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HomeMy WebLinkAbout15186 (8) --__--_ �X,���--� ��_ CITY OF DIAMOND BAR �U�.�O'��i/ DEPARTMENT OF COMMUNITY 8�DEV$LOPMENT SERVICES �'Z J �.dtt " a 21660 E.Copley Drive Suite 190 w (909)860-3195 Fas(909)861-3117 PRESS "�'�%»°�� BUQ.DING PERMIT APPLICATION FIRMLY JOBSITE APPLICATION PERMIT P/C p ADDRESS ��� ����/��"y � �� �^ DATE NUMBER # � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER '� _� `�73't�CLt-�A LL ADDRESS-S�' ZONING SETBACKS � CITY��� �- ZIP r s TEL��Q�Z.- FRONT RW ❑ APPLICANT TEL. REAR ❑ � SIDEISIQE STREET RW U � CONTRACTOR � �-`�"��+�-��� SIDE ❑ Q ADDRESS � 3 i ` PROPOSED USE � CITY �eV��� ZI�'' 7CL TEL. o ARCH/ENG/ W DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREA/VALUATION u� � OWNER-BUILDER DECLARATION 5FWADD/FiEM O [] I HEqEBY 11FFlpM UNDER PENALTV OF PERJURY THAT I AM EXEMP7 FROM THE CONTRAC70RS LI- � GaragelCarport W CENSELAWFOHTHE�LLOWINGREASON(SEC.7031.SBUSINESSANDPRO�ESSIONSCODBANVCITYOR C�J� COUNTYWHICHF�W�FiESAPERMITTOCONSTfiUGT,ALTER,IMPROVE.DEMOLISH,ORREPAIRANY57RUG W PatiO/DeCk w lUF�,PRIOR TO ITS IS9UANCE,ALS�REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w � STATEMENT h1AT HE OH SHE IS LICENSED PUflSUANT TO THE PROVISIONS OF THE CONTRACTOFS U- � CENSE UW(CHAPTER B(ODIAMENC�NO WITH SECTIDN 7000j OF�IVISION 3 OF THE BUSWESSAND PRO- � POOUSPd FESSIONSCODE)ORTHATHEORSHEISE%EMPT7HEREFROMANDTHEBASISFORTHEALLEGEOIXEMP- (� TION.ANYVbLATIONOFSECTION7031.5BYANVAPPUCANTF4RAPERMiTSUBJECTSTMEAPPLICANTTO Z Re-Rooi r A CML PEN/VLTY OF NOT MORE THAN FtVE FRINDRED DOLLARS(S5o0).): � ❑I.ASOWNEROFTHEPROPER7V,ORMYEMP�OYEESWITHWAGESASTHEIRSOLECAMPENSATION, � C0111RIBfC181 WILL OQ THE WORK,APA THE STR�ICTURE IS NOT IMENDED OR pFFERED FOR SALE�SEC.7od4,BUSI- J NESSMID PROFESSIONS CODE:'CME CONiMGTORS LICENSE LAW DOES NOi APPLv TO AN OWNER OF N PqOPER1YNM1lOBUILD50RMIPROVESTHEREON.ANDNMODOESSUCHWORKHIMSEIFORHERSELFOR = [L THFOUGH HIS OR HER ONM EMPLOVEES,PROVIDE�iFIAT SUCH IMPPOVEMENTS ARE NOT INTENOED Oti m Wn OFFEREDFORSALEIF,HOWEVER�E9UIL�INGORIMPHOVEMENTISSOLDWITHINONEYEAROFCOMPLE- Z TION,THE OWNER-BUILDEA WILL HAVE THE BURDEN OF PROVINO THAT HE OR SHE DID NOT BUILD OR � IMPROVE FOP 7HE M1RP0.SE OF SALE). ❑1,.45 ONRJER Of THE PROPERfY,M!EXCLUSIVELV CONTRACTINQ WITH IICENSED CONTRACTORS Q TO CONSTRUCT THE PRQIECT(SEC.70f4,BUSINES3 AND PROFESSIONS CODE:THE CONTMCTORS U- VdIU0Il01t ADJ.AREA W CENSEU�WDbEStJOTAPPLYTOANOWNEHOFAPROPERTYWFiOBUILDSOFIMPROVESTNEflEIXJ,AND � WVK100NTRACTSFORSUCHPROJECTSWITHACxJN1'RACTOR(S)UCENSEDPUR6UANTTOTHECONTMG QUANTIN DESCRIPTION FEE � TORS LICENSE LAW). ❑I AM E%EMPT UNDER SEC. B.d P.G FOR THIS REASON Q 3 � ¢ LL DATE OWNER � W de[ LICENSED CONTRACTORS DECLARATION W [� I HEflEBV AFFlRM UN�ER PENALTY OF PEHJURV THAT I AM IICENSED UNDER PROVISIONS OF CHAPTEP � � � fT.. s w l��... 'C"` [� D(CAMMENCINOWI7MSECTION70W�OFDIVISION30FTHEBUSINE93ANDPROFESSIONSCODE,AND Z 4Y17�+"•iD K/� MY UCENSE IS pV FULL FORCE AND EFFECT. �(� m � LICENSE GLASS. ��"`� LIC.NO. � ` ` `� � H J V pq7E �"��Y"'�J CONTRAC70R � W � WORKERS'COMPENSATION DEClARA710N —� Q � i HEREBY pFFIpM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLAR0.TIONS: � � Z Q L� �INAVEANDW�LLMAINTAINACERTIFICATEOFCON$ENTTOSELF-INSUREFORWORNERS' 2 Z CdAPENSAT�ON,AS PROVIDEO BV SECiION 3700OF THE LABOR CODE,iOR THE PERFORMANCE U Q OFTHE WORK FOR WHICM TMIS PERMIT IS ISSUED. � � w _I HAVEAN�WILL MAINTAIN WORKERS'('AM7ENSATION INSURANCE,AS RE�UIRED BY SECTION Q 370oOFTNELABORCDDE.FORTHEPERFORMANCEOFTHEWORKFORWHiCHTNISFERMITIS � ISSUED.MY WORKERS'COMPENSATIDN INSURANCE CARRIER AND POLICY NUMBER ARE: CONSTRUCTION � CqRqIEH ��� �u��� PLANREVIEW C� AOIICv NUMBER ���� �Ql f���3�'__. _ ELECTRIC '� __��T� Q (fHLS5EC7KYJNE�N0T8E��EDOFTHEPER�T��7C�1E'�nNJDRE�00�tA�lS��71���1 PLUMBING Z I CEHTIFY iHAT IN THF PERFOFiMANGE OF 7HE WOP.K FOR WHICH THIS PEqMIT IS ISSUEO,I ME.CHANICAL _ (,�} SHALINOTEMPLOYANVPERSONINANVMANNER50A5T06ECOMESUBJECTTOTHE � WORNEflS'COMPENSATION LAWS OF CALIFl1R41A,AND AGREE THAT IF 1 SHOULD BECOME INSPECTION FEE S SUOJECTTOTHEWORNERS'COMPE FIONYFiOV510�SOF5ECTION37000FTNEWBOR ISSUANCE .I�� _ CWE,ISHALLFORTHWITHCOMP WITHTHOSEaROVI.SI� . 7'� p DATE:�"'� APPUCA SMIP _C�l A 1�,���jy�R J -�---- �,'�vsni. WARN�Na:FAILUPE TO SEGUflE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHAL�BE ENERGY P1C =� SU&IECTANEMPLOYERTOCRIMINALPENALTIESAN�CIVILFINESUPTOONEHUNDRE�THOUSAND LL ppL�qRS(i1o0,o00),IN P,O�ITION 10 THE COST OF COMPENSATION,DAMAGES AS PROVIOED FOR M ENERGV PERMIT � SECTION370HOFTHELABORCOOE,WTEREST,AN6ATTORNEYSFEES. RETENTIONFEE: � CONSTRUCTION LENOING AGENCY PRE-ALT FEE: 0. I HEREBV AFFIRM UNDER PENALN OF CERJURV THAT THEFF IS A CONSTRUCTION LENDING AGENCY FOP 7HE PEfiFORMANCE OF iHE N�ORH FOR WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.CJ. Z -- W � IEPIDER'S NAME F— LENOER'SAD�RESS � ICERTIFYiNATINAVEAEADTHISAPPLICATIONANDSTATETHATTMEABOYEINFCRMATIONISCOfiRECL TOTAL FEES � -� � I AGREE TO CAMPLY W1TH ALL CIT'AND COVNTY ORD!WINCES AND STATE LAWS RELATWG TO BUILOING CONSTRUCTION,ANO HEREBY AUTHOP2E REPRESENTATIYES OF THIS COUNTV TO ENTEFl UPON TNE ZABOVE-MENTIONE�PpOPERTY FOR INSVECTION PUROOSFS. 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