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HomeMy WebLinkAbout16799 CTI'Y OF DIAMOND BAR -----��--- DEPARTMENT OF COIvIIvtUNITY&DEVELOPIv�NT SERVICES 21825 E.Copley Drive " pRESS �" (909)860-3195 Fax(909)861-3117 FIRMLY "':»�' BUILDING PERMIT APPLICATION � JOBSITE j AJ /��J� APPLICATION PERMIT P/C oADDRESS / �� S- �T^'D �J� O DATE ' � � D NUMBER # $ ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP °C OWNER f o ADD ESS 1 � l-O R ZONING SETBACKS o FRONT RW O Z CITY lP I TE� REAfi � o APPLICANT TE � � 7 SIDE/SIDE STREET RW ❑ � CONTRACTOR �l'� SIDE � o ADDR SS _ PROPOSED USE � � 5�'����� CITY ZIP �7 6� TE . w ARCH/ENG/ z DESIGNER NO.DWEL. NO. J NO. a ADDRESS UNITS � STORIES / BEDROOMS N CITY ZIP TEI. cn DESCRIPTION SQ.FT. FACTOA PSF ADJ.AREANALUATION � OWNEF-BUILDER DECLARATION SFR/ADD/REM O I HEREB�AFFIRM UNDER PENALTI'OF PERNRV THAT I AM E%EMPT FROM THE CONTRACTORS LI� G0f8g6/CBfpOR W CENSEUWFORTHEFOILOWINOREASON(SEC.70.31.6BUSINESSANDPROFESSION5CO0EANYCITVOR (n U COUNTVNM1iICHREOUIRESAPERM�TTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANYSTRUG W P8f10/DBGK WTURE,PRIOR TO ITS ISSUANCE.�LSO AC-0UIflES THE APPLICMlT FOR SUCH PERMIT TO FILE A SIGNED w � STATEMENT TNAT HE OR SHE IS 110ENSED PURSUMIT TO TME PHOVISIONS OF THE CONTRACTORS L1- � CENSE LAW(CMAPTER Y(COMMENCINO WITH SECTION 9000)OF DIVISION 3 OF THE BUSINESS AND PRO- � PaoUSpe ^ FESSqNSCODE)ORh1ATHEORSHEISEXEMPTTHEREFROMANDiHEBA515FOR7HEALlE4EDE%EMP� /�.� V TION.ANVVIOLATIONOFSECTION7o31.58VANVAPPLICANTFORAPEFMITSU&lECTSTHEAPPLICANTTO Z Re-Roof y�.7 � A CML PENALTY OF NOT MORE THAN FIVE HUNDPED DOLLAAS(f500).): , , � p1.A50WNEROFTHEPROPERTI.ORMYEMPIOVEESWITNWAGESA5THE1RSOlECOMPEN5AT10N. 0 Commerciel Z WILI DO THE WORI(AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SA�E(SEC.7041,BUSI- J N NESS AND PROFESSIONS CODE:THE CANTFACTORS LICENSE lAW OOES NOT APPLV TO AN OWNER OF � PROPERiVWHOBUILD50RIMPFOYESTHEREON,ANDWHODOESSUCHVIOFKNIMSELFOFHERSELFOF m � ,7HROUC3H HIS OR HER ONRJ EM7LOVEES,PROVIDED THAT SUpI IMPROVEMENTS ARE NOT IMENDED OR W OFFERmFOFSALE.IF,FIOWEVEfLTHEBUIL0INGORIMPROVEMENTI550LDWRMNONEVEAROFCQMPIE� 0 TION,TFIE OWNER�BUILDER WILL HAVE 7HE BURDEN OF PROVINQ THAT HE OF SHE DID NOT BUILD OR Z IMPROVE f-0F 7HE PURPOSE OF SALE�. = OI,ASONRJEROFIT/EPROPERTV,AMEXCLUSNEIYCONTRACTIN�WITNUCENSEDCONTRACTORS � TO CANSTRUCT THE PROJECT(SEC.7oN,BUSINESS AND PROFESSIONS CODE:THE GONTMCTORS LI- V01U8IIOf1 '� ADJ.AREA � CENSEUWDOESNOTAPPLV70M10WNEROFAPROPERTVWHOBUILDSORIMPqOVESTMEHEON.AND WFipCOliSRACTSFOFiSUCHPFOJECTSWITHACONTRACTOR(5)LICENSEDPURSUANTTOTHECONTMG QUANTIYY DESCRIPTION FEE TORS UCENSE LAW.j. t' OO I AM F�(EMPT UNDER SEC. B.8 P.C.FOR 7HIS REASON � E � v ,` � � A � DATE OWNER ~ L / 'O� O � � LICENSED CONTRACTORS DECLARATION w � � 2 I HEREBY AFFIRM UNDER PENALTY OF PERIURY 7MAT I AM LICENSED UNDER PROVISIONS OF CHAPTER � „ p� G(COMMENCINO WfTH SECTION 7a00)OF DIVISION 3 OF THE BUSINE55 AN�PROFESSIONS CADE,AND Z MY LICENSE IS IN FULL FOHCE AND EFFECT, m , F Z� � J � UCENSE OCRSS �' � � J J U � O CONTFIACTOR d DATE w � WORKERS'COMPENSATION DECLAFIATION -� • � a � U � I HEFEBV AFFIRM UNDEfi PENALTV OF PEiiIURV ONE OF TNE FOLLOWINQ DECURATIONS: Z Q O __I HAVE AND WILL MPJNTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR VAFNERS' 2 ' Q COMPENSATqN,AS PROVIDED BV SECTION 3700 OF TME L/�BOR CODE,FOH THE PERFORMANCE w OF TNE WORI(FOR WMICH iHIS PERMIT IS ISSUED. � � W �I HAVE ANO WILLMAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTKKJ / �O Q 3700 OF THE UBOR CODE.FOR THE PERFORMMICE OF THE WORK FOR WHICH 7HI5 PERMIT IS ��j r' � ISSUED.MV WORKERS'CAMPENSATION INS�U C1E CARRIErq�\r+D POLICY NUMBER ARE: CONSTRUCTION ' � CARRIER �'^� ■ v h� '-J PLAN REVIEW a aoucrr�n. ' R5~"� U ��Q ELECTRIC Z ¢ PLUMBING ' � ({FLLSSE(,'iIONNEIDNOT9ECOR�IEf�OFTHEPER�.4TISPoRONEFAX�OREDDJLURSltt00)Ofi�ESS1 w I CERTIFV THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL Z (' SHALL NOT EMPLOV ANV PERSON IN ANY ANNER SO AS TO BECAME SU&IECT TO TNE .. � WOqKERS'COMPENSATqNLAW50FCALl ORNI ANDAGREETHATIFISHOU BECOME INSPEC710NFEE � SUBJECT TO THE WORKERS'COMPENSATI N PR VISIONS ECTION 3700 THE ISSUANCE ���� � CODE.ISHALLFORTMWITHCAMPLVWITN OS RO�151 •�+ O SMIP J O p DATE � �� AP%.ICA . . J ENERGY P/C J WARNIN�:FAILURE TO SECURE WORKERS'COM�PENSATKKJ COVERACiE IS UNLAWFVI,AND SHALL 9E '� SU&IECTANEMPLOVERTOCRIMMALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT OOLURS(f 700,000).IN AODITION TO THE COST OF COMPENSATION,DAMAGES A$PFOVIDE�FOR IN � � J SECTION 3708 OF THE LABOR CADE.INTEREST,AND ATTORNEI"S FEES. RETENTION FEE: � w CONSTRUCTION IENDING AGENCY PRE-ALT FEE: d ... � I HEREBV AFFIqM UNDEH PENALTV OF PE{iIURV THAT THERE IS A CANSTRUCTION 1EN01NG AGENCV d FOfl THE PEAFORMANCE OF THE WORK FOA WHICH THIS PERMIT IS ISSUED(SEC.308�,CIV.C.). Z W � LENDER'S NAME F- lENOER'SADDRESS � O � f /T � I CERTIFV TNAT I NAVE READ THIS APPLICATtON AND STATE TFIAT hIE ABOVE INFORMATION IS CARRECT. TOTAL FEES d� w I AOREE TO COMPLV N7TH ALL CITV AND COUNTV ORDINMICES AND STATE UWS REUTING TO BUILDING � CONSTRUCTION,ANDHEREBYAUTFIORREREPRESENTATNESOFT111SCWNTYiOENTERUPONTHE - /� //�� Z AflOVE-MENTqNEO PROPERTY FOR INSPECTION PURPOSES. I /� JR� � COMMENTS o ���� , � J � m PERM E N E(PRIIJn ' � `���b-�� � Sl OFPENMIT7EE �ATE RECPT.NO. PAID BY �� VALIDATION � WHITE—Depertment Copy,YELLOW—Finance Copy,PINK—Assessor CoDY,GOLDENFOD—File Copy,GREEN—P,pplicent's Copy (�9�'�P �f� �9���(��ILC� �1�1L� 06�1�iQ'[�C��'0�f� f�f�C��ff�� ��.�G� � DGa� � �' o � � � O�I�C�� o � . 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