPEHTY,ORMVEMPI:OYEESWITHWA(7ESASTHEIRSOIEGOMhENSATION, 0 Gommercial - WRl DO THE WORK,AND THE STRUC7URE IS I�T INTENDED Oq OFKERED FOR SALE iSEC:7a44,9USb J � ��n NE55 AND PROFESSIONS GODE:TFIE CONTRACTORS UCENSE IAW OOES NO7 APPLY ip'AN OWNER OOF � ,�.+�� PROPERTY WFp BUIL�SOR IMPROVES THEREDN,AN�WFi000E5 Sl1CH WORK HILISELF Ofi FiEYiSELF O'A i(r 7HHOCKiHHI30RHEHONMEMPLOVEES,PROVDEDTHATSUCHIMpiiOVEF1ENTSARENO7INTENOEDOF'i � �}�1 ,OFFERmPDRSALEIF,HOWEVERTHE8U�L01NQOqIMPROV�MENT(SSCKDWRFtlNONEYEAROFCOMPLk`- � TION,THE OWNEfL8l10.DER WILL HAVE THE 9UpDBJ OF PqOVM6'7NAT HE OR SHE OIO NOT 8WL0 OA ,.- =� iMPROVEfORiHEPURPOSEOFSALE�. � � '- - � tN„/ ❑1,A6 OWNEA OF THE PROPERTV,AM E%CLUSIVELY COMRAC7ING NATH LICENSED CONfRACTl7�S �Y TD�NS'TR�CTTHE PROJECT'(SEC.704a,BUSMESS AND PROFESSIONS CO�E:THE CON7FiACTOifS'U• V01ll8liOn ADJ.AREA IL CENSELAWDOESNO7APPLYTOANONMEROFAPROPERT/WHOBUILD50RIMPROVESTNERE'ON,ANh �= WNO�NTR11C75FORSUCHPROJECTSWITHACONTRACTOR(S�LICEN5EDPURSUANTTOTH�C6NTRAC- pUANF DESCRIPTION FEE TORSIJ/CENSELAW.). � � ; '' --, �� BfAM EXEMPT UNDEHSEC. B.&P.G FOR THIS REASON Q :� V I'� DATE �^� OWNER �-° U 'Z W �� UCENSED CON CTORS DECIARATiON w 1� IHEREBVAFPIRMUNOERPENALTYOFPERJURVTHA71AMlICENSEOUNUERPPOVISIONSOFCHAPTER � �� 9(COMMENCINOWRHSECTION700o�OFDIVISION30FTHE8USINESSANDPROfESS10NSCODE.AN�� � iK MY UCEN9E IS IN FU.L FOACE AND EFFECT. m ,lJ �� LICENSE ClASS LIC.N�. � 1— �J DATE CONTRACTOH - � ' , d I1J i� WORKERS'COMPENSATION DECLARATION � �� IHEREBYAFFIRMUNDENPENALTYOFPERJURYONEOFTHEFOLLOWINGDECLARATIONS: Z IrJ_' _IHAVE/WDWILLIAAINTAINACERTIFlCATEOFCONSEMTOSELF-INSUREFORWORKERS' _ COMPENSAT�ON,AS PROVIDED BY SECTION 3Too OF THE UBOR CODE,FOR THE PEPFORMANCE C.) �� OFTHEWORKFORWHICHTHISPERMITISISSUED. � I� IW _�HAVEANDWILLMAIMAINWORKERS'COAAPENSATIONINSURANCE,ASREQUtREDBYSECTION � 37ooOFTHEUBORCOOE,FORTFiEPERFORMANGEOFTHEWORKFORWHICHTHISPERMITIS �'� � � ISSUED.MY WDRKERS'COMPENSATION INSUFANCE CARRIER RND POUCY NUMBERAflE: CONSTRUCTION � J j cr�aRiea_ PLAN REVIEW � PoIICY NUMBER _ . ELECTRIC � �xsEcravr��rareea�.erocFn�cea�vr�swaor�eFuwRe000u�s(a�ao�oa�Ess�. PLUMBING � ICEfiTIFYTHATINTHEPERFORMANCEOFTHEWOHKFORWHICHTHISPERMITtSISSUEO.I MECHANICA� (,� SHALL NOT EMPIOY ANY PERSON IN AN`!MANNER SOAS TO OECOME SUBJECTTO THE �A + . � WORKERS'COMPENShT10NLAW50FCALIFORNIA,ANDAGREETHATIFISHOULDBECOME INSPECTIONFEE _e�.�w _ � S SUBJECTTOTHEWORKERS'COMPENSATIONPFOMSIONSOFSEC7ION37oDpFTHEIABOR ���^����-c /�' CODE,I SHALL FORTHNATH GOMPLY WITH iHPSE PROVISIONS. �SSUANCE Y�X'sV,(�! (�ND� B.�+�� - •-� / o - SMIP .�7rrv ro-tiiwT.���1�F1S'.G1 L •^ sw .`� CI p DATE: APPUCANT: _ _____ ._ __ � ENERGY P/C _ WAFININO:FAILURE TO SECURE WORKERS'COMPENSATION CAV[PAGE IS UNLAWFIJL,AND SHALL B[ LL SU&IECTANEMPLOYERTOCRIMNALPENAL7�ESANDCiVILFMESUP700NENUNDREDTPiOUSAND ENERGYPERMIT WLLARS(5700.000).IN A�DITION TO TME COSTOF COMPENSATION,DAMAGES AS PROVIpED fOR IN - � SECTION37oeOFTHELABORCODE,INTERESLANDATTORNEY'SFEES. RETENTIONFEE: a CONSTRUCTION LENDING AGENCY PflE-ALT FEE: � O QI HEREBY AFFIRM UNDER PENALTV OF PEflJURY THATTHEftE IS ACONSTRUCTION LENOING AGENCY � � FORTHEPERFORMANCEDFTHEWORKFORWHIGHTHISPEflMITI51S5UE��5EC.3097,CIV.C.). . .. - .. Z W � . .. .. .. . �Z LENDER'S NAME �. . � ."yT � LENDER'SADDRESS � � .;, :. .�. .. .......... � ICERTIFYTNATIHAVEREADTH�SAPPUCA710NANDSTATETHATTHEABOVEINFORAAATIONISCARRECT. TOTAL FEES ��� � � IAGREETOCAMPLYWITHALLCfTYANOCOUPITYORDINPNCESANDSTA7EUWSREtATiNOTOBUILOiNG � , � CONSTRUC710N,ANDHEREBVAUTHORI2EREPRESENTA7IVESOFTHISCOUMYTOENTERUPONTHE �� ABOVE�MENTIONEDPRO FORINSPECT�ONPURPOSES. COMMENTS t _ �- � J..t'(' �`�C��� m ft EENAME�PRI ' C4l�° �' � �y.. . I;..ji ,.: y UREOF E OAT n��s,.�_-:. � RECPT.NO. __PAID BY ' - VALIDATION WHITE—DepaAment Copy,YELLOW—Finen�Copy,PINK—Assessor Copy,GOLDENROO--File Copy,GREEN—ApplicanYs Copy ,. .... ,. . .r...i.i i �.;�.- . -.� � .,��� ,� .,'N � n , r � nu�_ . .. .. .:.. . . �.`�.,. ..� . . .:. ...:�. 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