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HomeMy WebLinkAbout16882 (42) CITY OF DIAMOND BAR -q �- -�`"-- DEPAI�TMENT OF COMMUNfI'Y c�DEVELOPMENT SERVICES rrn.._.....i , � 21825 E.Copley Drive ��� (909}860-3195 Fax(909)861-3117 ,� PRESS '"'-tiri��` BUILDING PERMIT APPLICATION FIRMLY � JOBSITE �'""���,�� ��nw�� '�.m..e ! P APPLICATION � � �PERMIT ��P/C o ADDRESS_ n� YJ a/lh DATE _NUMBER # � ISSUE TYPE OCC APN �,y LOT,� �y� TRACT DATE CONST. GROUP p OWNER =�1°l'�'� '�-�Iy;�^n a Yt�",� C`�oG��`� o ADDRESS �'' ' M1l.�� � 1� ZONING SETBACKS � CITY ` I "5°" ZIP�,�j TEL. - C��•� FRONT RW ❑ � APPLICANT � TEL. ��(�(p�Sc REAR ❑ Z SIDE/SIDE STREET RW ❑ m CONTRACTOR I SIDE ❑ ¢ ,y�� Q CTM ESS � ZIP TEL. PROPO� =�•�rV � '� o ARCH/ENG/ � � ADD ESS I NO.DWEL. . NO. � , , UNITS STORIES ' BEDROOMS � CITY �_ ZIP TEL. cn , DESCRIPTION SQ.Ft FACTOR PSF ADJ.AREANALUATION . �. � QWNER-BUILDER DECLARATION SFR/AD�/REM O , I p; I HEREBY AFFIpM UNDEFI PENALTV OF PERJUfiV THAT I AM EXEMPT FROM THE CONTRACTORS LI- G2f8g2ICefPOK W'� CENSELAWFORTHEFO�LOWINGREASON(SEC.7051.SBUSINESSANDPROFESSIONSCODE:ANYCITYOq (n C��'� �COUNTYWHICNREt7UfRESAPER�ITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORPEPAIRANYSTRUG W pa��a�Deck Z� TURE;PRIOR TO ITS ISSUANCE, L50 qEQl11RE5 7HE APPLICANT FOR SUCH PERMIT TO FILE A SIGNE� w STATEMENT THAT HE OR SHE IS' ICENSEO PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI� W O�'�; CENSE LAW(CHAP7Efi 9(COMME GMG WITH SECTION 7000)OF�IVISIDN 3 OF THE BUSINESS AN�PRO- LL POOUSP2 '�FESSIONSCADEjOR�THATHEOR�HEISEXEMPTTHEREFFOMANDTHEBA515FORTHEALLEGEDEXEMP- � V�, TION.ANYVIOLATIONOFSEC,TION7o31.56YANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO Z Re-Roof � ACIVILP NALTYOFNOTMOflETI�PN�FIVEHUNDREDDOLLAR5�S5oo).�: ~ 50Wry�ROF7HEPROP RN,ORMYEMPLOYEESWITH:WAGESASiHEIRSOLECOMPc'NSATION, �' � 0 Commercial -� Z WI O i'HE WORK,ANb THE ST�UCTUPE IS NOf INiEN�ED OR OFFERED FOR SALE(SEC.7044,6U51� J �;� NESS AND PROFESSIONS CD�E: HE CONTFACTOPS LICENSE LAW DOES NOT APPLY TO AN OWNEH OF = PROPE'RTVWHOBUII��SOFiIMPP VESTHEREON,ANDWHODOESSl1CHWORKHiMSELFORHEFSELFOR �:�, THROUGfiHISORHEROWNEMPOVEES,PROVI�EDTHATSUCHIMPROVEMENTSARENOTINTENDEDOR m � � �'.I OFFERE�FORSALEIF,HOWEVER�THEBUILDINGORIMPROVEMENTISSOIDWITHINONEYEAROFCOFAP�E- ,Z�, I,,,;TION THE OWNER-Bl11LDER WIL4 HAVE THE.BURDEN OF PROVINO THAT HE Ofl SHE DID NOT BUILD Ofl �., IMPROYE�FOhTH�Pf1RPO5EOF.9ALE). f71,-ASOWNER OFTHE PROPERTY,AM EXCLUSIVELY WNTRACTING WITH LICENSE�CONTRACTORS ' �' TO CONSiRUCT THE IPROJECT($C.7a44,BUSINESS AND PROFESSIONS CO�E;THE CONTRACTORS LI- Va � Ir'� ADJ.AREA W�. CENSELpWWESNOTAPPLYTO NOWNEROPAPROPERTYWHOBUILDSORIMPFOVESTHEREON,AN� �', WHOCONTRAG7$FDRSIJCHPRO ECiSWITHACOMRACTOR�S)LICENSE�PURSUANTTOTHECONTRAP /�NTITY DESCRIPTION ' FEE � . . .TOPS LICENSE LAW):, � . ���, �� ' ❑I�AM EX��IPT UN�ER$�C,I� B.&P.C.FOR THIS REASON Q - �' V �� .�.; �. i J ¢ , DA7E. �.N�E'R F— Q' i W �:� � '��LfCEN$ED CONTRACTORS DECLARATION W ¢, ��i I HEREBYAFFIRM UNOER PENALT OF PEAJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER � �„� 9(COMMENCINGWIiHS�CYlON700)OF�IVISION30FTHEBl151NE5SANOPROFE5510N5CODE,AND Z �X';� MYUCENSE IS W FULL FORCE AN EFFECT. ''�, m ;�' LIGENSE'�GLASS � II LIC.NO. j , ����''�. �kTE CONTRACTOR a ' .W'.,', . " . ' . . � �, �� WORK�RS'COMPENSATION DECIARATION Q �,�; ',i IHEREBVAFFIRMUN�ERPENAL OFPERJURYONEOFTHEFOLLOWINGDECLARA710NS: z �2, _IHAVEANDWILLMAINTAI ACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' ¢ Q ,'� COMP�NSATIONASPRO IDED9YSECTION37000FTHELA30RCO�E,FORTHEPERFORMANCE U ;Q, , .' OFTHE WORK FOR WHICI�THIS PERMIT IS ISSUED. � �; _I HAVE ANp WILI7,MAINTAI WORKEHS'GOMPENSATION INSURANCE,AS F7E�UIRE�0Y SECTION -y�� Q' 37ooOFTHELABORCO��,FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMI7IS n� ' ISSUE�MVWOpKFAS'C�MPENSATIONINSIJRANCECARRiERAN�POLICYNUMBERARE: CONSTRUCTION *J � �j'� � G+aaiEa - � PLAN REVIEW '�� � . POUCYNUMBER I ELECTRIC �Z��� . � . .. �, ¢' I .� (IHISSECTIONNEmNOTB �v1PLETE�OFhEPERMRISFORONEHUNDREDDOLL4RS(5100)ORlESS). PWMBING .� I'CERT�FYrHpTINTiEP�RFOfiMANCEOFTHEWOP,KFORYlHICHTHISPERMITISISSIIED,I MECHANICAL ,C.�S 5HALL NOT�MPCOY ANY EIi50N IN ANY MANNER SOAS TC BECOME SUBJECT TO THE ��,(/), WORKEPSCOMPENSATIONLAWSOFCAUFORNIA,ANDRGFEETHATIFISHOULUBECAME INSPECTIONFEE �SU�JECT 70 YHE N{DRKERS'COMPENSATIIXJ PROVISIONS OF SECTION 3700 OF THE LABOR [`^tig"'� ��. �D�E ISHALLKOBiHWITkIiCOMPLYWITH7HO5EPROVI510NS. ISSUANCE o� 3 r'aJ4.I p. OATE: �� � � AI'PLICANT: SMIP ���� P='""^+�.., i � y � ,��y . i n� �f J, y� ENERGY P/C � � WARNING.FqILUqETbSECURE ORKERS'COMPENSATIONCOVERAGEISUNLAWFUL,ANDSHALLBE ���" � � SU&IECTANEMPLOYEIiTOCRIM�NALPENALTIESANDCIVILFiNESUPTOONEHUNDRE�THOU5AN0 � �S �. fJOL4ARS(;TOqpUO)�N',ADOITION OTHECOSTOFCOMPENSATION,DAMAGESASPROVIDEDFORIN ENERGYPERMIT P'R". � � ��J SECT10N3]OBOFTHELABOqCp�E,INTEREST,ANDATTORNEY'SFEES. e " ;o[ i � . RETENTION FEE:� � CO�ISTRUCTION LENDING AGENCY PRE-ALT FEE: f,�`'�-�,�T_=_ s r _I� t � 1 HERE81'AFFIRM UN�ER PENALTN OF PERJURV 1HATTHERE IS ACONSTRUCTION LENDMG AGENCY � �---_'--=",w.f = -�,,,4 '� wFOR;THE PERFORMANCE OF THE�.�ORK F'OR W HICH iHIS PERMIT IS ISSUED(SEC.3o W,CIV.C.�. �,j; LENDER'S�NAME � I � � LENOEfl'SA�DRE55 . I � ;� I AGFtEE 7 COM 4�'NW TH A�LL OI��V ANO CO NTY ORDINANCES AND STATOE LAW9 flELAT'IN�TO BUI�OING TOTAL F EES � �� CON$LRUCiION�ANDHEREBYAl7�HOfl12EflEPRESENTATNE50FTHI5GOUNTYTOElY1'ERUPONTHE ��i� ABOVE�MENTIONE�PROPEftTYFORINSPcCTIONPURPO5E5. COMMENTS � `t � ��y�� _ _ � I �`� TTEENAME(P��NT}! �� ;� .'. � . ' � � �G a ,�,/j" �REOFPEfiMITTEE �, ' DATE �� �_ �.�.��i, '. ' ' RECPT.NO. PAID BY VALIDATION ~ � � � " � WHITE—Depariment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—Fle Copy,GfiEEN—ApplicanYs Copy�' — . _. _.,r . ,. ,_� a M�, r.�_.. 3 ,,, � � , u, . � . , . . . 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