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HomeMy WebLinkAbout15289 (17) __.. ,>� , _,�,;�,. . , � �-� ��_ CITY OF DIAMOND BAR � DEPARTMENT QF COMMUNITY&DEVELOPMENT SERVICES _. � 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-311� P S 9�''�' svn.D�iG���vtrr A�rr.tcATTox _ ` >: FIRMLY o ADDRESS ,a .. �.,Q.., , ,,.. ISSUE.�., ��� Q. �,. �TYPE ER,. ..�r . ., , ,«,. _.. ., ...,�,: .., ,..., } JOBSITE �„"�,.�"��` ���,��� APPIICRTiON PERMIT �� P/C � OCC APN LOT 7RACT DATE CONST. GROUP p OWNER ��.�<4d�-�-�5 �..1�-�0''.� LL ADDRESS �� ZONING SETBACKS � CITY���'7+�K�-��"3�``�. ZIP,s�/�.�.. TEL.r� �r '��'6� FRONT RW ❑ APPLICANT TEL� REAR ❑ � SIDEISIDE STREET RW ❑ CONTRAGTOR vS-�I:.i�i���a=�_����'2C � SIDE ❑ � ADDR SS ���t` `""`��D'+�.'=�.t"`�»�' J pROPOSED USE a CIIY �-t'�:cs,�f�.%P'C.r:`xi.% ZI �k'a�Y"� TEL. ��S �,�.� _� ..r o ARCH/ENG/ � DESIGNER NO.DWEL. NO. NO. ADDRESS U N ITS STORI ES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER-BUILDER pECLARATION SFR/ADD/REM � � � O [� I HEREBY AFFIRM UNDER VENALTY OF PERJURY THAT I AM EXEMPT FROM THE CANTFACTOflS LI- � �arage/Carport {yJ CENSELAWFORTHEFf1lLON/INOREASON(SEC.70.91.68USINESSANDPROF'cSSIONSCODE:ANYCITVOR U COUNTYWHICHPEOUIfiESAP6iMtTTOGONSTRUCT,ALTER.IMPROVE.DEMQUSH,ORREPNRANYSTRUC� IW PetiOJDeCk WTURE,PqIOR TO 1T5 13SUANCE,/U.SO REQUIHES THE APPLICANT FOfl SUCH PERMIT TO FILE A SIf3NE0 � STATEMENT THAT HE Ofl SHE IS UCENSED PURSUANT TO THE PFtOYI510N5 OF THE CAMFiACTORS LI• CEN6E LAW(CHAPTER 9(COMMENCINO WiTH SECTION 70J0)OF DiVISION 3 6F TNE'BUSINESS AND PRO� V" POOVSpB FESSIONS COOE)OR 7HAT HE OR SHE IS E%EMP7 iHEREPNOM AND THE BAS�S FaR THE ALLEGGD�EXEMP• TKKJ.ANYVIOLA710NOFSECTION7o31.6BVANVAPPLICANiFORAPERMITSUBJECTSTHERPPLiCANTTO � R@-ROOT � A CML PENALTY OF NOT MORE TMAN FlVE HUNDRED OOLIARS IxSooJ.): � �I,�SOWNEROFTHEPROPERNORIAYEMPLOYEESWITNWACiESAS7HEIq80LECOMPENSATION, C� COroR18rCi81 � � WILL DO iHE WORK,AND THE STRUCTURE IS�NOT IN7ENDED OR OPFEREP FOR$AlE(SEC.�7a14,BUS4 _,.I NESSAND PROFESSlONS CODE THE CDNTRACTORS LICENSE lAW DOES NOT AFPLY TO AN OWNEP.OF � PpOPERiYWtiOBUILD50RIMPROVE3THEREON,ANDNMODOESSUCHWpRKH1l,iSELFORHERSELFOR � � THROUGH NISOR HER ONM EMPLOYEES,PROVIDEO THAT 5UCH IMPflOVEMENiSARENOT INTENDED OP � L}1 .OFFERE�fORSALE IF HOWEVER 7'FIE 9UIlDINQ ORIMPROVEMENt IS SO(D WrfHIN�OIJE VEAq OFCOb1PLE- � �TH7N,TNE OWNER•B111L0ER WILL HAVE THE BUR�EN OF PROVING 7HAT ME OR$NE bID NOT BUILD OR = IMPilOVE FORTHE PURPOSE OF SA4E�. � ❑�.AS ONMER OF THE PHOPERIY.+�M EXCLUSNELY CONTRACTING WITtI LICENSEP CONTRACTORS � i0 CONSTRUCT THE PR0.IECT(SECJoaI,9USINESS ANO PROFESSIONS CnDE'fFIE CONTRAC70RS U- ValUation ADJ.AREA � CENSEl,�W00E5NOTAPP4YTOANOWNEROFAPROPERTYWFIOBU11A30RIMPROVE3THEFlEON,AND NAiOCONTFUCTSFORSUCHPROJECTSWITHACONTR4C70R�S)LICENSEDVURSUAPITTOTHECONTRAG QUANTITV DESCRIPTION FEE - Y roas ucr7+se uw.). � �71AM EXEMPTUNDERSEC. 8.Z P.a FORTHIS RFi�SON � � - OC LL DATE OWNER'_ U � UCENSE�CONTRACTORS DECLARATiON W '""'�"^--.- �� ��-�... � - �� �� � I HEREBY AFFIRM UNDER PENAITY OF PERJURY THAT I AM LICENSEO UNDER PROVISIONS OF GHAPTER � � �� ��t e.t��:��'�,���` i � B(CqMMENGINp'MTH SECTION 70a0)�F DIVISION 9 OF THE BUSMESS AND PqOFESSiONS CODE,AND Z `aes� MY UCENSE IS ml FUIL FORCE AND EFFECL � Q LICENSE CLASS_ �"�� LIC.MO. �✓����� � F �j DATE "1`j-�...••4,.�..•� CONTRACTOR.�' 0. . _ W � WORKERS'COMPENSATION DECLAKtATION� �Y�'�� � � aY6 U � IHEREBYAFFIWAUNDERPENALNOFPERJURVONEOFTHEFOLLOWINGDEClRR7 S. � 4 0 ^IHAYEANOWIILMAINTAINACERTIflCATEOFCONSENT705ELFINSUREFOPWOitKEFS' X � COMPENSATION.ASPROVIDEOBYSECTION37000FTHELABORCODE,f-0RTHEPEFFOFMA �U _ OF TIE WORK FOF WHICHTHIS PERMIT IS ISSUEO. � � — W _I HAVE ANO WILL MAINTAIN WORKEflS'CAMPENSATION IN5URANCE,AS REQUIRED BY SECTION Q 37o00fTHELABORCODE,f'ORTHEPEPFORMANCEOF7HEM/ORKFORWHICHTHISPERMITIS � ISSUED.MV WORKFAS' IRPENSATION INSl1RANCE CARy�I�+Fi AND POLICY NUMBER AflE: CONSTRUCTION � CMPIEF��'�F�'sL'!`^��%''s., i.�:.b�,'b..J�Ld.'�:"fi-��.: � PLANREVIEW � POLICYNUMBER �-c--=e�='r��Et".'����-"-=.�"- � � ELECTRIC 0 [�+tss[tiqrdtiE�rpieEoanv�E7e�oF'r�!evEw.ur�sFOFlFla�er+urua[�yb41o1i� 1. PLUMBIN .. � w � MECHANICAL � I CERTIFYTHAT IN THE PcflFORMANCE OFTHE NIORK FOfl WHICH 7MI5 PE�Mii IS IS�UED,I ('f SHALL NOT EMPIOY ANY PEF7SON IN ANY MANNER SO AS TO BECOME SUBJECTTO THE gp WORKERS'COMPENSATION UWS OF CALIFORNIA AN�AGREE TMAT IF I SNa1LD BECOME INSPECT�ON FEE f SUBJECTTOTHEVJURKERS'COMPENSATIONPROVISION&Q�,SECTiON37oCOFTHELABOR ISSUANCE � �A (� � -�j CODE.I SHALL FOftTHWITH COMPIY WITFlTHOSE PRQYISIONS.`� Q /'"^�}��-.4�„,=1 -'ti�e...-..,...,..._...-,.�..�.�,. - 91vi�P p OATE:, r_.,_'"+�✓ APPLICANT: V��--�"""---�—. . � � ENEPGY P/C WARNWO:fAILUAE'"O SECUfiE WORi(ERS'COMPENSATION COVEPAGE IS UNL4WFUL,AND SHALL 0E 9 � SU&IECTANEMPLOYERTOCPIMINALPENALTIESANOCMIFMESUPTOONEHUNDREDTHOUSANO ENERGYPERMIT d OOLLARS(5100.000).IN A�DITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIOED FOR IN � SECTION 3708 Of THE LABOR CODE.�NTEREST,ANDATfOFWEYS FEES. RETENTION FEE:R"�7a 4 + .y. � CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � a � 1 HERE6V AFFIRM UN�ER PENAL7Y OF PEFJURY 7FiAT7HERE IS A CONSTRUCTION LENDING AGENCY 1 B e� , , , a- FqRTHEPERWRMANCEOFTHEWOpKFORWHICH7HISPERMITISISSUED(SEC.30W.CIV.C.). ' ' .. Z W � lENOER'S NAME . i_- LENOER'SAODRESS C � � � er� p /� WICERTIfYTHATIHAVEREADTHISAPPLICATtONANOSTATETHATTHEABOVEINFORMATIONISCORRECT. TOTAL FCES J 1 1 /v � IAGREE TO COMPLY WITH ALLCITY ANO COUNTY Ofl01NANCES AN�STATE LAWS REINTING TO BUiIAING / / d CONSTRUCTION,AND HERE6Y AUTHOPA2E RE7RESENTATIVES OF THIS COUNTV TO ENTER UPON THE ZA90VE�MENiIONED PRO ERiY FOR INSPECTION PURPOSES. COMMENTS � ��.�=��:4��;�'��,�-�..,a�-..�:�.i_.`-,d ro ��` Q PERMITTEENAME(PRIlST) .� ) � "�.�„-'.-....�.,..,._��a.., g."-�a�� � SKiNATUREOFPERMITTEE OATE = RECPT.NO. 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