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HomeMy WebLinkAbout13599 (14) _`,�� CITY OF DIAMOND BAR DEPARTMENT OF COIviMUNITY&DEVELOIPMENT SERVICES w 21560 E.Copley Drive Suite 190 (909)860-3195 F:u(909)861-3117 r pREss ��^, SUII.DING P� APPLIGAT�ON " ' , FIRMIY . .: , ....,: . � _ � JOBSITE � APPLICATION PERMIT ' G" P/C a ADDRES � q DATE NUMBER� �J� # � ISSUE—�C-� r'-� (�(� TYPE OCC APN� l r� TRACT_ `_ pqTE =7 t��``"� CONST. GROUP p OWNER '+e-�- p ADDRE$� A ZONING SET8ACK5 � CITY�_� _ ZIP TEL.. RE�ART RW �O APPLICANT TEL. SIDE/SIQE STREET RW ❑ � CONTRAC� � `L �,S_ ' SIDE _ ❑ � ADDR SS PROPOSED USE o CI ZIP TEL. � DESIGNER/ y�i��%�F�5��4..�1 N�"`i"�a 4��<..'"�°�.. `pi'_ ADDRESS NO.DWEI. O. NO. � CiTY 21P TEL. UNITS STORIES BEDROOMS � �ESCRIPTION Sq.FT FACTOR PSF ADJ.AREA/VALUATIpN � OWNER-BUILDER DECLARATION SFR/ADp/REM O 1 HEREBY AFFIRAd UNDER PcNALTV OF PERIURY THAT I AM EXEAIPT Fp061 THE CONTPACTORS lL t'jdfeJeJCBfpaft W CENSELAWfORTIiEFOILCNlINOHERSON(SEC.7o31.56USiNESSAN�PROFESSION5CO0E:ANYGTVOR (f� CJ COUNtYNMICHREqUIRESA�EqMI7TOCONSTRUCT,AITER,IMPROV[,DEMOUSN,ORAEPNRANYSTHUG� �jj pyti0/DeCk Z TURE.PRIOR TO tl'3 I5SUANCE,ALSD REQUIRES THE APPLICANT�FOR SUCH PER4IIT TO-FILE A SIGNED � STATEMENT THAT HE OR SHE IS CICENSEO PURSUANT TO THE PFlUYISIONS OF THE CONTRACTdFiS LI- W � CENSE U1W ICHAPTER 9(COA�IMENCINO WtTH SEC71ON 7000)OF�lVISION e OFTHE 9USINESSANti PRO- � POOUSpB FE3SqNSCODE)OflTHATHEORSHE7SEXEMPTTHEAEFAOMANDTHEBASISFORTHEALIEOEDEXEMP- (� TION.ANYYIOLATIONOFSECTION7031.68YANYAPPIICANTFORAPERMITSU&IECTSTNEAPPLICANTTO � Re-Roof r ACML PENAL7V OF NOT MORE THAN FIVE HUNDRED DOLIARS�55aDJ.): � �I,ASOWNEROFTHEPROPERTY,ORMVEMiLOYEESVdI7HWAGE5A5THEIR50LECAMPF.NSATION, {.� CortlmefCial - Wlll DO THE WOHK,AND 7HE STRUCIURE IS NOT INTENOEO OR OFFERED FOR SAI.E(SEC.7odd,Bl1Sl• J NESS M1D pROFESSIONS CODE:THE CONTRFCTORS LIGENSE LAW DOES NOi APPLV TO AN OWNcR OF � PROPFATYWH09UNDSORIAiPRDVESTHEREON,0.NDWHODOESSUCNWORKNIMSELFORHERSELFOR � � THRq1GHHISORHEROWNEA/PLOV6ES.PROVIOEDTHATSUCHIMPROVEMENTSARENOTIMEAIDEDOP- m 0 ,OFFEREDFORSALEIF,HOWtYERTiEBUR�INGORIMPROVEMEN'fISSO(DWI7HINONEYFAROFCAMPLE- TION,THE OWNER-BUiLDER WiLL HAVE THE BURDEN O�PROVINd THRT HE OR SHE 01�NOT BUILD OR = IAAPROVEFORTHEPURPOSEOFSALE). � _ ❑I,AS OVJNEF OF THE PROPEFfTY.AM E%CLUS�VELY CANTRACTING WITH L�CENSEO GONTaACTOfl3 � TO CONSTPUC7 hfE PROJECt(SEC.701a,BUSMESS AND PADFF.SSIONS C%)DE:THF CONTRACTOFS LI- V81U3ti A'aJ.AREA L.6! CENSELAWDOESNOTAPPLY70ANUNMEHOFAPNOPERTYN'HOBUtt.p50pIMPHOVES7NEREON,AN� — - � WNOGONTMCTSFOflSUCHPROJECTSWITHACON7'MCTOR�S)LICENSEDPURSUANTTOTMECONTRAG (a�jp.NTITY DESCRIPTION J FEE Y TORS LJCENSE LAWJ. � � O ❑I AM EXEMPT UNDER SEC.�_ ____.�—__.8.b P.C.F09 THIS REASON Q � __ U � ¢ DATE Ob'MER,^ ._�„ I W L��—_ � LiCENSED CQNTRACTORS DEGIARAT{CN W C,� IHEREBYAFFlRMUNDERPENAITYOFPE�iJUflYTHATIpMLICENSEDUNOERPROVISIONSOFGMAPTER � ` p� 9(COMMENCINO WliH SECTION 7oW)Of ISION 3 OF T�NE55 AND PROFESSIONS CODE.AND .� 7�C MY UCENSE i51N�ULL FOFiCE AND EF T �R m LIJ (�^�y)\ 0 LICENSE CtASS LIC.NO._ �"'� _ j V PATE � CONTPAC70R � ___ a 1J,1 C� WORKERS'COMPENSATION OECLAR,4TIGN �� —� � � � .r�. .,...:; _ '�. :.,....,. . � I HEREBYAFFIRM UND6P.PENALN OF PERJURV ONE OF7HE fOLLOWING DEC�.RA71(1NS: � � z a � __IHAVEFNOWII.iMAMTAIPIACE.'iTiFICATEOFCANSENTT�SELF-INSURFFOqWORKEPS' z ' - ' "" - " ' "�^ ' GOMPENSATION,ASPflOVIDE�6Y5£C710N3�COOFTHELhBOFCODE,FOR7HEP'cFFORMANGE ,,'�J� OF THE WOAK FOH NM1dICN THIS PEFMIT IS ISSUEO. � O � _IHAVEAN�WILLMkMTAINWORKERS'CCA4PEP15ATi0IdINSURANCE,ASREQUIRE08V5ECTION ` ( d 37�o OFTHE LAfiOR CODE,FOR TFiE PERFORMANCE OF THc'WOftK FOR WHICH TFIIS PERMIT IS �\ (��� O ISSU�.MY WOAKEfiS'COMpENSATION INSURANCE CARP�ER ANO P6LICV NUMBER Af2E: CONSTRUCTION �-��i l.� ¢ -'� y cnaaiEa----.— ----- PLANREVIEW _ """� �. G—.� � poucvNUMeER_ . -- ELECTRIC - � g �r�ss[�cnourt�nmTeec�r.e��oFn+E�ar.xr�sr�aiE�+urs�a�ooa.inasas�o)oa�Ess�. P�UMBING � w � 1 CERTIFY THAT Ih TNC PERFOAMANCE OF THE WORX FJF WHICH TW6 PERMIT tS ISSUED,I MECHANICAL _ '�"�`��`� � WORNE STCOMPENSATIONUIWSOF�CALIFORNA,AODAGR FEHATEFIUSHOI A WF<E INSPECTIONFEE , {�°§'kg {� ( ���� "� � SUBIECTTO Tlic'V/ORKERS'COMPENSAiION PFlOVISIONS OF SECTION 370o OS'THE IABOR - � � d '.uL Y � fAOE,I SHALL FdR7HWITH CQM7LY WITH hiOSE PROVISIONS. ISSUANCE a `-`'��F" ��� '�> ---� � ' � � p DATE_�_ APPl1CAPd7: _ __ SMIP "� �,�,_�, �k`�j���� .',Y � t .. . �"� WARNING FA0..UfVE TO SECl1RE WORKERS'COMPENSATION COVEflAGE IS UN�A'NFUL.ANO SHALL BE ENEPGY P!C t �' :5�-�-"' � SUBJECT AN EMPIOYEFl TO CRIMINAL PFIJALTIESAND CIVIL FINES UP TO ONE HUN�RE�THOUSAND � DOL(AFISlS100,000),INAOOITIONTOTHEGOSTOFCOMPENSPTION,DAMAGESASPROVIDEDFORIN ENERGYPEFIMIT � SECTION37080FTNEI.J�BORCOOE,INTEREST.ANDATTORNEYSFEES. RETENTIONFEE: d CONS7RUCTION LENDING AGENCY PRE-ALT FEE: '� O � iHEREBYAFFIRMUNDERPENALTVOFPERJURYTHATTHEfiEiSACONSTRUCTIONLENDINGAGENCY , \ FOR THE PERFORMANCE OFtHE WORK FOR WHICH THIS PERMIT IS ISSVED�SEC.309�,CIV.C.). �--}�� �' � W �'�'�� � LENDER'SNAME_ _ � _ t!��.q--^'—� 6-- LENDEWSADORESS . . .. _...� .., , w ICERTIFYTHATIHA E HISAPPLICATIONANOSiATE7HAT7HEABOVEINFO A7 �s�RaE�T. TC�TAL F'EES � �..,`p� a ' � � IAGREETOCOMP WIT LICINANDCOUNTYORDINANCESANDS7ATE E INOTODUIL 7NG �a CONSTPUCTI AN� EBVAUTHORIZEflEARESENTATIVESO NI TO�ENTE E 9 e � ABOVE-ME OP[RTY F N ECTI N PL' OSES � � COMMENTS P � ci r•�, J � -,_ . .. , i .. ¢ PERMITTEENAME( N7) - � ____ _ � � SIGNATUAEOKPERMITTEE DATE '� ' � = RECPL NO. 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