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HomeMy WebLinkAbout15116 �.��J<r� CITY OF DIAMOND BAR G fl�� A��I ' " 4 "'� DEPARTMENT OF COMMUNTfY&DEVEL�PMENT SERVICES � 21660 E.Copley Drive Suite 190 ��� ....,. (9 0 9)8 6 0-3 1 9 5 F a z(9 0 9)8 6 1-3 ll 7 s`=�"C./ P R E S S ,�.- _. „Ttorr -- FIRMLY BUII.DING PERMIT APPLICA, . . .,,, ,, „ � ... .. . . . oN JOBSITE � � /✓ % APPUCATION '� PERMIT i P/C ADORESS -"�� G DATE � / � NUMBER� ' f # � - �SSUE TYPE OCC APN LOT T T DATE CONST. GROUP p O NER �` AD SS > ZONING SETBACKS 0 W FRONT � CI ZIP TE . � REAR RW � AP LICANT EL. SIDE/SIaE STREET RW ❑ � CONTRACTOR �, SIDE ` ❑ ADDRE ' � CITY ZIP T , - PROPOSED USE w ARCWENG/ ' ����i`— � DESIGNER a�i NO.DWEL. NO. NO. 4 ADDRESS � CITY ZIP TEL. UNITS STORIES BEDROOMS � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER-BUILDER DECLARATION SFR/ADO/REM O 1 HE0.EBV AFFlRAI UNDER PENALTV OF PERHJRV THAT I PM E%EMPT FROM THE CONTRACTORS U- G8(8J0/C31pOfI W CENSELAWFOR7HEFOLLOWINGREASON(SEC.70�7.6BUSIMESSANOPROFESSIONSWDE:ANVCITVOR (� ZCOUNTVWHICFiREOUIHE6APERMITTOCONSTRUCT,ALTER,IMPRDVE,DEMOUSH,ORREPAIRANYSTRUC• W Pe,fiO/DeCk �j� TURE,PRIOR TO ITS 18SUAPICE,AL90 REQUIRES THE APPLICPNT FOR SUCH PERMIT TO FILE A SIGNED W � STATEMEM THAT HE OR SNE IS IJCENSED PUflSUANT TO Tl1E PROYISIONS OF THE CONTRACTORS U- � CENSE LAW(CHMTER e(COMMENCINO WITN SECTION 7oao)OF DIVISION 3 OF 7HE BUSINE55 AND PR0. Pooi/Spa FESSIONS COUE)OR THIR ME OR SHE IS EXEMP7 7HEREFROM AND THE BA515 FOR THEALLEOED E%EMP- 710N.ANYVIOLATIONOFSECTION7031.SBYANYAPPLICANTFORAPERMRSU&IECTSTHEAPPLICANTTO Z R8-R001 � A CMl PENALTY OF N�T MORE THAN FNE HUN�R�DOLLARS(5500).): � �I.ASOWNEROFTHEPROPERN,OHMYEMPLOVEESWITHWAGESASTNEIRSOLECOMPENSA710N, ❑ Comm9fCial — WILL DO TNE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SAIE(SECJo4a,BUSI- J � NESS AIA1 PROFESSIONS CODE:7HE CONTRAC70pS LICENSE UW OOES NOTAPPLV 70 AN OWNER OF j PROPEFlTY WFIO BUILDS OR INPROVE6 THEREON,ANO WHO DOES SUCH WORK HIMSELF OP HERSELF OR 2 TMHOUOFiHISORHEqOWNEMPLOYEES,PROVIDE�THATSUCHIMPROVEMENTSARENOTMTENDEDOR m O OFFEREDFORSALEIF,FpWEVERTFIEBUILDINGOFi1MPROVEMENTI3SOlDWITHINONEYEAROFCOMPLE- Z TION,THE OVMIEH�BUNDER WILL HAVE THE BURDEN OF PROV1Np THAT HE oR SHE DI�NOT BUILD OR � IMPIqVE FORTHE PURPOSE OF SAL�. w �I,ASOWNEPOF7HEPROPERTY,AME%CIUSIVELYCONTRACTINGWITHLICENSEDCONTRACTORS � TO CONSTRUCT T1E PROJECT(SEC.7044,BUSINESS AND PROfE5510NS CODE:THE CONTRACTORS LI- VelU81iOR ADJ.AREA CENSE UW DOES NOT APPLV TO AN OWNER Of A PROPERTV WHO BUlLDS OR IMPROVES THEHEON,AND � Wk10WNTRACTSFOflSUCHPRQIECTSWITHACONiRACTOR(SjLICENSEDPl1R5l1ANTTOTHECONTRAG QUANTII'Y DESCRIPTION FEE � TORS LICENSE UW.). O I AM E%EMPT UNDER SEC. B.fl P.C.FOR THIS REA^uON Q 3 U � DATE ONMEF � � W � LICEN5ED CONTRACTORS DECLARATION W � I HEREBY AfFIRM UNDER PENALN OF PERJURY iHAT I Mi LICENSED UN�EH PFlOVISIONS OF CHAPTER � d B�COMMENCINOWITHSECTION700o)OFDIVISION30FTHEBUSINESSANDPROFESSIONSCO�E,AN� Z G i j� M'/LICENSE IS IN FULL F E �EfF�CT, m � UCENSE C - �y� 11' LIC.NO.� �[�C 4�'� r � V DATE CONTAACTOR a W � WORKERS'COMPENSATION DECLARATION —i � I HEREBV AFFIRM UNDER PENAL7V Oi PERJURY ONE OF THE f-0LIAWING�ECLARATIONS: Z � _IHAVEANDWILLMAINTAINACERTIFICATEOFCDNSENTTOSELF-IMSUREFORWORNERS' a _ COMPENSATION,AS PHOVIDED BV SECTION 37000F i HE LABOR CODE,FOR THE PERFORMANCE IU Q OFTHE WDRN FOR WH�CH THIS PERMIT IS ISSUEO. � � _I HAVEAND WILL MAINTAIN WOHKER5 COMPENSATION INSUFANCE,AS FEOl/1RED BY SECTION Q 37000FTHELABORCODE,FORTHEPBif-0RMANCEOFTHEWORKFORWHICHTHISPERMITIS ISSUED.MY WOfiKERS'COMP 1 AT IMSURANCE CARRIER AND POLICV NUMBER ARE: CONSTRUCTION � CARRIER � ] 7 �''��` -���.� � PLAN REVIEW Z PaICYNUMe� ��CF�LrC—f--�,�—+�--� ELECTRIC .� � (THISSEciqNNE�NOTBECOMPLEfEDOFnEPEFUMISFO(iONE�-NnOFlEDW�1PFis(5tao)ai�Es). PLUMBING f c--��.' Z I CERTIFYTHAT INTHE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMITIS ISSUED,I MECHANICAI. .�' ��?�`VS SHALL NOT EMPLOY ANY PERSON IN ANY MANNEfi SO AS TO BECOME SUBJEC O THE ��,�" � WORNERS'COMPENSATIONL0.WSOFCALIFORNIA: DAGREETHATIFISHDUL ECOME �NSPECTIONFEE ___ ..-'�- SUBJECT TO THE WORKERS'COMPENSATION P OVI 5 OF SECTION 3�oD OF E LABOF DE,IS ALLF NWITHCAMPLVWITHT EPROVI S. �SSLJANCE J p �ATE:����� APPLICANT: �.•- SMIP ��E� � ��� ���F� J WARNINO:F LURE TO SECURE WORKERS'CO fION COVERAGE IS UNLAWFUL,AND SHALI BE ENERGY P/C � _ �y SU&IECTANEMPLOYERTOCRIMINA�PENALTI ANDCIVILFINESl1PTOONEHUNDREDTHOUSANO � � �a. L.,91 #a'if '�,.FS'�E. d �e.e:'��� OOLtARS(S10D,000),INADOITIONTOTHECOSTOFCOMPENSATION,OAMAGESASPi70VIDEDFORIN ENERGYPERMIT � SECTION 37oe OFTHE LABOR CODE,WTEREST,AND ATTORNEV'S FEES. k Y i,J� �3�°W���'��',�y„?°�,;;ao;,('���y , .. . RETENTION FEE: OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: � 1 HEREBYAFFIRM UNUER PENALN OF PERJURV THAT THERE IS ACONSTqUCTION LENDING AGENCY FOR THE PEFlFORMMICE OF TNE WOHN FOR WHICH THIS PERMIT IS ISSUED(SEG 3D97,CIV.C.). . Z W � LENDEF'S NAME F— IENDER'SADDRESS W IC IFYTHATIHAVEREAl1THISAP ATIONANDSTATETHATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES � d I R TO COMPLV WITH PLL CITY D COUN7Y ORDINMlCESAND STA7E UWS RELATINGTO BUILDING � ST CTION,AND HEREBY Al1T RIZE REPRESENTATIVES OF hIIS COUNi'(TO ENTER UPON THE . A VE- f�TIONEO PRDPEi1TV R7R 1 P TION PURPOSES. COMMENTS 0 nr� J / l m ' . ... � ...a . 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