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HomeMy WebLinkAbout15780 (23) E���r� _��__ CITY OF DIAMOND BAR `�/�U/� � „ DEPARTMENT OF COMMLTNITY�DEVELOPMENT SERVICES 21660 E.Copley Drive Suitc 190 w (949)860-3195 Fax(909)8b1-3117 .�� PRESS ��"�+�� BUILDING PERMIT APPLICATION _ FIRMLY �sM ... . . . . . .... .. ... ... ...:i...,:.. ...�...:.. ...::.:;:,-4�.,.......:. Q ADDRiESS ��2� P�SC-G7 C'-T APPLICATIO PERMIT � �i►� P/C p DATE NUMBER FJ`" # � APN LOT TRACT ISSUE TYPE OCC —�- DATE CONST. GROUP p OWNER �7CA"i�ff 1'CG�i..�2�L�33�'L.� " ADD SS�^'V ZONING SETBACKS Z CITY��`�a� �Z ZIP TEL.��/�"'���A' REART RW ❑ g APPLICANT TEL. � � SIDE/SIDE STREET RW p CONTRACTOR [,'��7r-� SIDE ❑ ADDRESS 3`u'z3 �"L�N'i�';�I'Lf � GTY ��GF�'�a.Y.Lti� Zip�+'7�1 TEL. �S'�^4`� PROPOSED USE o ARCH/ENG/ � DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � �n DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADD/REM O I HEREBV AFFIRM UNDEH PENALTY OF PEflJl/RY THAT 1 AM E%EMPT FROM THE CONTRACTORS LI� Gyf2g0/CdfpOft W CEN3ELAWFORTtIEFOIIOWINOREA50N(SEG7031.68USINESSANDPROFESSIONSCADE:FNVCITYOR (J� ZCOUNTYWHIGHREWIRESAVERMfiTOCDNS7RUCT,N,TER,IMPROVE,DEMOLISH.ORREPAIRANYSTRUC W P81i0/DBCk ��� TUHE,PRIOR TO I75 ISSUANCE,ILLSO REQUIFiES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W � STATEMENT TFNT HE OR SHE IS UCENSEU PURSUANT TO THE PROVISIONS Of THE CONTRACTORS l4 � � CENSEUW(CHAPTERB�WMMENCINGWITHSECTION7000)OFOIVISION3OFTHEBUSINESSANDPRO� POOUSpB FESSIONSCODE)ORTHATHEORSHEISEXEMPTTHEFlEFROMANO'fHEBASISFOR7HEALLEOEDEXEMP� (� TION.ANVVIOI.ATIONOFSECTIdi7o91.58YANVAPPIICANTFORAPERMITSUBJECTSTHEAPPLICANTTO Z Re-Roof � ACINIPENALTY OF NOT MOpE THAN FIVE HUNDRED DOLL4R5(f500).J: � ❑I,ASONRJEROFTHEPROPERTV,ORMVEMPLOVEESWITHWAGESA&THEIRSoIECOMPENSATION, CORIR10fC121 - VlILL 00 THE WORK,AN�THE STRUC7URE IS NOT INTEN�Ep OR OFFERED FOR SALE(SEC.7044,BU56 �J � NESSAND PfiOFES310N3 COOE:THE CANTRACTORS UCENSE LAW DOES NO7 APPLY TO AN oWNER OF � PROPENiV W}i0 BURDS OR IMPROVES THEFiEON,ANDYVHO DOES SUCH WORN HIMSELFOR MERSELF OR � THROUGH NIS OR HER OWfJ EMPLOYEES,PFOYIDEO THAT SUCH IMPROVEMENTS ARE NOT INTENOED OF m 0 ,OFFEREOWRSALEIF,HOWEVER1/iE9UIlDINGORIMVROVEMENTISSOLDYA7HINONEVEAROFCOMPLE Z TION,THE OWNER-BUIlDER WILL HAVE THE BURDEN OF PROVING TNAT HE Ofi SHE DID NOT BURA OR = IMPROVE FOR THE PURPOSE OF SALE). W ❑1,11SOWNEROF7HEPFiOPERTY,AAIEXCLUSNELYCAN7AACTINGWI7HLICEkSEDCONTPACTORS � TO CONSTRUCT TNE PRQIECT(SEC.1DU,BUSINESS ANO PROFESSIONS CODE:THE CANT0.ACTORS LI� VflIU8ti0I1 ADJ.AREA W CENSEUWOOESNO7APPLVTOANOWNEROFAVROGFRTYWHOBUILDSORIMPHOVESTHEiiEON,AND � Vh1000NTRACTSFORSUCHPHQIECTSWITHACONTMCTOR(S)LICENSEDPURSUANTTOTHECONTRAG Q�JqNTITY DESCRIPTION FEE - � TOqSl10EN5ELAW.). o ❑I AM EXEMPT UNOER SEC. B.&P.C.FOR hIIS REASON Q 3 � � � DATE OWNER U Q W � LICENSED CONTRACTOFIS DECLARATION W � I HEREBYAFFIRAI UNDER PENPLTV OF PERJURY THAT I AM UCENSED UNDEF PROVISIONS OF CHAPTER ' p� Y(COMMENCINOWITHSECTION70o0)OFOIVISION3OfTH[BUSINESSAN�PROFESSIDNSCADE,AND Z k (� �X MY UCENSE IS W FUII FORCEAND EFFECT. m � LICENSE CLASS ��V IIC,NO. ��"'�—� � H .�.t V �ATE �` `� CONTRAC70R � _ d W � WORKERS'COMPENSATION�ECLARATION -� Q � IHEREBYAFflRMUNDERPENAL7YOFPEFJURYONEOFTHEFOLLOWWGDECLAR4TION5: Z O IHAVE/VlOWILLMAINYNNACERTIFICATEOFfANSENT70SELF-INSUREFORWONNERS' 2 Q COMPENSATION,AS PROVIDEO BY SECTION 370o OF THE IAeOF CDDE,FOR THE PERFORMANCE W OFTHE WORK FOR WHlCH THIS PERMIT IS ISSUED. � � � _IHAVEAN�WILLMAINTAINWORKERS'COMPENSATIONINSUHANCE,ASREOUIFEDBVSECTION Q� 37oopF TNE LABDR CODE,FOH THE PERFORMANCE OF THE WORK fOR WH;CH THIS PERMIT IS ISSUEO.MY WORK{��$✓S'COMPENSATION INSURANCE CARRIER AND FOLICY NUMBER ARE CONSTRUCTION ? CARRIEF ` �-����� p�,.y������ PIAN REVIEW � POLICYNLIMBER l.t�J�GA� ��l�'JJIJ�\ ELECTRIC � (1FiSSEtit10NrvE�NOTBECaMPLEfEDOF711EPEw.sTtsFORONcHUK�REODounitS(Steo)okLEss} PLUMBING ����d 'S n • W ��� 4q"�]�� Z I CEA7IFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I MECHANICAL ;v�r ����+5J (} SHM.INOTFMPIOVANVPER50NINA.UVMANNERSOAST09ECOMESUBJECTTOTHE ��..... �/ (� � WORKEFS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULO BECOME INSPECTION FEE.�y z `✓-t¢' � 4�.. .. SUOJECTTOTHEWORKERS'COMCENSATI fONSO CTIDN37DOOFTHELABOR 4]�� �"'y s,���^: -� '-"'"'�`� es`. �`y� ~ CODE,ISHALLFORTHWITHCOMPIVWI TiiOSEPROVI510NS. ISSUANCE -s/�;41ky� �"'p4T �'C O r � . E.,�e��'�i�� p DATE: �`�-�o APP'L.iCANT: �`"". SMIP J WARNINa:FAILURE TO SECURE WORKEPS'COMPENSATION COVERAGE IS UNLAWFUL,ANO SHALLBE ENERGY P/C � SUBJECTANEMPLOVERTOCRIMINALPENALTIESANDCiVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT DOLIARS(�too,Wo),IN AODITION TOTHE COST OF COMPENSATION,DAlAAGES AS PPOVIDEb FOR IN � SECTION3TdeOFTHELABORCODE.INTEFlEST,ANDATTORNEI^SFEES. RETENTIONFEE: � CONSTRUCTION LENDINGAGENCY PRE-ALT FEE: O � 1 HEREBV AFFIRM UNDER PENALTV OF PERJURV THAT THERE IS A CONSTRUCTION LENDWG AGENCY FOR THE PEPFORMANCE OF TNE WORK FOR WHICH THIS PEFMIT IS ISSUED(SEC.30W,CIV.CJ. Z W � IENDER'S NAME 1— LENOERSADDRE55 � ICERTIFVTNATIHAVEREADTHISAPPIICATqNANOSTATETHATTHEABOYEINFORMATIONISCOflRECT. TOTAL FEES W IAGREE TO COM7LV WITH ALL CITV AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILOING � CONST{3UCTION,AND HEREBV AUTHORRE REPRESEMATNES OFTHIS COUNTV TO ENTER UPoN THE � ABOVE-MENT ED PROPERTY FOR INSPECTION PURPOSES. COMMENTS 0 � ' �,�.. h � m PERMITTEE NAFAE IM) � ti�1� � SIONATUREOFPERMITTEE DATE = RECPT.NO. 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