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HomeMy WebLinkAbout17360 (26) r-'°,�=�„' ---—�"='`'----• CITY OF DIAMOND BAR �� ' i)EPAKT'MENT OF COMIvgUNITY&DEVELOPMENT SBRVICES 21825 E.Copley Drive (� (909)860-3195 Fa�c(909}861-3117 ` PRESS ``''%.vri�� BUI[,DINGPERMITAPPI,ICATIDN FIRMLY o� JOBSiTE � Cj DAT�ICATI�N `� � O NUMBER '� #/� ADDRESS o� ISSUE r TYPE OCC APN �.OT T CT DATE �J CONST. GROUP p OWNER L— o ADDRES�y ZONING SETBACKS Z CITY ZIP TEL �' FRONT RW ❑ � APPLICANT TEL, REAR ❑ � SIDE/SIDE STREET RW C Q CONTRACTO SIDE C o' ADDRE S � p�K�ED US � CITY ZI TEL. � � o ARCHIENG! W, DE$IGNER NO.DWEL. NO. NO. n.' ADDRESS — UNITS S70RIES BEDROOMS � CITY ZIP TEL. cr� � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADD/REM O �;,, I HE(iEBY AFFIRM UNDER PENAL7W OF PERJURY TNAT I.AM EXEMPT FROM THE CONTRACTOfiS LI- GdfdgE/CdfpOfl r W. CENSELAWFORTHEFOLLOWINGREASON(SEC.703i.50U51NES5AN�PflOFE5510N5CODE:ANYCIiYOR (n , Z':,'COUNTVWHICHREQUIRESAPERt�ITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORflEPAIRANYSTRUC- W pyf10/DBCk ; w,�: TUflE,PRIOR?O ITS ISSUqNCE,�L50 ijE�UIRES THE APPIiCANT FOR SUCH PEf�AiT TO FILE A SIGNEO W �i �,,', SiATEMENT THAT HE OR SHE IS ICENSED PURSUANT i0 iHE PROVISIDNS OF 7HE CONTRACTORS LI- �, .CENSELAW�GtIFPTER9(COMME CING,WITNSECTION'IWo)OF�IVISION3CFhiEBUSINE55AN�PRO- � POOVSPd FESSIONS CODE)OR THAT HE OR SHE I&ExEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- � TION.ANVVIOLATIONOFSEGTION7031.59YANYAPPIICANTFORAPERMIT5l1BJECTSTHEAPPLICANTTO z R&ROOf . ACIVIL PENALN OF NOT MORE TNAN FlUE NUN�RED DOLLARS(SSoOJ.): ~ � ❑I.ASOWNEROFTHEPROP�RTY,ORMYEMPLOYEESWITHYJAGESASTHEIfiSOLECOMPEN5A710N, � �,WILL�O 7HE WORK,AND THE STRUCTURE IS NDT INTENDED OR OFFERED FOR SALE(SEG.�044,Bl1Sl- J Commercial Z��' NESS AND PROFESSIONS COOE:7HE CONTRACTORS IiCENSE LAW�OES NOT APPLY TO AN OWNER OF �".� PROPEHTYWHOBUILOSOFIMPRQVESTHEREON,ANDWHO�QESSUCHWORKHIMSELFORHERSELFOR � .a".�"�����7HROUGHHISORHEROWNEMPL,OVEES,PROVf�EDTHATSUCHIMPROVEMENTSARENOTINTEN�EDOR m �Q .OFFEREDFORSALE.IF,NOWEVER,IhfEBUILDWGORIMPpOVEA1ENTIS50LOWIiHiNONEYEAROFCOMPLE- z TION.THE OWNER-BUILDER WILL�,HAVE�THE BURDEN OF PROVING THA7 HE Oa SHE OID NOT Bl11LD�R ��. IMPROVE FORTHE PURPOSE OF SALE�.�''�, W„�.,,, ❑I,ASOWNEROFTHEPROpERTV,AMEXCLUSiVE�YCONTRAC71NGW17HLICENSEDCOMRACTOAS d' �TO CONSTRUGT THE PROJEGT(SEC.7044,BtJ51NE5$AN�PROFESSIONS COOE:TYE CONTRACTORS LI- Vdlile�l0� ADJ.AREA W� CENSELAWOOESNOTAPPLYTOANOWryEROFAPROPEPTVWHOBUILCISORIMPROVESTHEREON,ANU �� WHOCONTRFCTSFORSUCHPRO.�ECTSWI7HACONTRACiOft(5)LICENSEDPURSUANTTOTHECONTRAG QUANTITV �ESCRIPTION FEE � TORS UCENSE LAW.). � . o� ❑i AM EXEMPT UNDERSEC.�i, B.&P.C,FOP THIS REASON U �„ � V"' OATE ' ' OWNER �" Z, U ���, LICENSED CONTRACTORS DECLARATION W � �- I HEREBY AFFIflM UNDER PENALTY OF PERJURY THAT I AM LICENSEO UNDEfl PROVISIONS OF CHAPTER � p„ 9(COMMENCING WITH SECTION�000)OF DiVISION 30F iHE BUSINESS AN�PROFESSIONS CO�E,AND z 1X. MY LICENSE IS IN FULL fORCEANO EF ECT. ', m ��' UCENSE CLASS � LIC.NO. � j J V" DATE� � CONTRACTOR a W � WORK�'RS'COMPENSATION DECLARATION ¢ . _ ' U �' IHEfiEBYAFFIRMUNDERPENALTI�OFPERJURYONEOFTHEFOLLOWINGOECIARATIONS: � 2 O, INAVEANDWILLMAINTAi ACERTIFICATEOFCONSENTTOSELF•INSUREFORWORKERS' _ . CAMPENSATION,AS PFiO�IDED BY SECTION 370o OFTHE LABOR CO�E,FOR THE PERFORMANCE C3 ¢� OFTHEWORKFORWHICI�THISPERMITISIS5UED. � � ' � W" _IHAVEANDWILLMAINTAII�WOqKERS'COMPENSATIONINSURANGE,ASRE�UIRE�eVSECTION Q' 3�oaOFTHELP80ROJbE�,FORTHE'��PERFORMAM10EOFTHEWOPKFORWHICHTHISPERMITS � ' ISSUEO.MYWORKERS'mMP'cNSATIONIN5l1RANCEGRRIERANDPOLICYNUMBERAFE CONSTRUCTION J j caaw6a ' PLAN REVIEW Z POLICY NUMBER � ELEGTRIC Q �.. (fHISSEC�KKJNEFDNOTBE'COMPLETEDOFTHEPERMfTISFOLiIXJEHUIJ�REDDOLLPAS($1m�ORLE55J. PLUMBING w ICERTIFVTHATINiHEPERFORMANCEOFiHEWORKfORWHICHTi-IISPERMI?LSISSl1ED,l MECHANICAL Z (rs SHALLNOTEMPLOVANVPERSON�NANYMANNERSOASTOAECOMESUBJECTTOiHE � WORKERS'COMPENSATIO�J LAWS OF CALIFORNIA,AND AGREE THAiIF I SHDULD BECOME INSPECTION FEE � SUBJECTTOTHELVORKEPS'COMPENSATIONPROVISIONSDFSECTION37ooOFTHELABOq CODE,I SHALL FOfl7HWITFi GOMPLV WIiH iHOSE PROVISIONS. ISSUANCE � SMIP � p DATE: APPIJCAN7. � WARNING:FAILURE i0 SECURE WORKEF75'COMPENSATION COVERAGE IS VNLAWFUL,AND SHALLBE ENERGY P/C �. SUeJECTANEMPLOYEftTOCRIMiNALPENALTIESAN�CIVILFINE5UPi00NEHUNDREDTHOLISAND ENERGYPERMIT OOLLARS(St oo,0a0),IN AD�ITION 70 THE COST OF COMPENSATION,DAMAGES AS PROVIOED FOft IN � SECTION3]oBOFTHELABORCO��,INTEREST.AN�ATTORNEY'SFEES. AETENTIONFEE: � � CONSTRUGTION LENDING AGENCY PRE-ALT FEE: O I CC IHEFEBYAFFIflMUNDERPENALTYOFPERJURYTHATTHERE!SACONSTRUCTIONLENDINCAOENCY a- %OR iHE PERFORMANCE OF THE 4YORK FOR WH'CHTHIS PERMIT IS ISSIJED�SEC.3097.C:V.CJ. -�- � ��- � z w - S LEN�ER'S NAME � � 1— LENDER'SAODRESS � TOTAL FEES " '� � � I CERTIFYTHAT I HAYe READ THIS APPLICATION ANO STATE THA7 iHE ABOVE INFORMATIDN IS CORFECT. W' IAGREETOCOMPLVWITHALLGTti'AND�OUNTYOR�INANCESANDSTATELAWSRELATINGTOBUILDING ¢, CONSTRUCTION,AN�HEREBV AUTHORIZE PEPftESENTATNES OF THIS COUN7V TO EM`cR UPON THE �nn�^ `}�' ��. ABOVE-MENTIONEO PROPERTY FdR INSPECTION PURPOS . COMMENTS - � !Y/� � "' �' J _ m PEFMITTEE NAME 7) ' C/S r. �'' SIGNAiUqEOF A11TTE � [1A � _ � AECPT.NO. PAID BY VALIDATION ~ ' WHITE—De artment Co YELLOW—Finance Co PINK—Assessor Copy,GOLDENROD--File Copy,GREEN—A IicanPs Co � P PY. 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