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HomeMy WebLinkAbout17424 (26) CITY OF DIAMOND BAR 8� — �---1 DEPARTMENT OF COMMUMTY&DEVELOPMENT SERVICES - 21825 E.Copley Drive (909)860-3195 Fa�c(909)861-3117 PRESS BUILDING PERMIT APPLICATION FIRMLY o AD�RESS�S���� �` DATECATION�,,/ c�� �� NUMBER�� �/C � ISSUE TYPE OCC APN LOT ,TRACT pATE CONST. GROUP p OWNER " ADDRESS ° ZONING SETBACKS Z CIN IP �� TEL. d-^ FRONT RW ❑ � �y . � APPLI AN E�, - REAR ❑ � " SIQEISiDE STREET RW C] � z a CONTRACTOR SfDE ❑ p� ADDAESS � CITY ZIP TEL. PROPOSED USE Q ARCH/ENG/ ,� W OESIGNER NO.DWEL. Q. NQ. a ADDRESS UNITS STORIES BEDRODMS � CIN ZIP TEL. cn � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREAlVALUATION p� OWNER-BUILDER DECLARATION SFR/ADD/REM O 1 HEREBY AFFIFM.UNDER PENAIiY OF PERJURY THAT I AM EXEMPT fROM THE CONTRACiORS LI� G8f3JE/GflfpOfl �W' .CENSELAWFORTHEFOLLOWINGREASON(SEC.7o31b8U51NESSpNDPflOFES510N3CO0E:ANYGITYOfl (/� U���CWNTYWHICHRC-0UIRESAPERMITTOCCNSTRUCT,ALTER,IMPROVE,OEMOLISH,ORREPAIRANYSTRUP W patio/Deck TUR6,PfiIOR TO ITS ISSUANCE,ALSO REQUIflES TNE APPLICANT FOR SUCH PEflM1T TO FILE A SIGNE� V"� �.�STATEMENi THAT HE OR SHE IS UCENSED PURSUANT TO THE PROVISIONS OF i HE CONTpACTORS LI- W . ��"�CENSE LAW�CHAPTEF 9(COMMENCING WITH SECTION 7W0)OF DIVISION 3 OFTHE 6USINESS ANO PRO� � POOUSPB ,.FESSIDNSCO�E)ORTHATHEOR5HEISE%EMPTTI-IEREFROMANDiHEBA51a'FORTHEALLEGmEXEMP� (�. a '��710N,ANYVIOLATIONOFSECTION7o3l.cBYANYFPPLICANTFORAPERMITSUBJECTSTHEAPPLICHN7T0 Z R2-ROOf ,AGIYILPENALTY OF NOT MORE iHAN FIVEHUNORED DOLLARS(S5a0).): I p, , ' ❑I,ASOYMEROFTHEPROPERN,ORMVEMPIOYEESWITHJiJApE5A5THEIRSOLECOMPENSATION, � Commercia� - '�� �I, ',WILI DO THE WORIC,AN�THE STRUCTUflE IS NOT INTENDED OR OFFEREO FOR SALE(&EC,7044,6USI� J �, ;"'�NESS AND PROFESSIONS CWE:hIE CONTpAC70R5 LICENSE LAW DOES NOTAPPLY TO AN ON/NER OF ? , .�;'PqOPERTYWHOeUILA50RIMPROVESTHEflEDN,ANOWHODOE55l1CHWORKHIMSELFORHEf15ELFOR ��.�''THflOIIGHHISOflHEflOWNEMPLDYEES,PriDVIDE�THATSl1CHIMPfl�VEMENTSARENOTINTEN�E�CR m Q ,,.'.OFFEREDFORSALEIFHOWEVERTNEBUILDINGORIMPROVEMENTISSOLDWITHINONEYEAROFCOMPL°� �,'��.TION,TNE OWNER-BUILDEA WILL HAVE THE BURDEN OF PflOVING THAT HE OR SHE�ID NOT OUIL�OR � �IMPROVE FOR THE PURPOSE OF SAL�. W�i�� �-+.A50WNEROFTNEPROPERTY,AMEXCLUSNELYCONTRACTINGWITHLICENSE�CONTR4CTOR5 �'.���,��TO CONSTRUCT THE PflOJECT(SEC.70d0.BUSINESS ANO PROFE5510N5 CADE'THE CONTflACTORS LI� V9I112110f1 � ' ADJ,AFlEA W'I"CENSE IAW qOES NOT APPLY TOAN OWNEFi OF A PROPERTY WHO BUILDS OR IMPHOYES THEREON,PND �,'���,�'WHOCONTRACTSFOflSUCHPPOJECTSWITHACONTRACTOq(S)LICENSEDPURSUANTTOTHECONiRAG QUANTIIY DESCRIPTION FEE Y .,'TORSLICENSEIAW.), �� �� ❑I AM E7(EMPT UNOER&EC. 8.&P.G FOF'fFiIS qEA50N Q ' � . � ..,,,� U u-- onrE ✓'" ,�" � �.,, OWNER ✓ � '� 0 W F„ LICENSED CONTRHCTORS DECLARATION � Q', �.��,I,HEREBYAFKIRMUN�ERPENALTYOFPEPJl1RYTHATIAMLICENSE�UNDERPROV!SIONSOFCHAPTEP � � ';��:9(COMMENqNGWITHSECTION7o00)OFDIVISION30FTHEBl/51NE55AN�PROFE5510NSCO�E,AND z �',MY 4�CENSE 131N FULL FORCEpND EFFECT, m . d��.LICENSE CU155 UC.NO. j ~���`OATE�� CONTRACTOR � - U, W �, WORKERS'COMPENSATION DECLARATION 4 � U � ' IHERFBYAFFIRMUNDERPENALTYOFPERJURVONEOFTHEFOLLOWINGDECLpflATIONS: Z Z `IHAVEAN0INILLMAINTAINACERTIFICATEOFCONSENTiOSELF-INSUREFORWORKERS' ¢ 2 COMPENSATION,AS PROVIDED BY SECiION 370a OFTHE LABOR CODE,FOR TNE PERFOf7.tANCE C� ¢ OF THE WOflK FOq WHICH THIS PERMIT IS ISSUED. � 0 . W ,�IHAVEANDWILLMAW7AINWORKERS'COMPENSATIONINSURANCE,ASREQl11REDBYSECTION fj..�7 � Q 37Do OFTHE LABOR CODE,FOq THE PERFOflMANCE OF THE\YOflK FOR WHICH iM5 PERMIT IS �` J ��-y ISSUE�.MYWORKERS'COMPc'NSATIONINSUqANCECARPIERANDPOLICYNUM6ERARE: CONSTRUCTION J J � j CARRIER PLAN REVIEW Z POLICVNUMBEF ELECTRIC . __-.. _ .._. .-_-_-----.._._. Q � 0 (THISSECI'ANNEmNOT6ECOMPLETEDOFTHEPERMLTISW�90NEHUNDRED�OLLARS�310%ORLESS). PLUMBING � - '- ' W � MECHANICAL . Z� I CERTIFY THAi IN THE PERFOPMANCE OF THE WORK FOR WHICH THIS PEflMIT IS ISSUED,I � y . (.�J ' SHALLNOiEMPLOVANVPERSONINANYMPNNE4750A5iO6ECOMESUBJECTTOTHE � F !(� � �, � � WORKERS'CAMPENSATIONLAWSOFCAIiFORNIA,ANOAGREETHATIFISHOULDBECOME �NSPECTIONFEE ��'d � f G.4� V � F,' SUB„ECTTOTHEWORKEFS'�.COMPENSATIONPRWISIONSOFSEGTION3IOOOFTHELABOR � � CO�E,ISHAILF�RTHWITHCOMPLYWITHTHOSEPROVI510N5. �SSUANCE �_ � � SMIP - . �� p.' DATE: � APPLICANT: � ^�-...... _ _ .__...._ , .-__. - - ..... �� J , WARNING:FAILURE TO SEQIRE WOflKEfiS'COMPENSAl70N COVERAGE IS UNIAWFUL.AND 5HALL BE ENERGY P/C � � �:SUBJECT�ANEMPLOYEqTOCRIMINAL.PENALTIESANDCIVILFINESUPTOONEHUNDRFDTHOU5A4D ENERGYPERMIT � �DOLLARS(Etao,OOD?.INAOOITIONTO'lHECOSTOFCOMPENSATION,OAMAGESASPROVIDEDFOflIN — �—�--� J J �'$ECTION37oBOFTHELA80flCODE,INTEfl[57ANDATTORNEY'SFEES. RETENTIONFEE: ! � Q., � n�. CONSTRUCTION LENDINGAGENCY PRE-ALT FEE: , � I HEREBV AFFIRk1'liM4Fft PENALTYOF Pc^RJURY THATTHERE IS ACONSTtiUCTION LENDING AGENCY � 'FOH THE PERFORMANC�WORK FOR WHICH THIS PERMR IS ISSUED(ScC.309�,CIV.G). - . W �"`°-�.� �� � LENDER'SNAME ._, ', F-� 'LENDER'SA�DRESS � TOTAL FEES �� � '�� �� W �..ICERTIFVTHATIHAVEREADiHISAPPLICATIONANUSTATETHATTHEABOVEINFORMATiONISCOP7ECT. , �f !.Y:4GHEE TO COMPLV W1TH ALL CITV ANO COUNTY OPDINANCES AN�STATE LAWS RELATING TD 6UIL�ING � '.CONSiRl1GT10N,ANOHEREBYAUT}N]RI2EREPRESEN:ATNESOFTHISCOUNTYTOENTERUPONTHE I Z; 'ABOVEMENTIONED PROPERTY FOR I PECTION PURPOSES. COMMENTS ' o' " _ - L .a'�;' �. ' `' `J —� � m. �.F� . EE NAM �Pfll .) -- , Q' fj � � � N �SIGN FiEO P MI EE D0.TE ' _ �. RECPT.NO._._ PAID BY�� C.��"___ VALIDATION______._ ~ � WHITE—Depariment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Capy,GREEN—ApplicanYs Copy __. . ., ,A... : _. , ,;. .: ,.,:.,. . r ._� ��... , � :' . . � ��!._ . 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