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HomeMy WebLinkAbout17261 CITY OF DIAMOND BAR � � �°` --' DEPARTMENT OF CONA�fUNITY&DEVELOPI4�NT SERVICES I I 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 PRESS �"-y«r' BUILDINGPERMTTAI'PLICATION FIRMLY � JOBSITE C 1 �C��` /-�a o ADDRESS r�Q� �CJC�1 ��� r DATECATIO � PERMIT y p/C NUMBER�f� # � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER �i'����/�{ o ADDRESS ZONING SETBACKS z CITY ZIP TEL. FRONT qyy � � APPLICANT TEL. REAR ❑ z SIDE/SICE STREET RW ❑ ¢ CONTRACTOR r ✓�'� SIDE � ADDRE S n o CITY : e ZIP��TE . �g ,7q' ,�z-CJ�' " PROPOSED USE r 3r'��G�'2.Z ' ei��e► V�' o ARCH/ENG/ ~ '� z DESIGNER w NO.DWEL. NO. NO. � ADDRESS q = CITY ZIP TEL. UNITS STORIES G�- BEDROOMS � � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNEFi-BUILDEF DECLARATION SFRlADD/REM O p I HEFE6V AFFIRM UNDEfl PENALTV OF PERJURY THAT I AM EXEMPT FROM THE CONTflACTORS LI� GHfdJE/CBfpOfi W CENSELAWFORTHEFOLLOWINGREFSON(SEC.7031.SBUSINESSANDPROFESSiONSCADE:ANYCITYOfl (f� U COUNTYWMICHFE�UIRESAPERMITTOCONSTRUC7,ALTcR,IMPRCVE,DEMOLISH,ORREPAIRANVSTRUC� W TURE,PRIOR TO ITS ISSUANCE,ALSO REQUIFES THE APPLICANT FOR SUCH PEFMT TO FILE A SIGNEO W Patio/DBCk � STATEMENT THAT HE OR SHE IS LICENSEO PURSUANT TO THE PROVISIONS OF THE CON7RAC70RS LI� � CENSE UW(CHAV7ER 9(COMMENCING WITH SECTION 7(w0)OF DIVISION 3 OF THE 9USINESS AND PRO� u' POOUSp2 O FESSIONSCO�E)ORTHATHEORSHEISE%ENP7THEREFROMANOTHEBASISFORTHEALLEGEDE%EMP- (� V TION.ANVVIOL4TIONOFSECTtON7o31.58YANYAPPLICANTFORAPERMITSJBJECTSTHEAPPLICANTTO Z Re-Roof ACIVIL PENALTV OF NOT MORE THAN FlVE HUNDRED OOLLARS(E5ooj.): � ❑I,ASOWNEROFTHEPROPERTY,ORMYEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSFTION, � COfilrtlBfCl21 Z WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7044,BU51- J � NE55 AN�PROFESSIONS WDE:TME CONTRACTORS LICENSE LqW DOES NOT APPLY 70 AN OWNER OF � PROPERTV WHO BUILDS OR IMPROVES THEREO�,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR � iHROUGHHISORHEAOWNEMPLOYEES,PROVI0ED7HATSUCHIMPROVEMENTSARENOTINTENDEDOR N � OFFEREDFORSALE.IF,HOWEVER�MEBUILDINGORIMPROVEMENTISSOLDWITHIVONEYEAROFCOMPLE- Z TION.THE OWNER-BUILDER WILL HAVE THE 9URDEN OF PROVING TI�IAT HE OR SHE DID NOT BUILD OR = IMPROVE FOR THE PURPOSE OF SALE). W ❑I,AS OWNER OF THE PROPERTY,AN E%CLUSNELY CANTRACTING WITH LICENSED CONTRACTORS � TO CONSTRUCT THE PROJECT(SEC.7044,BUSINESS AN�PROF[SSIONS CODE:THE CONTRACTORS LI� V8IU8IIOfl �s� ADJ.AREA W CENSEIAWDOESNOTAPPLYTOANOWNERO-APROPERTVWHOBUiLO50RIMPROVESTNEFEON,AN� � WFIOCONTRACTSF09SUCHPFOJECTSWITHACONTRACTOR(5)4GENSEDPURSUANTTOTHECONTqAC- QUANTITY DESCRIPTIDN FEE Y TORS LICENSE LAW.). � ❑I AM EXEMPT UNOER SEC. B.&P.C.FOR THIS REASON Q � U �'1' DATE OWNER � Z U � LICENSED CONTRACTORS DECLARATION W Q � IHEREBVAFFIRMUNDERPENAI.TYOFPERJURYTHATIAMLICENSEDUNDERPROVISION50FCHAPTER � d 9(COMMENCING WRH SECTION 7000�OF DIVISION 30F THE BUSINESSAN�PROFESSIONS CODE,ANO Z 1X MY LICENSE IS!N FULL FOFCE,yAND EFFECT. � m . � LICENSE CLASS L' / / LIC.NO._4� F/� �� � V �ATE������� CONTRACTOR G. W � WORKERS'COMPENSATION DECLARATION Q � I HEREBYAFFIRM UNDER PENALTV OF PERJURV ONEOFTHE FOLLOWING DECLARATIONS: Z Z _IHAVEANDWIILMAINTAINACERTIFiCATEOFCONSENTTOSE�FINSUREFORWORKERS' ¢ 2 ¢ CAMPENSATION,ASPROVIOEDBVSECTION�7ooOFTHELA80RCO0E,FORTHEPERFORMANCE U Q OF THE WORK FOR WH�.CH THIS PERMIT IS ISSUED. � w _IHAVEANDWILLMAIN7AINWORKERS'COMPENSRTION�INSURANCE,ASREDUIREDBYSECTION 1-- O 3700 OF THE LABOR CODE.FOR THE PERFOPMANCE OF THE NbRN FOR WHICH THIS PERMIT IS ���Ej ISSl1ED.MYWO KERS' OMPENSATIO INS��RANCECARRIE�R}+ANDPOLI�CV1Nl1MBERARE: CONSTRUCTION � CARRIER � ,��� .L�i: G.-�,L,�d' PLAN REVIEW Z POLICYNUMBER '. .�� , ___ ELECTRIC ¢ � .. . ......�..,.-.,�...,m.:.^�.-.. . � (IHISSEC'qNNE�NOT0E00MPI.EfEDOFT1iEP=MAfrISFORONEHUNDFiEO LLAAS(5100�ORLESS�. PLUMBING � �'..".�.z� i � W ,� _ , . v,...,. Z I CERTI:YTHAT IN THE PERFORMANCE OF THE W'ORK FOR WHICH THIS PERAl1T IS ISSUED,I MECHANICAL (� SHAILNOTENPLOYANVPERSONINANVUANNERSOASTOBECOMESUBJECT70THE w��. �n � '� c� � WORKERS'COMPENSATIONLP.WSOFCALIFORNIA,ANOAGREETHATIFISHOULOBGCOME INSPECTIONFEE * .1�� � � SUBJECTTO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 970o OF THE LABOR � COOE,ISHALLFORTHWITHCOMPLVWITHTHOSEPROVISIO,ys. _. ISSUANCE s O �'�"" �+ Lp DATE:�/� APPLICANE e ,, -- SMIP � e 7 d .,»----"-, J WARNING:FAILURETO SECURE WORKERS'COMPENSATION COVERAGE IS VNL4WFUL,AND SHALLBE ENERGY P/C . � � SUBJECTANEMPLOYERTOCR:MINALPENALTIESANDCNILFlNESJPTOONEHUNDRE�THOUSAND ENERGYPERMIT DOLLARS(5100,0007,IN AD�I710N TO THE COST OF COMPENSATION,DAMAGES FS PROVIDED FOR IN J SECTION37080FTHELABORCODE,INTEREST,ANDATfORNEY'SFEES. E� p� FETENTION FEE: OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: � IHEREBVAFFlRMUN�LRPGNALTVOfPERJURYTHATTHEREISACONSTRUCTIONLENDMGA�ENCY n- FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSLIED ISEC.3097,CIV.C.). Z W � LENDER'S NAME 1— LENDER'SADDRE55 W ICERTIFVTHATIHAVEREAOTNISAPPLICATIONANDSTATETHATTHEABOVEINFORMATIONISCARRECT. TOTAL FEES � � � `�� � I AGREE TO�b1PLY WITN ALL pTV AND COUNTY OFDINANCES AND STATE LAWS RELA7ING TO BUILDING � � � CONSTRUCTION,ANO FEREBV AUTHORRE REPflcSENTATiVES OF'HIS COUNTV TO ENTER UPON THE z ABOVEMENTIONE�PROP[flTY FOR INSPECTION PURPOSES. COMMENTS � �{ /S✓ � / ��/��� � PERM�I NAME(P � i�17'r�~ lC�!i.��� f � SIGNA R PERMIITEE —�—�OAT� �� � � = FECPT.�O. y PAID BY � VALIDATION ~ WHITE—Departmen[Copy.YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanPs Copy .. . . .� .... .�.. ...... ...- .. ,p, �... 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