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HomeMy WebLinkAbout16906 (40) CITY OF DIAMOND BAR `"--� ----�--- I3EPAATTMENT OF COMMUNTI'Y�I�EVELOPMEl`dT SERVICES '''—' 21825 E.Copley Drive '' "'" {909)�60-3195 Fasc(909)861-3117 PRESS � '�`<�ri�'" BiJILDING PERNIIT APPLICATION FIRMLY � JOBSITE APPLICATIO >- ,�,,r�. � PERMIT ' P/C o ADDRESS��� ��� �tsl �� � DATE�� NUMBER "�� # � ISSUE TYPE OCC APN LOT TRACT DATE CONST. � ` GROUP °C OWNER �'�d�.�`� � OO ADD�SyS ZONING SETBACKS z CITY 4�7 ZIP TEL. � FRONT qt/�/ ❑ � APPLICANT TEL. d REAR ❑ Z SIDE/SIDE STREET RW ❑ ¢ CONTRACTOR SIDE ❑ � CITY r �IP TEL PROPOSED USE o ARCH/ENG/ z DESIGNER w N0.DWEL. NO. NO. � ADDRE5S UNITS STORIES BEDROOMS = CITY ZIP TEL. c� cn I DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION �� OWNER-BUILDER DECLARATION � � SFR/A�D/REM p�� I HEREBY AFFIRM UNDER P�NALTY OF PEflJURY THAT 1 AM EXEMPT FAOM THE CONTRACTORS LI� GflfH90ICHfPOII 'W' CENSELAWFORTHEFOLLOWINGREASON(SEC.7037.SBUSINESSAN�PROFESSIONSCO�E:ANYCITYOR (n ' �U � CDUNTYWHICHREQUIRESAPER ITTOCONSTRUCi,AL7EA,IMPROVE,DEMOLISH,OHREPAIRANYSTRUG �,�,w TURE,PRIOR TO ITS ISSUANCE, LSO qC-0UIfiES THE APPLiCANT FOR SUCH PERMIT TO FILE A SIGNE� W PatiO/D2Ck STATEMENT THAT HE OR SHE IS ICEN5ED Pl1RSUANT TO THE PROVISIONS OF THE CONTRACTORS LI� ��'. CENSE CAW(CHAPTER B(COMME CING WITH SECTION]ooa)OF DIVISION 30F THE BUSINESS AND PHO- u' POOVSPB �.'���, �� FESSIONSCODE)ORTHATHEOR HEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEOEXENR (� �,,�,V ',710N.ANYVIOLATIONOFSECTIO 7031.5BYANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO Z Re-Roof '�ACIVIL PENpLTY OF NOT MOFE THAN FIVE HUN�FiED DOLLARS(5500).�: � LJI,ASOWNEROFTHEPflO RTl,ORIdYEMPLOYEESWiTHSVAGE5A5THEIRSOLECOMPENSATION, � COfi1rt18fC18I - Z�, WILL DO THE WOflK,AND THE ST�UCTURE IS NOi INTENDED OR OFFERED FUF SALE(SEQ 7044,BU51- J � ,,NESS ANO PROFESSIONS CbDE:7HE CONTRACTORS LICENSE LAW�OES NOT APPLV TO AN OWNER OF � "i PROPERTY WHO BUIL�S OR IMPRbVES 7HEREON,AND WHO DOES SUCH WORK HIMSELFOR HERSELF OR �". '���THpOIJGH'HIS OR HER OWN EMPLOVEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTEN�ED OR m W'� '�.OFFEREDFORSAIE.IF,HOWEVER7HEBU�LDlNGOflIMPROVEMENTI550LDWITHINONEVEAROFCOMPLE- � ,'TION,THE OWNER-BUILDER WILL HAYE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OF �'� ��',IMPROVEFORTHEPURPOSEOF ALE). w � ❑I,ASOWNEROFTHEPRO ERTY,AMEXCWSNELYCONTRACTINGWITHLICENS"eDCON?RACTORS ���'� �TO CONSTRUCT THE PROJECT( C.7044.BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- I ValUatiOn ADJ.AREA W� ,CENSELAW�OESNOTAPPLVTO NOWNEROFAPROPERTVWHOBUILDSORIMPROVESTHEREON,AN� , '�.�� ��'�.WHOCONTRACTSFDRSUCHPRO�IECTSWITHACON7RACTOR(S�LICENSEDPUFSUANTTOTHECONTRAC- QUAN�TY DESCRIPTION FEE �.� �TORS UCENSE LAW.). I ?� �� ❑I AM EXEMPT UNOEF SEC.II B.&P.C.FOR THIS REASON Q - U � ' , ¢ DA7E OWNER F— � W � . LICEN$ED CONTRACTORS DECLARATION W ¢ '2 i I HEREBV AFFIRM UNOER PENALT�'OF PERJURY THAT IAM LICENSE�UN�ER PFOVISIONS OF CHAPTER z , �,d� ��„9(COMMENCINGWITHSECTION�pW)OFDIVISION30FTHEBUSMESSANLIPROFE5SI0N5CODE,AN� �XIS MY LICENSE IS IN FULL FORCE ANh EFFEC7. � g "��j6 �c m ��"�, UCENSECL�S r ^""4s.> LIC.NO, �" ✓` / `S� � � � 'V I'�� OATE � �`�/� I CONTRACTOR��__ a W � � � WORK�RS'COMPENSATION DECLARATION ¢ ��� ' IHEREBVAFFIRh1UNDEFPENAL OFPERJIJRYONEOFTHEFOLLOWINGDECLARAT10N5: Z ��z�, _IHAVEANDWILLMAINTA�ACEFTIFICATEOFCONSENT705ELF-IMSUREFORWDRKERS' 2 �¢. , COMPENSAiION;AB,'PRO IDED.BYSECTION3�ooOFTHELABORCOOE,FORTHEPERFORMANCE U , Q�, OF THE WORK FOR WHIC{�THIS PERMIT IS ISSUED. � W � �I HAVE AND WIL�IdA1NTAI�1 WORKERS COMPENSATION INSURANCE,AS flEDUIRED BYSECTION O� 37000FTHELABOfi.CODF�,FOF7THEPERFORMANCEOFTHEVJOFiKFORWHICHTHISPERMiT15 � ISSUED.MY WORKERS' OMPENSATION INSURANCE RRIERAN�POLICY NUMBERARE: CONSTRUCTION �j CARRIER� _ _ PLAN REVIEW � . aoucvNUMeER ��,��� � ��� ELECTRIC ¢ � (IFIISSECTIONNEEDNOTBE�APLEfE�OFhEPERMITI$WRONEHUNDREDDOlL4RS($100)ORIESS). PLUMBING . pT_ z I CER7IFY THAT IN iHE PJF�PFORMANCE OF THE WOP.K FOft WHICH THIS PERMIT IS ISSt1ED,I MECHANICAL � ,('} SHALL NOT EMPlO'I(ANY PEfl50N IN ANY MANNER SOAS TO BECOME SUBJECT TO THE (n WORKERS'COMPENSATI(�NLAWSOFCALIFORNIA,ANDAGREETHATIFISHOULDBECOME INS?ECTIONFEE � SUBJECTTOTHEWDRKE S'COMPENSATIONPflOVISION50FSECT�N37000FiHELA80R . � � CO�E I AL Fi]qTHW17�iCOMPLYWITHT405EPROVISIONS. ISS�JANCE �p �A7E: � A�PLI¢ANT _ SMIP � WARNINGFAIIURETOSECUREN�OFKERS'COMPENSAT�COVERAGEISUNL4WFUL,ANDSHALLBE ENERGYP/C �y SUBJECTANEMPLOVEHTOGRIMNALPENALTIFSAN�CIVILFMESUPTOONEHUNDREDTHOUSANO ENERGYPERMIT DOlL4RS(S7o0.o00),IN ADDITION O THE COST OF COMPENSATION,DAMAGES AS PROVI�ED FOR IN � �� J SECTION3]oBOFTHELA�6FIC0 E,INTEREST,ANOATTORNEY'SFEES. [C, RETENTION FEE: OCO STRUCTION LENDWG AGENCY PRE-AlT FEE: :��;� IHEREBYAFFIPMUNDERPENALT�YDFPERJUFYTHATTHERG'ISACONSiRUCTIONLENDIN�AGENCY FOR THE PERFORMANCE OF'THE ILYORK FOR WHICH THIS PEFMIT IS ISSUED(SEC.309T,dV.G.). -" Z W � LENDER'S NAME 1"+ IENDER'SA�DRE55 ' q WICERTIFYTHATIHAVEREADTHI$APPLICA710NAN�STATETHATTHEABOVEINFDRMATIONISGORRECT. TOTAL FEES ��i �p .;( '�� . I AGflEE TO COMPLY WIiH ALL q'TLV AND COUNTY OR�INANCES AN�STATE LAWS RELATING TO BUIL�ING 4 6d° � CONSTRUCTION,ANDHEREBYAyiHORIZEREPRESEN"fATIVESOFTHiSCOUNTVTOENiEflUPONTHE Z AeOVE�MENTIONE�PROPERTY FbR INSPECTION PURPOEES. 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