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HomeMy WebLinkAbout13595 (17) _`�_ CITY OF DIAMOND BAR DEPAIYTMENT OF COMMUNITY 6�DEVELOPMENT SERVICES � 21660 E.Copley Drive Suite 19U (909)860-3195 Fax(909)861-3117 - �PRESS �,� BUII.DYNG PE, APPLICATION FIRMLY, � JOBSITE �^ APPLICATION � PERMIT �2 �/1[" P/C o ADORES � ti' DATE NUMBER J ��`�� � # c� ISSUE (� C' TYPE OCC APN�L TRACT DATE ��•�"`� �� � � CONST. GROUP p OWNER �' AD S ZONING SETBACK5 � CITY � ZIP TEL. REART RW ❑ APP�ICANT TEL SIDE/SIDESTREET RW ❑ � CONTRA SIDE ❑ � ADDRES � PROPOSED USE C IP TEL. � w ARCWEPIG! R.1��\ ����_--^I��a_c-�„ , z DESIGNER �� � NO.DWEL. NO. NO. � ADDRESS _-_.`--__. __— UNITS STORIES BEDROOMS � CITY ZIP TEI.. , � DESCRIPTIQN SQ.FT. FACTOR PSF ADJ.AREANALUATION v� oOWNER•BUILDER DECIARATION SFR/ADDlAEM o I HEREBY AFFIRM UNDER PEN.LLTY OF PERJURY THAT I AM CXEMPT FROM THE CONTRACTORS U- G8f8lJB/C8f(701t W CENSEUWFORTHEFOLLOWINGREASON(SEC.7031.5BUSINESSANDPROFESSfONSCODE:�AtdYqTYOR (f� G.7 CpUPfTYVyNICHREOUIRESAPERMITTQCONSTRUCT,ALTER,IMPRQYE,�EMOl15H2ORREPAIiiANYSTRUC• W Pyt10/DBCk WTURE.PRION TO ITS ISSUANCE,ALSO REOUIitES TNE APPLICANT fOR SUCH PERMIT TO FILE A SIGNED w � STATEMENT 7HAT HE OH SHE IS LICENSED PURSUANT TO TNE PNDVISIONS OF THE CONTRACTORS L6 � CENSE UW(CNAPTER 9(COMMENCINa WITH SECTfON 7Wo)bF�71V1310N��OF THE6IJSINE�S"AND PFiO- V" POOL�Sp2. FESSIONS ODDE)OR THA1 HE OR SHE IS EXEMPT THEREFFOM ANb THE BASI5 FOR THE ALLEQE�EXEMP- TION.ANYVIOLA710NOFSECTION7031.68YANVAPPLICANTFORAGERMI7SUBJECT5THEAPPUCANTTO Z Re-Rooi � ACIVILPENAI.TYOFNOTMORETHANFIVEHUNDREDDOLLARS�S$oo).j: "-'- � � ' � ❑I,ASOWNEROFTHEPHQPER7Y,ORMYElAPLOYEESW17HWAGESNSTMEIRSOLECOMPENSATqN, Q Commercial - WILL 00 THE WORK,AND THE STRUCTURE IS NOT INTENOEd OR OFFERED fOR SAIE(SEC.704a,BUSI- _1 NESS AND PROFESSIONS CO�E:THE CONTRACTORS LICENSE LAW�OES NOT APPLY TO AN OWNEii OF � P0.0PER7YWHOBUILDSOR1MpROVESTNERE�J,ANDWMODbESSUCHWORKHIMSELFORNEFiSELFOR � � THROUGHHI90RHEROWNEMPLOYEE5,7ROVIDEDTHATSUCHq.1PROVEMENT5ARENOTINTENDEDOR m � OFFEREDfOR5ALEIF,HOWEYERTME8UIL01NGORIMPROVEAIENT1SSOfDWI7HINONEYFAROFCOMPIc- Z TION,THE OWNEH•OUIIDEfi WILL MAVE THE 9UROEN OF PROVINCa THAT ME'OR 5ME DID NIST�BGILD'OR = IMPROVE FORTHE PUAPOSE OF SACF). �� '� - - �/ ❑1,AS OWNER OF TNE PROPERTY,AM EHqL51V6LV CDNTRACTWG WRN LICENSEO C6N1'RAC70AS � TO CONSTRUC7 THE PROJEC7(SEC,Ic44,9USINESS AND PPOFESSIONS COUE:THF CQN'RA<:70RS ll� ValtJatlOn � ADJ.AREA W CENSEUWDOESNOTMPLVTOANOWNEROFAPAOPERTVWHOBVILD50RiMFRQVESTHEREON,AND -- � WFIOCOMMGTSFORFiUCHPpOJECT9WITHACONTqACTORjSjL:CENSEDPUftSUANi'iOTFIECCNJTMG QUANTI DESCREPTlON FEE Y TOflS UCENSE tAW.). - � ❑I AM E%EMPT UNDER SEC. �.e P.Q FOF TNIS REASON �� � —_ . ---_� .___� � � DATE OWNER U LLI ds[ LICENSED CONTRACTORS DECLARA710N u� C'r I NEREBY�FFIqM UNDER PENALTV OF PENURV THA71 AM LICENSF.D UN�ER CROV'�.SIONS OF CHAP7EF � � B(COMMENCINO WITH SECTION 7 OF DIVIS70N 3 0F TN BUSINESS RNO OFESSIONS CODE,ANO � XL' MY IICENSE IS IN FULL FORCE D fFEC7. m LLi `//l��_��{'(� �l['�J o LICENSE CLASS liC.NO.___`�_T.�_ ��..� � . J� � DATE ,__ CONTNAC'OR. ___ _ Q- W . � WORK£R5'COMPENSATION DECLARATIOPI _ . � � y,„� . �• �-:; � � - . „ � , .� .��e 4 , .. :�.<.k,r >�z�.-.�... . ti -.� , R,< . , � I HEREBYAFFIRM UNOFR PENALTV oF PERJUAY tINEOF THE t'-0LLOWING DECLARATIONS: � a _-- � _IH�IVEMNWII�l.iAAINTNNACERTIfICATEOFCONSCNT'fOSEIFdNS'JftEF6RWORKERS' � � COMPEN5/4TIDN,AS PidOViDED 8Y SEC710N 3NOOF TNE IABCR CODF,FO�THF PEFF6RMANCE w OF�'HE WCNiK FOR WHICH THIS PEiiMIT IS ISSUED. g O W _IHAVEANDK'lLLAAAIMAIN`MORNERS'CAMPENSATIONINSURANCE,ASflEQUIREDBYSECTION � 3700 OF THE LABOR(70DE,FOR THE PEAFOAMANCE OF THE WORN FOR WH�CH THIS PERMR IS �` � ISSUEQ.MVWOFlKEFS'(Y]M.^ENSAiIONINSURANCEC0.RRIERAN�POLICYNUMBERARE: CONSTRUCTION _ C�°1���.�"l..° � � l �, c,waieq_ ______ PLANREVIEW _ A — � Pa.ICYNUueFft __-� . ELECTRIC _. 'st ....-�� p (tHSEECilONNE�NCTBEO�W'lETEDOFTHEPEHNdTISFORCNEIiLMJ�F2EDC0l.LAFiSI5100)ORL[SS}. PLUMBING __ -..�-�.�� -�'::7.F 1 ;y,�.".�� Z ICERTIFVTHATIN7HEPEHfORMANCEOFTIi[WORKfORWHICHTHISPEf:MITISISSUE�,I MECHANICAL �-�''�a� '� SHALL NOT EMPLOY M'Y PERSON IN ANY MANNER 50 AS TO BECAME SuBJEC?TOTtIE i ,}p (q WORK=RS'CAMPENSATIONLAWSOFCALIFORNIA.ANDAGREETHATlFISY.OULfJ9E(:OME y INSPECT�ONFEE ���9+bd� �, S SU0JEC7T0 THE WORKERS'COMPENSATION PROVISIONSOF SECTION 37CODF THE LAAOR 6 �, � �"� CAOE,I SHALL FOffTHVdITH COMPLV WiTH THOSE QROVISIONS. � ISSUAIVCE $ A w l^. `'� .���� �--� . l J�`� p OATE: APPLIGANT: _ �_ SMIP ��a� 4 ,V �� ,,'b�rtl-�� —�-'l.) . J WARNIYG:FAILURETO SECURE WORKERS'COMGENSATION COVERAGE ISUNLAWFIJL,AND SHAL�BE J ENERGY P/C q � .�'S+� � ''�:� � "� ' , yy SU&IECTAN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UB TO CNE HUt�pRED THOUSAND ENERGY PER�fiAI�a �" � ���x� DOLLARS(E10D,000).IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDE�FOR IN �;,.," � SECTION37080FlHELA00ftCODE,INTEREST,ANJA7TORNEY'SFEES. RETENTIONFE�'£ � a CONSTRUCTION LENDING AGENCY pRE-ALT FEE: /'�y�/ j �..� � I MEREBV AFfIRM UNOER PENALTY oF PERJURY 7HAT TNERE IS A CONSTRUCTION LENDIN�pGENCY 4.�'j/�4—..(� d FOR THE AER WRMANCE OF THE WORK FUR WHICH TMIS PERMIT IS ISSUED(SEG.3a9],dV.G.): . �'� Z W "__" __ � LEN�ER'S NAME F— IENpER'S ADDRESS .. .. ... . . � TOTAL F S w I CER7IFY THAT I HA EA� IS APPLICATION At�STATE THAT THE A80 FOR ATION IS CORRECT. _j�r �^�-� � I AGREE TO WITH CIN AND L'OUNTY ORDINANCES AND S R LATING TO BUILDING � „�.}��` .��. ;.,1�/�� CONSTRUCT ,ANO 6YAUTHORIZEREPRESENTATNES ISC NTYTO��HE a�� Z PBOVE-M PERTY F N ECT N SE ` COMMENTS � � � � . - .' �/ . 4 ....... . . . � / _ . __.- . .. . m PERMITTEE NAMe�P T� - � " a cn _ � SIGNATUREO PE0.MITTEE �ATE j �....: .:. .... . ' � = RECf'L NO. 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