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HomeMy WebLinkAbout10705 (5) ...A . __..,�--F- ..._� ., ..____ __ . _ �_ _ � ; -N .,._��:_..:: , . _ti�.< _,�___,_.._,�,..,.- ,,_ -_-.-� , _.. . . ... _ �_ - CITY OF DIAMOND BAR t ' '�' COMMUNITY DEVELOPIv1ENT DEPARTIvIENT ;�,,,V . 21660 E.Copley Drive Suite 190 � , �� � PRESS (909)860-3195 Fax(909)861-3117 ��''H"" BUILDING PERMIT APPLICATION FI RMLY JOB$ITE,. : � ' APPLiCATION PERMIT. , o ADDRESS DATE___� NUMgE'Fi � �l�� ' � ISSUE TYPE OCC APN T RA T DATE CONST. GROUP p OWNER p ADDR ZONING SETBACKS z CITY ZIP TEL. FRONT RW ❑ g APPLICANT TEL. REAR ❑ SIDE/SIDE STREET RW ❑ � CONTRACTOR J�,�B��� +�.5� SIDE ❑ ADDRESS _ p ��.�.,� � , n� � PROPOSED USE o ARCWENG/ �G�,CA����� �z DESIGNER N4.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � cn DESCRtPTI�N SQ.Ff. FACTOR PSF AOJ.AREANALUATION � OWNER-BI:ILDER DECLARATION SFR/ADD/REM O ' I HEREBV AFFlRM UNOER PENAITV OF PERRIRV THAT I AM EXEMP7 FROM THE CONTRACTORS LI• G8f8 BICS OfI W CENSELAWFORTHEFOLLOWINOREASON(SECJo37.6BUSINESSANDPROFES510NS'CODE:ANVCITYOR (� 9 � U COUNTYWHICHRE�UIFiESAPERMITTOCANSTRUCLALTER,IMPROVE,DEMOIASH,ORREPAIRANVSTRUC• W PefiOlDeCk w TURE,PRIOR TO ITS ISSUANCE,ALSO REOUIRES THE APPLICANY FOfi SUCH PERMIT70 FILE A SIGNE� W STATEMENT THAYHE OR SHE IS LICENSE�PUFSUANT TO7HE PROVISIONS OF7HE'CONYRAC?ORS LI� � GENSE UW(GWPTER B(COMMENCIN�WITH SECTION 7000)OF DIYISION 9 OF THE BUSMESSAND PRO• V' PODUSpB FESS�ONSCADE)ORTHATHEORSHEISE%EMPTTHEREFROMANDTHE6ASISFOR7HEALLEGEDEXEMP� (J � 710N.ANVVIOLATIONOFSECTION7o37.5BYANVAPP�ICANYXOqAPERAIITSU&IECYSTHEbPpLIdAN7t0 Z Re-ROO} ACIVILOENATYOFNOTMbRETHANFNENUNDREODOLCARS(56Bo):). ��"-�� ` �"���"� � Z ❑I,ASOWNEROFTHEPROPERTV,ORMYEMPIOVEE6WITHWAOESASTHEIRSo�ECOAIPEN6ATION, O Commercial WILL DO THE WORR,AND THE STRUCTURE IS N07 INTENtlEO OR'OFFERED FOR SALE($EC.io44,BU31� ._I N NE55 qN�PqOFESSIONS COOE:TNE CONTRRCTORS IACENSE lAW OOES NOT AP7LY TO AN QWNER OF � PROPERTY NMO BUIL0.5 OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSEIF bR�HECISELF OH C[ THPWGHHISORHEROWNEMPLOVEES,PROVIDEDTHA7SUCHIMPROVEMENTSARENOTIN7ENOEOOR m OOFFEBEDFORSALEIF,HOWEVER,7HEBUILDINGOHIMPROVEMENiISSOLDWITHINONEY�ACi�dF'COMPCE Z iION,THE OWNER•BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHEbID NbT 9UI��OF = IMPROVE FOf17HE PURPOSE OP SALE�. ''� ' �� ��� '���" � ❑1,AS OWNEi1 OF THE PROPERTV.AM EXCLUSIVELY CONTRACTINO WITH LICEN9ED CONTRACTORS � TO CONSTRUC7 7HE PRO.IEC7(SEC.7044,BUSWE55 AND PROFESSIONS fADE:THE'CONYpACYORS LI� V81U8i1017 ADJ.AREA W CENSELAWDOESNOTAPPLYTORNOWNEROFAPRDPERTYWHdBUILOSORIMPROVE§�iFIEAEON,ANO � WFIOCONTRACTSFORSUCHPR0.IEGTSW�THACANIAAC70R(S)UCENSEDPURSUMRTOTHE'CONTRAC- QUANTITY DESCRIPTION �E Y TORS LICENSE LAWJ. � .., � O I AM E1(EMPT UNDER SEC. B.i P.C.FOR7HIS REASON Q � U � ¢ DATE _OWNER_ U Z W � UCENSED CONTRAGTORS DECLARAl70N W ¢ � I HEREBV AFFIRM UNDER PENALN OF PERJURY THA7IAM LICENSED UNDER OROVISIONS OP CHAPTER � !�,/3^ � 9(COMMENCINGWITHSECTION7000)OfDIVISIONSOFTHEBUSWESSANOPROFESSIONSCODE,AND z q7 �X MY IICENSE IS IN FULL FORCE AND EFFEC7 m / � 0 UCENSE C SS LIC.NO. � U DATE � CONTRACTOFi a W � WORKERS'COMPENSATION DECLARATION Q � IHEREBYAFFIRMUNOERPENALTYOFPERJURYONEOFTHEFOLLOWMGDECURATIONS: Z � _I HAVE AND WILI MAINTAIN A GERTIFICATE OF CANSENTTO SELF-INSUPE FOR WORKERS' a - ' a COMPENSATION,AS PROVIDED BV SEGTION 370o OF THE LABDR CODE,FOR THE PERFORMANCE W Q OF THE WORK FOR WHICH THIS PERMIT�S ISSUEO. � � _I HAVE AND WILL MAIMAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION Q 37ooOFTHELAeORCOOE,FORTHEPERFORMANCEOFTHEWORKf-0HWHICHTHISPERMITIS ISSUE6.MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBERARE: CONSTRUCTION Q "�. �. CARRIER PLAN REVIEW �'��:a�� zPOLICY NUMBEfl ELECTRIC ��-- Q 0 �rF+�ssEcnaaN�raTeeoxna.trEDOFn+EPEw.wr�swFloruE�Doott,�tsgtao)ori�ssJ. PLUMBING Z I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PEP/AIT IS ISSUEO,I MECHANICAL �� " t (f SHALLNOiEMPLOYANYPERSONINANYMANNER50ASTOBECOMESUBJECTTOTHE �� - � � WORICERS'COMPENSATIONLAWSOFCALIFORNIA,ANDA6REETNATIFISHOULDBECOME INSPECTIONFEE " ` � SUBJECi TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 370o OF THE LA80R �_�r � CODE,ISNALLFORTHWITHCOMPLYWITHTHOSEPROVISIONS. �SSUANCE ' P�'� a /�� �-' p DAT�� APPItCANT: lY���i SMIP J WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE ENERGY%C LL, SUBJECT AN EMPLOYERTO CRIMINAL PENALTIES AN�CIVII fINES UPTO ONE HUNDRED THqUSAND ENERGY PERMIT DOWRS(S7oo,o00).IN AODIT�ON 70 THE COSTOF COMPENSATION,OAMAGES AS PHOVIDED FOR IN � SECTION37oeOFTHELABORCODE,INTEREST.ANDATTORNEWSFEES. � RETENTIONFEE: �W CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � 1 HEREBV AFFIfiM UNOER PFNALTV OF PERJl1RV THATTHEPE IS ACONSTpL'CTION LENUING AGENCV FOR THE PERWRMANCE OF THE WORK FOq WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.CJ. W � � IENDER'SNAME 1—' IENDEfYSMDRESS_ � TOTAL FEES w 1 CERTIFY THAT I HRVE REAO THIS APPLICATtON AND STATETHATTHE ABOVE INFORMATION IS CARRECT. Q IAGREE 70 COMPLY WITH ALL CITY AND CDUNTY OROiNANCES ANO STATE lAWSAEi.ATING TO BUILDING -� .��'/J^` � GONSTflUCTION,ANDNEREBVAUTHORIZEREPRESENTATNE50FTHI5COUNTVTOENTERUPONTME . ., . Z ABOVE-MENTIONED VROPERTY f-0HINSPECTION PUFPOSES. � COMMENTS � �. � m VERMITTEENMIE(PRINT) - � �- � � Q � � 910NA7URE OF PERMITTEE DATE ��� ����� = RECPT.NO. PAID BY ' VA�.t1�ATION � " , F. _ , ~ WHITE-Depaem�t Copy,YEILOW inence Copy,PINK—Asaessor Copy,GOLDENROD--File Copy,GRE N—AppllcanYs Copy ' ,., . �:.,. :..:• ,. . , .. . <. ,. � . .:,. _. .,.,. , , .. 0 ■ •. .V/� �I �R, ��F�e�..yV�� Y. . . ... Y�# .'.w_ _.� . � T'� q'p�y�/� ' � . .. ...f...r Y.i...,�.s��«mt��.Y.�^� w ,.. �`'�"� � " <����-�°�� ������ . �,.., , =�� r�,�:,., . __ , ... . � '�` , _ . . 0 • i �. ; � . „� . , .,� . � .. ::: � � � � . ■ � . . ._ . . . _ ...._ .. . . ......� . � ..... .. .. 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