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HomeMy WebLinkAbout13592 (14) _��_ CITY OF DIAMOND BAR DEPARTMENT OF COMMUMTY&DEVELOPMENd'SERVICES w . 2166U E.Copley Drive Suite 190 BUII.DiNG PERMrr A-311� " PRESS ... �� FIRMLY ( ) 60-3195 Faa(909)86 """ . ...,.�,., �_ . PPLICATYON � JOBSITE � C DATE�CATION NUMBER ��'✓`"I�#f C a ADDRESS � ISSUE �'� i (��"' TYPE OCC APN T T DATE .� �}-{�%�_ "' � �� • CONST. GROUP p OWNER o ADDR �- ZONING SETBACKS � CITY ZIP TEL. � FRONT RW ❑ � APPtICANT TEL. �°"-' � S DE/SIQE STREET RW ❑ � CONTRAC,�' SIDE ❑ ADD S � CI �' 21P TEL. PROPdSED USE o ARCti/ENGI /, . ��� ��,, DESIGNER �^-���_ PIO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS = CITY ZIP 7EL. � v� DESCRIPTIpN SQ.FT. FACTOR PSF ADJ.AREA/VALUATION � OWNER-BUILDER DECLARATION SFR/ADD,REM O I HEREBV AFFlR1d UNDER PENALTY OF PERJURY TSiAT 1 AM EXEMPT FFOM THE CONTflACTORS LI- G2.f890/CelpOfl � CENSEUWWHTHEFOLLOWINGREASON(SEC.7031.SBUSINESSANDPROFESSbNS".ADE:ANYCRYOR (n COUMYNMICHREOUIRESAPEflMITTOCONSTRUCT.ALTER.IMPROVE.OEMOIISH,ORREPAIRANVSTRUC- W pat10/DCCk NRE,PRIOR TO ITS IS3l1ANCE,AL50 RE�UIHES THE APPIICANT FOR SUCH PERMR TO FILE A SIpNED W STATEMENT THAT HE Op SFIE IS LICENSED PURSUANT TO 7HE PROVISIONS OF THE CONTRACTORS U- � CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 700a)OF�IVISION 30F'THE BUSINESS�AND PRO- u' POOVSpe FES310NSCODE)ORTHATHEORSHEISE%EMPTTHEREFROMAND7HEBASISFORTHEAILEGEDEXEMP- (� TIOP7.M1YYpLATpNOFSECTION70.91.3BYANYAPPLICANTFORAPERMITSU&lECTSTHEAPPi.ICANTTO Z Re-Rooi � A G1VIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(5500).): � ❑I,ASOWNEROETHEPROPERTY.ORMVEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, � COtntTi9rGial �� WILL 00 THE WORK,AND THE STRUCTURE IS N�T�N7ENDED OR OFFEFED KOR SAIE(SEC.7ou,BUS!- J � NESS AND PqOFESSIONS COD[:iHE CONTRACTORS IICENSE LAW DOES NOi APPL4 TO AN OWNER OF � PROPERTY N7108UILOS 6R IMPRDVES THEREON.AND WHO DOES^uUCH WORK HIMSELF OR HERSELF OR � THROUGHHISORHEROWNEMPIOYEES,PFOVIDEOTHATSUCHIMPROVEMENTSARENOTINTENDEDOR m ^ 0 OFFEREUFORSALEIF,HOWEVERTMEBUILDINGORIMPROVEMENTISSOLDWITFIINONEYFAROFCOMPLE � �TION,TNE OWNER•9UIIDER NALL HAVE 7HE BURDEN OF PROVINO THAT HE OA SHE DID NOT BUILD OR = IMPROVE FOR TNE PURPOSE OF SALEI. W ❑1,ASOVMEROFTHE PROPERTY,AM EXCLUSR/ELV CDNTRACTMG WITH LICFNSED COMRACTORS p[ TO CONSTRUCT THE PR0.IECT(SEC.704t,BUSINESS AND PROFESSIONS COP`�E:THE CONTRqCTORS LI- V8IU3t� ADJ.AREA W CENSELAWDOESNOTAPPLYTOANOWNEROFAPftCPERNWHOBUILO50RIMPR04E5THEREON,pND � Wr1000NTRACT5FOR5UCHPR0.7EC75W17NACONTR4C70R(5)LICENSEDPURSUAMT70THECONTRAC- Q(JANTITY DESCRIPTION FEE Y TORSLIGENSELAW.). o ❑I M1 EXEfAP'f UNDER SEC._ B.&P.L`.FOA TNIS REASON a 3 U u- � — DA7E O\YNER _ � O W �e[ LICENSED CONTRACTORS DEGLARA710N W OC IHEREBYAFFIRh1UI�DERPENAl.1YD ERJURYFNRTIAMLICENSEOUNDERPROVISIONSOFCHAPTER � d Y(OOAIMENCINO WITI SECTKKd 7 DIVI510N 30F THE BUSINE5S AND PROFEESIONS CODE,ANO z � AIY UCENSE IS IN FULL FORCEAN6 F -CT. -I�YI/ . > O] O I�f�\� � '—. _ � UCENSE CLASS �LIG NO. ,7py�_g�� � V DATE CONTRACTpR____,�__ O- W � WOFKERS'COMPENSATION DECiARATION ¢ , . � I HEREBYAFFIRM UN�ER PENALTY OF PEfiJURV(N1E OF THE FOLLOWING DECLA��� U �- � FlATlONS: Z ` � _IHAVE/VdDWILLMAINTMNACERTIFICATEOFCANSENTTOSELF-MSUREFORVVORKERS' � COMPENSATfON,AS PROVIDED BY SECTICIV 3700 OF THE I,ABOR CODE,FOfl THE PERFORMANCE w O OFTHE WORK FOR WHICH THIS PERMIT IS ISSI!E�. g � ^IHAVEANDWtLLMAINTAINWORKERS'CAMPENSATIONINSUR4NCE,ASREOUIREDBVSECTION O 37ooOFTHELA@OftCOOF,FORTHEPEflFORMANCEOFTHEWOPoCFOflWHiCHTHISPERM1T15 �(�'� ISSUEO.MY WORKEAS'COMPENSATION INSURANCE CARRIER AND PGLICV NUMBER ARE: CONSTRUCTION __��}..`,l � } j cnaaiEA PLAN REVIEW ��� Z va.iCYNUMBER __ EIECTRIC ��ri.��:'":.:'.":,.� � (I}I{55Ei;TpNNE�PiOTBEWi.9R.EtmOF7F�PEFN1(ISFORIXJEMIDDREDOC�IMS(5100)OPLESS� PLUMBlNG � ICERTI�YTHATINTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERIAfTISIS5UED,1 MECHANICAL �-�--{y {°,���� LJ SHALLNOT EMPLOYANY PERSON IN ANY MANNER SbAS TO 9ECOME SUBJECT TO THE ''� y� ` � WORKEHS'C%1MPENSATIONLAWSOFCALIFORNIA,ANDpOREETHATIFISHOULpeECQME INSPECTIONFEE —�.� "' �e? ���'{f.� S SUBJECT TO THE WOflKERS'GOMPENSATION PPOVISIONS OF SECTION 370o OF TME LA@OR :'G CADE,I SHAU.FOR'THWt7H COMPLY WITHTHOSE PFOVISIONS. ISSUANCE u�:�#�'� �'�^�°�'� a '�",��� � � o a ��N x.r^a - ?.�q,w „ DATE:_�___ APPUCANT: SMIP �_ -$:y�a �. �.'�:"��f��..� r.. w ENERG`/P/C �a'��"� 1 � � � WARNINO:FAILURE TO SECURE WORKERS'COMPENSA710N COVERAGE IS UNL0.WFUL,AND SHALL BE � SU&IECTANEMPtAYERTOCRiM1NALPENALTIESAN�CIVILFINESUPTOONEHUNDREOTHOUSANO ENEflGYPERMIT OOLLARS(5100.0OO�.IN AODITION TOTHE CQSTOF COMPENSATION,OAMAGES AS GPOVIDEO FOft IN � SECTION 3708 OF TNE LABOR CODE,INTEREST,AND ATTORNEV'S FEES. RETENTION FEE: OCONSTRUCTION LENDING AGENCY PRE•ALT PEE: 4 1 HEREBV AFFIRM UNDER PENALTY OF PERJURV THATTNERE IS 0.CONSTRVCTION LENOMG AGENCY �,� f-0R THE PER W RMANCE OF THE WORK FOR WNICH THIS PERMIT IS ISSUED�SEC.3007,CIV.0.). , Z W — - � LENOER'SNAME_ _ " ' F- LEN�ER'SADDRESS � �'OTAL FEES �- � I CERT�FY'HAT I 71qVE APPLICATION AND STATE THRT THE ABO I O MATION IS GORRECT. �� W IAGREE TO CAMP TH AL ITV ANO CAUNTY ORDINANCES AND S, ELATING TO B LDING � CONSTRUCTI D HE AUTHORIZE REPRESENTATIVES I . 70 E�THE ��� �� Z A80VE-ME ERN SP CT N URPOSE. � � �, e1� COMMENT � ' � m ERMITTEE NAME(PR ) � Q � �/y SIGNATURE OF PER6AITTEE DATE p �� = RECPT.NO. PAI�BY _J VALIDATION- ~ WHITE—De aAment Co VELLOW—Finance Co PINK—Assesso�Co GOLflENROLl—File Co GREEN— P PY. PY. nY. PY. 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