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HomeMy WebLinkAbout15456 (23) �.._ _ �wr-..�,.,,,.�.,�.,.._ __ --. _. _. ..._.,. ._ ._. ,. � �xp�r� CITY OF DIAMOND BAR lG/3�/o ( --1�— DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES *� ` f �w . 21660 E.Copley Drive Suite 190 /%l--!' ;,,,� ,,,,, (909)860-3195 Faz(909)861-3117 L PRESS �'. BTJI�:bING PERMIT PL�CATIiON "_" . __ ., „.. .. _ ._.:.. ' FIRMLY , t 0� JOBSITE � / r � LICATION � � � NUMB R /� #!C ADDRESS �L ,DATE $ -ISSUE � �l p� TYPE OCC APN LOT ACT DATE � d CONST. GROUP g O ER " ADD S ZONING SETRACKS � CITY ZIP TEI. R�RT RW o APr[. ANT L" TEL. SIDE/SIDE STREET RW ❑ � CONTRACTO ' -Gt,. �-G SIDE ❑ � ADDR CITY ' ZIP EL. PROPOSED USE o ARCWE DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � cn DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANA�l1ATION � OWNER-BUILDER DECLARATION SFR/ADDIREM O p 1 HEHEBY AFFlRM UNDEH PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI� GflrOge/CB�pOrt tlJ CENSEIAWFORTHEFOLtOWINGREASONI5EC.7031.6BUSMIESSANDPROFESSbNSCODE:ANYCITVOq (/) C.) COUMYNMICHREOUIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORHEP0.IRANY&1AUC- w Z TUNE,PRIOR TO RS ISSUANCE,ALSO pEQUIHES THE APPUCANT FOR SUCH PERMIT TO FILE A SIGN� Patio/Deck �� STATEMENT THAT HE OR SNE IS LICENSEO PURSUANT TO THE PqOVISIONS OF THE CONTRACTORS U- w CENSE LAW(qiAPTER 9(COMMENCINQ Wlhl SECTION 7000)OF�IVISION 3 OFTHE Bl1SINESS AND Pf,10- �'�' Pool/Spa FESSpNSCODE)ORTHA7HEORSHEISEI(EMPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXEMP- (� TION.ANYVpIAT10NOFSECTION703i.6BYANYAP7LICANTFORAPERMIT5U8JECTSTHEAPPLICANTTO Z Re�Raof � ACML PENALTY OF NOT MORE 7HAN FNE NUNDRE�DOLLARS�S5ao).): � ❑I,ASONMEROFTHEPROPERTV,ORMYEMPLOYEESWTHWAGESAS7HEIRSOLECOMPENSATION, � COfnrtlBfCi81 - YVILL 00 THE WOAK AND THE STRUCTURE IS NOT INTENDED Op OFFERED FOR SALE(SEC.7041,BUSI� J � NESS AND PROFESS�ONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF � PRDPERTY NIl10 BUILDS OR IMPROVES THEREON,AND NRiO DOES SUCH WORN HIMSELF OR HERSELf'OR Q 7NROUaHHISORHEROWNEMPLOVEES,OROVIDEOTHATSUCHIMPROVEMENTSARENOTINTENOEDOR m QOFFEREDFORSALEIF,HOWEVERTMEBURWNGORIMPROVEMENTISSOLDWITHINONEVEAROFCOMDLE� Z TION,THE OWNER-BULDER 4ALL HAVE THE BURDEN OF PROVING THAT HE OF SHE DID NOT BUILD OR = IMPROVE fORTHE PUPPOSE OF SALE). ' ❑1.AS OWNER OF hIE PRpPERTY,AM EXCLUSIVELY CANTRACTINO WfTH LICENSED CANTRACTOR9 � TO WNSTflUCT TFIE PRQIECT(SEC.7aM,BUSINE55 PNO PROFESSIONS CADE:THE CONTRACTORS�ll� V01U8110f1 ADJ.AREA W GENSEUWDOESNOTAPPLVTOANON?JEROFAPROVER7YWHOBU!LDSORIMPROYESTHEREON,AN� Z YYIqCONTRACT5FOR5UCHPROJECTSWITHACONTRACTOR(5)UCENSmPURSUANTTOTHECONTqAG QUANTITY DESCRIPTION FEE � TORS LICENSE U1W.). 0 ❑1 AM E%EMPT UNDER SEC. B.&P.G FOH THIS REASON Q 3 �-' � � OATE ONMEP V W � LICENSED CONTRACTORS DECLARATION w - � I HEREBYAFFlRAI UNDER PENAITY OF PEiiJURY THAT I AM UCENSF�UNDEF PROVISIONS OF CHAPTER � a B(COMMENCINOWITHSECTION7o0D)OFDIVISKKJ30FTHEBUSINESSANDPROFESSIONSCO�E,AND Z X MY LICENSE IS IN NLL F CF D FFECT, ''7 L1J r,� � / � . � � � � � LICENSE ��'� LIC.NO. � � J V DATE � CONTRACTOR � a W � WQHKERS'COMPENSATION DECLARATIDN Q = U � IHEHEBYiIFFIRMUNOERPEWLLTYOFVERJURYONEOFTHEFOLLOWINGDECLARATIONS: Z 0Z IHAVEANDWILLMAINTAINACERTIflCATEOFCONSENTTOSELF-INSUREFORWORKERS' a Q COMPENSATION,AS PROVIUED BY SECTION 370o OF THE LA80R CODE,FOR THE 7ERFORMANCE �U OFTHE WORN FOR WHICH THIS PERMIT IS ISSUEU. � 0 W _I NAVE AND NALL MAINTAIN WORI�RS'COMPENSATION INSl/RANCE,AS REQL11RE0 6Y SECTION Q3700 OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMITIS � ISSUED.MV WORKERS'COM,PENSA�C}�ry,11,S�RANCE CARRIER AND 70LICY NUMBEF ARE: CONSTRUCTION [A L/ �, CARRIER �� �"`l - .`a A PLAN REVIEW Z Pw.ICV NUMBER_T . � �' � �a G� " ELECTRIC 7� �/' 4 /�,-���(/ o (nfiss[t.'nor+r+E�t+oTBEmNw..�noFn+Ea�wur�sr�or�EHuwraEooalaas(Siao)or+�ssl. PLUMBING Z ICERTIFYTHATJNIHEPEFiFORMANCEOFTHEWORKFORWHICH7HISPERMITISISSUE�,1 MECHANICAL �j' SHALL NOT¢K3?LOY ANY PERSON�N ANV MANNER SO AS„j0 BECOME SUBJECT TO THE . @ � WORKERS COMPENSATION LAWS OF CALIFORNIA,FN AGREE TMAT IF I SFiOULD BECOME �NSPECTION FEE S 7HE WOfiKERS'COMPENSA7ION PROVI510 OF 5 ION 3700 oF THE LABOR H F HWITHCOMPIVWITHTHOSEP VI51 ISSUANCE � SMIP �I�� � ! DATE: APPLICAN7: —P.�� WWARNING.F LURETOSECUREWORKERS'COMPEN I GOVERAGEI WFUL,ANDSHALLBE ENERGYP/C i + � y��r � SU&IECTANEMPLOYERTOCRIMINALPENALTIESA CIVI FINESUPTOONEHUNDREDTHWSAND ENERGYPERMIT �+ pC'P.+ DOLLARS(5100.000�.IN A�OITION TO THE COSTOF 2 SATION,DAMAGES AS PROVI�ED FOR IN y� '�'� C�J���-�3� ¢ SECTION 37oe OFTHE LABOR CODE,INTEREST.AND ATfORNEY'S FEES. RETENTION FEE: A�L�'-- d CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � I HEREBYAFFIflM UNOEH PENAITY OF PERJURY THATTHEflE IS A CPNSTRUCTION LEN�ING AGENCY FOR THE PEfiPoqMpNCE OF THE WORK FOR WHICH THIS PEflMIT IS ISSUED(SEC.308�,qY.C.�. . Z W � LENDER'S NAME � LENDER'SADDRE55__ , � ICERTIFVTHATIHAVEREADTHISAPPIICATJOqANDSTATETHATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES �� - �� � i E TO CPMPLY WITH ALL CITY AN� UNTYORDINANCES ANO STpTE LAWS REIATINa TO BNLDING -� 5 FjUCTION,ANOHERE6VAUIHORI REPRESENTATIVESOFTWSWUNTYTOENTEFU N�fiWE � VE•�.1E EDPRORE FOPINSP TIO PURPosEs. COMMENTS _ �,,� Z.,-�,� m P MI7TEE NAM (PRIM)� � �� ' � J _—.__'_—_. _ *,.. " y SIONATUREOFPE � EE OATE � RECPT.NO. PAID BY � VALIDATION � WHITE-0epartment Copy,VELLOW—Finance Copy,PINK—Assessor Copy,GOLAENRqD—File Copy,GREEN—ApplicanY Copy ...... , ......�,. .y,,.�,; , i;-'� � �•��:. -,.�.zir. 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