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HomeMy WebLinkAbout13597 (14) ^ �,� CITY OF DIAMOND BAR DEPARTMENT OF C(�M1VfUNITY&UEVELOPM�ENT SERVICES 21660 E.Copley Drive Suite 190 PRES$ :W r (909)860-3195 Fax(909)861-3117 9��. ; Bva:�ai�'c`r�E.;: At�pi,�Ca�oN. , 4,., _ __...,...r FIRMLY � JOBSITE �!,(i(�f� t,�� APPLICATION PERMIT �-(� P/C Q ADDRE5S4,��g,�� '"����''14-e ���- DATE NUMBER '�f � li ISSUE TYPE OCC � APN T T DATE �����-��� CONST. GROUP p OWNER lS , p ADDRE� `Z .. ZONING SETBACKS z CITY � �_�f'��_ZIP TEL. ' FAONT RW ❑ g APPUCANT �'L.3�...� TEL ,, ,i,, REAR O � SIDE/SIDESTREET RW ❑ � CONTRAGT@ � � ' t SIpE ❑ � ADD S 1 �� PFOPOSED USE _ _ CI ZIP TEL. '�:'�" .�� t.�/� A:!M i f\ � w ARCH/ENG/ �� ���, ��y-, � ��_�`'C ° ' � � Q DESIGNER�--c`�.,-�--_7��_��S ADDRESS fVO.DWEI. NO. NO. UNITS STORIES BEDRdOMS � CITY ZIP TEI. � DESCRIPTION SC].FT. FACTOR PSF ADJ.AREANAWATION N Q OWNER-BUIIDER DECLAFATION �� �SFWADD/REM O L] I HEREBY AFFlRM UPAEP�ENALTY OF PERJl1RY THAT i AM E%EMPT FROM TNE GONifiACTORS�ll� ' � Gdr�.q0!4af(JOII W CENSEUIWPoRTHEFOIIOWMGREA30N(SEG7a31.58U51NESSANOPpOFE5510N5CODE:ANVCI7VbR � CpUNi`fWHiCHREQUIRESAPEflMRTOCpNS'TFiUCT,ALTER,IM?ROVE,DEM04�SH,ORREPAIRANI'5T,RUG � py�i0/D@Ck W 7UqE,PRIOR TO ITS ISSUANCE,QSb hEQUIFFS THE APPLICANT FaR SUCH PEAIAIT io F14.E A§IGtv'�0 W � STATEMENf THAi HE OR SHE IS IICENSED PURSUANT TO THE pROVI51bNS OF THE CAN7R0.CTOR$LI- � CENSE UW�GiAPTEF B�COMMENCINO WITH SECTION�OOo)OF�IVISION 30F THEAUSINE55 A(JD PF1G � POOVSP2 FESSIONS OODE}OR THA7 HE OR SHE IS EXEMPT7HEflEFPOM AND THE BASIS FOR TI-IEACLEGEb�ICE�P� TpN.ANYVKK.ATI0NOF5EGT�ONTOJ1.58VAtiYApPLICANTFORAGERMITSUBJECTSTMEAPpLIC0.NTY0 Z Re-Roo4 � A61VIL PENA4TY dF NOT MORE THAN FN:HUNDRED�oLLAFS(5600).�: . � �I,AStlWNEA�FTHEPROPERTY.ORMYEMPLOVEESWITHWAQESASiHEIR$OLECOMPENSATION, L�� Com111erCidl r � � � WIL100 THE WORK,AND TNE STRUCTUqE IS NOT INTENdEO OF OFFEAED FOR 5:5LE(SEC,�oai.¢USL ,J NESSANO PROFESSIONS COOE:TME CON7RaCTOPS LICFPISE lAW OOES�NOT APPLY TO�AN OWNER�OF � � PROPEl1TYWFiOBURDSORIMPqOYESYHEREON,ANDWrIbdJOE3SUCHWORKHIMSEIFOqFIERSELFOR m OC THflOUGHH�50RHERONMEMPLOYEES,PROVIDEDTHATSUCNIAIPI'IOVEMENTSAY�ENOTINTEPlpEDOR 0 _OFFEREPWRSALE.IF,HOWEVEFL7HEBUILDIN60RIMPROVEM6NTISSOWWITHINlSNEYEAV70FCDPAPLE � 'TION,THE OWNER-6UIIDER WILL H0.VE THE BUFDEN OP PROVINt:TFIAY FIE OR SHE�ID�NOT BUILO OR � IMPROVEFORTHEPURPOSEOFSAL�.�. � -� i o i,AS oWNER oFTHE PPOPERTY,AM F%CLUSIYELV CANTFIAC7'ING WITH LiCEN�ED CONTRAC70R5 � TO CONSTRUCT YME PROJECT(9EC.704s,BUSINESS mIdD�PROFESSIONS COt7E:7HE COIJTkiACTbFS'41� VdIU2.11 ApJ.AREA t�.l CENBEUWDOE9NOTAPPU'TOANOWIdEROFAPFtOPF.R7YWHOBUILpSORIMPROVES7HEREON;dNO -- �1 WFIDCONTMCTSFOflSUCHPi30JEMSWitHACXJNTMCTOR(5�LICENSEOPU(iSUANTTOTNEIXiNTG1AC- qUAPlT DESCRiPTIOPI FEE � TOqS LICENSE L11k.). —.. - --. p ❑I AM E%EMPT UP10ER SEC. 6.&P.C.FOR?FII5 REASON� � _ '� L[ � OATE ` OWNER_�.____�. U � 2 LL� Q LICENSECJ CONTRACTOiiS DEGiARATION --� � �. 1 HEREBYAFFIflM UN�ER PENAITY OF PER.iURY iHAT I AM LlCF.NSE�UNOER PROVISIONS OF CHAp7EF �.. � D(CORIMENCINO WI7H SECPION 7000 IVISION 3 OF THE USME55 ANO PROFFSSIONS C06E,AND � X MYUCENSE IS IN FULL FOACEAND E F T yY''� p��,✓� j� LL3 ���/�.�A\ � � � O L�CENSHCLASS liG.NO.. 4 �� � � OA7E CONTRACTOR_ ___.__—_ a Ll.! � WORKERS'COAAPENSATVON DECLARATIQN � ,�:_ � , y ,�,q,;� � rf�y.,�� � IHEHEBYAFFIflMUNOEfl?ENPLPYOFPERJURYONEOFTHEFOLLOWMGQECLARATIOPIS: ��� � �. . . ' � � `t a Ci IHAVEAN�WILLMAINTAINACEHYIFICATEOFCONSENTMSE4F-fNSUF[FORWOPKERS' � .. , '. � " ' , , � �COMPENSATION,AS PROVIDED BY SEC71�Pd 37a00F7HE LA90R CADE,Fqp T!IE P[RFORMANCE � _ � _ OF iT1E WGRN FOR WHICM TH15 PERMIT IS ISSUEO. �G � � .. s'. ��. : - � ,,a:.'�. W `I HAVEAND WIt1 MAINTAIN YVORKERS'COMPENSATION INSURANCE,AS REQUIREp BY SEC710N � � - � � a7000fTNELABORCOOE.fOR7H[PERFORMANCFOF7NEWORKFOFWHIC4THIuPcPMITIS 5���'�� ISSUEP.MY W4flKERS'COMPEN9ATfON INSUfLWCE CARRIEA AND POL�CV MUMBER ARE: CQNSTRLICTION jcaaaiEa _ PIAN REVIEW _.__. ��� � Pa.ICV NUMeEn�_ ELECTRIC _. - � (iHSSECl10�1NEtUNOTBE�hA'(kTE00FTHEPE.�1.9T4SFOfiONEM.irANEDCIXd.ARSfStoD)OIiLESS). PLUMBING ��`�-z'c:�"��'-"�. � MECHANICAL Z I CERTIFYTHA��IN THE PERFORMANCE Of THE WORK FpR 4VHICH THIS PERMiT iS iSSUE�,l (�$ SFW.LNOTEMPLOYANYPERSONINANYMANNERSOA5706ECOMESUBJECTTOTNE q, CG� WORKERS'COAiPENSATION LAWS OF CAl,IFORNIA,ANO AGREE THAT IF 1 SHOUI.O BFCOMF INSPECTION FEE (� �/'� f,L_����',�_ �[p `� ` � SUBJECT TO THE M�OAKERS'COIAPENSATION PROVfSIONS Of 5ECTION 3700 QF THF LABOR ISSUANCE �`d h+pi� ` � ' b�'!'i� /�-�? C�__ � fADE,ISHALLFORTNWITHCOMPtYWITHTNOSEPPOViSIONS. -------�-�. � _ SUIIP xr�.���'`-- � �}r�'�x ,:a���� � �ATE: APPLIGANT; - � WAHNINGFAIWHE?OSECUREWORKEflS'G6MPENSATIONCOVERAGEI3UNAWFUI,ANOSHALLBE E�dE�CYP/C � + "`�'^'� � W SU&IEGTANEMPLOYEFlTOCRIMINALPENALTIESANDC�VI�FINESUP700NEHUNDREDYHOUSAND EN�RGYPERMIT�����v��x OOUARS(ii oo.00D�.W AODITION TO THE COST OF COMPENSATION,�AAIAGES A5 PROVIDED FOfi IN � SECTION37080FTHELABORCODE,IN7EREST,ANDATTORNEY'SFEES. RETENTIONFEE: ___._ __—_ � CONSTRUCTION LENDING AGENCY PRE-ALT FEE: LC I HERE6YAFFIRM UNDER PENALTV OF PERJURY THATTHERE IS ACONSTRUCTION�LEN�ING AGENGY �- FOR THE PERFOHMANCEOF THE WORK FOR WHIGH THIS PERMIT�S 15SUED(9EC.3097,CIV.Gj. � ' � I^ W � LEP'DEH'SNAME_ � LENDER'SADDPE55. . . ' -� W ICEHTIFYtHA71HA EAD HISAPPLICATIONAN�STATETMA7THEABOVEW Rn+rroniscoaAect TOTAL FEES � ,. � IAGREETOCAMP WITN CINANOCOUNTYORDINANCESANOSTAT RE TING708UILpING ��� �� � CANSTRUCTI ,AND BYAUTHOHIZEREPRESENTATIVE50 'I� U T0� TEPUPO E ' Z A80VE-M OpERTYFO SP CTIONPURPOSES � y���� �w``� GOMM£NTS t , � r/ _ .. .. .., . � m "PERM17TEE NAIAE(A } ' Q � �: � � 31GNATUREOFPERMfTPEE DATE �-�} '� RECPT.NO.__. - �� PAID BY - '� VALIDATIpN��� F- — • WHITE—Department Copy,YELLOW—Financs Copy,PINK—Assessor Capy,CyOLDENROD—File Copy;GREEN—ApplicanYs Copy �� ��� �..s`,.�°'� ��`�a�tt��..�....',,.���r ��^��� . < , � _ �������-°�"�"���� ������� � , ��������� ���� � .� ��� �� � �� � � � �� � ���� a �c :���, g�"� ° �t��,��`�� � � ° � �� � � 'a � ��� �� � y+�`�� ' � � � �� � �w °a� �� . � �� '� �� �u - ..�<d� �. � � .��. � s�,,.s• . `: � �" � �. .�e�12'��--; .�:.��" �4.���� .,, . -� �" ... "" . ; . I . 1 . 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