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HomeMy WebLinkAbout13590 .,. , __ -� , - _ _ _�� CITY OF DIAMOND BAR � DEPARTMENT OF COMIVIUNITY&DEVfiIAPIVIENT SERVICES � a 21660 B Copley Drive Suite 190 w (909)860-3195 Faz(909)861-3117 '-"'y `�'f'I�� PRESS � � BUII,1`lI1V�P��TT�il'PLICATI('/N " " ; . . "� �(� FIRMLY . ,,. ,,..... � JOBSITE �p�- APPLICATIpN ERMIT j�P/C Q ADDRESS �° 1 �� pATE NUMBER�,�„%# c� ISSUE �' TYPE OCC APN T T A T� DATE ��. L'�^��� CONST. GROUP p OWfJ�R _ "" ADDRESS �� ZONING SETBACKS � CITY ,� �Z�IP���,�v�-�� TEL. - FRONT RW ❑ APPLICANT____ 'L'Lv"L�-'' T • '�"'� SIDE/SIDE STREET RW ❑ � CONTRAC SIDE ❑ � ADDRE PROPOSED USE CITY � TEL. � ARCWENG7 ���� Q �..�� • .• DESIGNER �s� NO.DWEL. NO. NO. ADDRESS IJNITS STORIES BEDRpOMS � CITY , _ _ ZIP TEL. � DESCRIPTION SQ.F7. FACTOR PSF ADJ.AREA/VALUATION OpWNER-BUlLDER D�CLARATlON , $FR/ADDIREM � I NEREBY PFFlRM UNDER PENILLT'OF PER/URY THAT i AM FXEMPT FR4M THE CONTRACTOflS U- G81'BgBJCef�JOfI W CENSEUWFORTiEFOLLOWINGREASON(SEC.7a�1.5BUSINESSANDPpOFESSbNSCODEiANVCITYOR (f) CJ CIXINiVWHICHREWIRESAPERMRiOCONSTfiUCLAL7ER.IMPROYE,DEMOLISM,OFREGNRANV57RUG W pai�C/DBCk WNRE,VflIOR TO RS ISSUANCE,AISO�ItEQUIRES THE APPULA.NT FOR SUCH PERMIi TO�LL.E A�SYGNED W � STATEMENT THAi HE OR SHE IS UCENSED PUFlSUANT TO Tl1E PROV�SIONS OF THE CANTRACTORS�II� � CENSE LAW(CHAPTER e�COMMENCINa WITH SEC'fION 7000)OF DIVISION 3 0F THE BUSINESS ii1JD"Pq0. LL- Poob'Spa FESSIONS COO�ORTHAT HE OR SHE IS EXEMPT THEREiROAI AtdD THE BA515 FOFl TFiF ALLEGE��EAEMP• TION.NIVVIOlAT10NOFSECTiON7031.6BYANVAPPUCPNTK'ORAOEPh��TSU&IECTSTH�_APPLICANTTO � Re-Roof � A CIVIL PENAtTY OF NOT MORE h1AN FNE HUNORED bOLLARS(5500�.): - �.� � pt,A50NT1EqOFTHEPROPERTV,ORFAVEIAPLOYEESWITHN'AGESAS7NEIflSCLECOMPENShTION, C3 COfnmerCi21 ' WILL DO TNE WORK,MID 1HE 5TRUCTURE�IS�NO7 INTENOEp 6R OfFEREO FOp SACF(SEC�04:1,'9USI- J N65SAND PROFESSIONS t�E:TME CANTRACTOpS UCENSE lAW DOEu kOT AORIV TO qN OWNER OF t � Pf�PERTYWFIOBUILD50RIMVFOYESiMEREON,ANDWHOdO'ESSUCHWORKHIMSELFORHER9�LK'OR � � THRd1CiH HIS OR HERONTI EIdPLOYEES,PppV10ED 7NATSl1CFl IMPROVEMENTS ApE N�T MTENOED OR �� � OFFEAEDFORSALEIF,HOWEVF,Fi.TNEBUILDINGORIMPROVElAcNTI550LAW1Ti11NONFYEAROFCOKiPlE- Z TION,THE OWNER-BUILpEF WILL HAVE 77iE�RDEN OK PRdVINO THAT FIE OR SHE DID NOT 13UIlA,OR = IMPROVE FOR THE PURPOSE OF SALFJ. ` ❑I,AS OWNEN OF THH PROPERiV,AR7 EXCLllSIVELY CAhIYRA(:TING WRN LlCENSFO.ANT�CS'ORS � TO GONSTRUCTTHE PROJECT(SEC,7oat,BUSINES3 AND PROFESSIONS COCE TH�CONYRACTOpS Ll- V81Ud1 ADJ.AREA LAJ CENSELAWDOESNOTAPPIYTOANOWNEROFAPROPEfl7YWH06ULD5DRiNPROVESTNEREON.ANO -.-- ��� 3• W11000NTRACTSFOfl3UCHPROJECTSWITHACONTMCTOR(S�LICENSEDPUFl6UA'�ITTOTHECONTRAG pUp,NT3TY DESCRIPTION FEE f` TtlRSUCENSELAW.). � � � O IAM EXEMPTUN�ER SF.C.^ ..__—_—__..�•&i�.C,FOR THIS FiEA5ON U V � � DATE _� �OWNER_.____ � Z W 4 LICENSED CONTRACTORS DECLRRATION -� .y "'--� ac IHEREBY�FFIRMUNOERPENALTY PERJURYTNATIAMUCENSED'JNDERVROVISIONS.7FCHAPTER � p. B�COMMENCINt3VJITHSECTION Of01VISION30FTHE U INESSANDPROFESS�ONSCACE,ANO Z. SC MY UCENSE IS IN FULI FORC FECT. � CL � � UCENSE CLAS@ LIC.NO.� � V DATE CON7RACTOR, __ �- W 0� WORKERS'COMPENSATION DECIARATION --� � � � '!� -:i .��. � 1 HEREBYAFFIRM UNOER PENAUY OF PERJURY OYE OFTHE WLLOWING DECLARAiIONS: � � Q' . � ._, . ... . � _INAYEANDWILL�dAINTAINACERTIFICATEOFCAN5ENT7p3E4F�INSUftEfO^WDRKGfiS' :_ � �� � , - �� " '�' COMPENSATiON,ASPqOVIDED9YSECTfON3TDOOFTHEI�.BORCODE,FOR7HEPERFORMANCE cU �__ U 1 OFTHE WORK FOR WHIGH TMIS PERMIT IS ISSIIED. �� I - G] '"e I—_� W _IHAVEANDWILLh1AINTAINWQRKERS'fAMPENSATIONINSURANCE.A5AE0U1REDSV5EC710N � � � 870007F TkE LA80R GODE,FOR TF7E PERFORMANCE OF THE WORK FOH WHICH THIS PEfiM1T IS r � L"�`�� �Y�I n ISSUm.MY WORNERS'GOMPENSATION INSUAANrE CARRIER AND POLICV NUMBEri ARE CONSTRUCTION __. � `� I � ¢ CARRIER_ � PLAN REVIEW t't t �;�� . �2�. � - 7' --� a � POLICYNUMBFR —. �--- ELECTRIC ��g ���`� ���4k'���+� d � °� a �tFnssFcmn!n�tvr�oreeo�a+A.ErFro'rwrvw�r�FcwoNEr,u�au�Eoiaei.ans�5iw)oA�essa j PLUMBING a +� as n�t;�* ..~��a, .�,� ... W I CERTIFY THAT P!?NE PERFOFiMANCE OFTHE SVORK FOR WHICN THtS PERMiT iS ISSLIEC7,l MECHANICA� g' m` H '�� �,° �'4� '+ . Z ,_ � VY9HKERS'COMPENS TIONIAWSIOf�'F ANIA,0.NOAGREETHAMEF SHOUL�6 COlAE INSPECTION FEE f��N .aa"�^;'u'A� � SU&IECT TO TXE VdORKERS'COMPENSATION PftOVISiONS OF SECTION 3�00 OF THE LA80F / � WDE,I SHALL FORTHWITIi COMPLY WfTH TFiO5E PROVIS�ONS. �SSUANGE _ -�•�y t-/ � � SMIP `J�--i p DATE: APPLICANT: . . � ! ENERGY PIC � WARNING FALURE TO SECURE WOFKERS'COMPENSA710N COVERAGE IS UNtAWFUL,AND SHAL4 gE �y, Sl/B.�ECTANEMPLOVERTOCflIMINALPENALTIESANOCIVILFINESUPT�ONEHUN�AEOTHOUSAN� E4ERGYPERMIT DOLLARS(SiCO.00Ul,IN ADDITION TO THE COST Of COMPENSATION,DAMAOES AS PROV'.DED FOR�IN —' � SECTION37080FTHELABORCODE,INTEREST,ANDATY�RNEV5FEE5. RETENTIONFEE: OCONSTRUCTION LENDiNG AGENCY PRE-ALT FEE: � INEREBVAFFlRMUNDERPENALNOFAERJURYTF7ATTHEREISACONSTRUCTbNLEN�INGAGENCV � FOATHE 7ERFORIAANCE�FTiE WORK FOfl WHICH THIS PERMIT IS ISSUEO(SEC.309i,CIY.CJ. Y`�-�r�"'6"� � � W —` � LENDER'S NAME ,— � I—^ LENDEA'SADORESS � ICERTIF'ITHA7IHAV EAD ISAPPUCATIONAND9TATETHATTH£A90V � �A7bN�s�RA«T. 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