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HomeMy WebLinkAbout10753 (5) ,4,,,�..� __——�-- ,. . __ _- ---- - - - - -- - ��.�..�,.�..�o,.... ��. �_ _ _.. . t_— ___ __ __ �.�. �� , . W . , ; _ --- CITY OF DIAMOND BAR COMMUNITY DEVELOPMENT DEPARTMENT .;r w' 21660 E.Copley Drive Suite 190 PRESS (909)860-3195 Fax{909)861-3117 �'v�" BUILDING PERMIT APPLICATION FIRMLY o DDRIESS �_/V ���.G AP'TJ J Lt� � pATE CATION(� �'�..,.�;.-^� NUMB R /D ��C 1 � c� ISSUE TYPE .. N� OCC APN LOT T CT DATE CONST. GROUP p OWNER � � ADDRESS ZONING SETBACKS z CITY ZIP�� TEL. �!' '"" FRONT RW ❑ p APPLICANT TEL. S DElSIDE STREET RW ❑ z ¢ CONTRACTa S�dE �� � ADDRESS � PROPOSED USE "�"-' � CI'fY ZIPC�.�_'�q,� TEL. ''� � ARCH/ENG/ � z DESIGNER ���"��"� � ADDRESS NO.DWEL. NO. NO. � CITY ZIP TEL. UNITS STORIES BEDROOMS cn � DESCRIPTION SQ.FT: FACTOR PSF ADJ.AREANALUATION p� OWNER-6l;iLDER DECLARATION SFR/ADDJREM O W CI MEREBY AFFlRM UNDER PENALN OF PERJUPY THAT I AM EXEMPT fFOM THE CONTRACiORS LI� G&f298IC81POfI ENSELAWFOflTHEFOLLOWINGREASON;5EC.7031.56U5iNESSANOPROFE5510NSCODE:ANYCITYOP (n U COUNTYWHICHRE�UIRESAPERMITTOCON$TRUCT,ARER,IMPROVE,OEMO!ISH,OflPEPAIFANYSTRUQ� W TURE.PRIOFi TO ITS ISSUMICE.AL50 REQUIRES THE APPLICANT FpR SUCH PERMIT TO FILE A SIGNEO W PatiOlOBCk �� � - -� -� - STATEMENT THAY HE OR SHE IS LICENS'e�PLIRSUANT TO THE PROVISIONS OF THE CONTRAC70RS LI� � CENSE LAW(CHAPTER D(COMMENCING WITH SECTION 7000)OF DIVISION 3 0F 7HE BUSINESS AND PRO- LL' PooUSpa FESSIONSCO�E)ORTHATHEORSHEISEXEMPTTHEFIEFROMANDTHCBASISFORTH�ALL[G[O�EXEMP� (� � TION.ANYVIOLATIqJOFSECTION7o31.5BVANYAPPLICANTFORAPERMiTSUBJECTSTHEAPPLICANTTO z Re-Raof A CIVIL PENALTY OF NOT MORE THAN F7VE HUNDRED DOLlARS(SGDO).): � ❑I,ASOWNEROFTHEPROPERTY,ORMYEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, � Comm8ICi81 WILL DO 7HE WORH.AND THE STRUCTURE IS NOT INTEN�ED OR OFfERED FOR SALE(SEC.7044,BU51� J � NESS AND PROFESSIONS CODE:THE CANTqACTORS LICENSE LAW DOES NOT APPLY TD AN OWNER OF ? PROPERTY WHO BUILDS OF IMPROVES 7HEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR C.'t THROUGHHISORHEROWNEMPLOVEES,PROVIDmTHATSUCHIMPROVEMENTSARENOTINTENDEDOR m Q OFFEREDFORSAIEIF,HOWEVER,THEBUILDINGORIMPROVEMENTISSOLDWITHINONEYEAfiOFCOMPLE� Z TION,THE OWNER-BUILDER WILL HAVE 7HE BURDEN OF PROVING THAT HE OR 5!1E UID NbT BUILO OR = IMPflOVEFORTHEPURPO5EOF5ALE). W ❑I,ASOWNEflOFiHEPROPERTY,AMIXCLU5IVELYCONTRACTWGWITHLICENSEOCONTRACTORS OC TO CONSTRUCT THE PROJECT(SEC.7044.BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- V21U84io11 ADJ.AREA W CENSELAWDDESNOTAPPLYTOANOWNEROFAPPOPERNWH08l11LD50RIMPROVESTHERF.oN,AND � WHOCONTFACiSFOftSUCHPR0.IECTSWITHACONTRACTOR(S)LICENSEOPURSt1ANTTOTHECOMRAP QUANTITY D SCRIPTION FEE Y TOR&LICENSE LAWJ. ��.,;'$]��-}w � ❑I AM EXEMPT UNDER SEG B.&P.C.FOR THIS REASON Q (j�C..�."' > � � Ll_. � DATE OWNER � Z W � LICENSED CONTRACTORS DECLARATION W � I HEREBYAFFIFM UNDER PENALTY OF PERJUFY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER � � BI�MMENCINGWITHSECTION7000)OFDIVISION30FTHEBUSINESSANDPROFESSIONSCODE,AND Z �X MY IICENSE IS IN FULL FORCE AND EFFECT. .� m � LICENSE CLASS - LIG NO.� � � V DpTE��.^C�I CONTRACTOR ' a W `��� WORKERS'COMPENSATION DECLARATION. Q � I HEREBYAL'FIRM UNOER PENALTY OF PERJURY ONE OF THE FOLIOWING DECIARATIONS: , Z Z _I HAVE AND WILL MAIN7AIN A CEPTIFICA7E OF CONSENT TO SELF�INSURE FOR WOflKERS' _ ¢ COMPENSATION,AS PROVIDED 9V SECTION 370o OF iHE LA60R CODE,FOR THE PENFOpA1ANCE IU O OF THE WORN FOF WHICH THIS PERMIT IS ISSUEO. � W _I NAVE AND WILI MAINTAIN WORKERS'COMPENSATION INSURANCE,AS RE�UIRED BY SECTION O 3700 OF THE LA90R CODE,FOR THE PERFOfiMANCE OF THE WORK FOR WHICH THIS PEHMIT IS y � ISSUED.MYWORKERS'COMPENSATIONINSURANCECARRIERANDPOUCYNUMBERARE: CONSTRUCTION J Q ----�----> -cnnaieA...__-. PLAN REVIEW • � POLICYNUMBER ELECTRIC Z Q � (THISSEC7IONNEmNOT9EOJMPLEfEDOFTHEPERMRISFORONEHUNORE000LtAR5�5100)ORLESS)_ PLUMBING Z ICERTIFYTHATINTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITISISSUE�,1 MECHANICAL � � C'J SHALL NOT EMPLOY ANY PERSON IN ANY MANNER 50 AS TO BECAME SUBJEC7 TOTHE (/� WORNERS'COMPENSATIONL4WSOFCAUFORNIA.ANDAGREETHATIFISHOULDBECOME INSPECTIONFE� = SU&1ECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 37000f TNE I.ABOR � COOE,ISHALLFOqTHWITHCOMPLYWITHT OSEPROVISID� ISSUANCE p DATE:����-"� APPLICANT. .—".�N—_—tf—.. _ SMIP Cg � WAPNWG FAILURE TO SECURE WORKERS'COMPE SATION COVERAGE IS UNLAWFUL.AN�SHALL BE ENERGY P/C �/ � Sl1BJECTANEMPLOVERTOCRIMINALPENALTIESANDCiVILFINESUPTOONEHUNDRE�THOUSAND ENERGYPERMIT /� � �OLLARS(5700.000),IN ADDITION TO TNE COST OF COMPENSATION.DAMAGES AS PROVIOE�FOR IN � SECTION3�oeOFTHEIABORCODE,INTEREST,ANDATfORNEYSFEES. � RETENTIONFEE: OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: � I HEREBV qFF�RM UNDER PENALN OF PERJURY THAT THEflE IS A CONSTRUCTION LENDING AG[NCY FOR THE PERFORMANCE OFTHE WORK FOR WHICH 7HIS PEflM1T IS ISSUEO(SEC.9097,CIV.C.). Z W � LENDER'SNAME F— �ENDER'SA��RESS � TOTAL FEES � ICEFTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETHATTHEABOYEINFOPMATIONISCORRECT. W I AGREE TO COMP�Y WITN ALL CIiYAND COUNTV ORDINANCESAND STATE lAWS RELATING TO BUILOING � CONSTRUCTION,AND HERE6Y AUTHOFIZ'c REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE � ABOVE-MENTIONED PqOPERTY FOR INSPECTION PURPOSES. Z COMMENTS � k �. h��2-�.�r�' _ m PE MI EENA RWT) p�/'� Q y �(A O � S TUR MITTEE \ OHTE = RECPT.NO. PAID BY VALIDATION ~ WHITE—De artment Co YELLOW—Finance Co PINk:Assessor Co GOLDENROD—Fiie Ca GRE N—A IicanPs Co P PY. PY. PY. PY. 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