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HomeMy WebLinkAbout16834 (40) ^ _��` CITY OF DIAMOND BAR ,�,,/�� r DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES /� jl w 21660 E.Copley Drive Suite 190 j (909)860-3195Fax(909)861-3117 '..�� PRES$ 9�'� BUILDING PERMIT APPLICATION __ � FIRMLY -- � _. Q DDRESS ���SP�� P�oC��'XlA I� �1��� ��l DATE CATION ; � V� NU BER � �� #/C � ISSUE u � TYPE OCC APN �OT' TRACT DATE CONST. GROWP p OWNER � "� ADDRESS � � ��° �iL � � � ZONING SETBACKS z CITY�1�t �`3 ��'ZfP �� �� TEL � ��7 FRONT RW ❑ g APPL{CANT �ii. .K�e�`�x.��TEI.���,'3J�1��p� SIDE/SIDE STAEET RW ❑ � CONTRACTOR CsTt.�9 N4 �.C�1(1�"T��C"�'•� SIDE ❑ ADDR S p � PROPOSED USE ' Q CffY �C�Y"f���C� ZIP ���� EL.C�r��'�l��i:��J Q AR4HlENG/ W f DESIC,NEt4_ NO.DWEL. NO. ' ' NO. a ADDRE�S � UNlTS STORI ES BEDROOMS � .CITI' ZIP TEL. �, ' u� DESCRIPTi�N SQ.FT. ' FACTOR PSF ADJ.;AREANALUATION p� aWNER-BUILDEFi DEGtARATION SFR/ADD/REM d I HEREOY AFFlRM UN6ER P;ENPLTY OF PER1t/FY THA7.1 AM EXEMPT FROM THE CONTAACTOpS LI- ['jafd9B/Cdfp01'I �, 0.�1] CENS�tAWFOF9SHEFOLIOWIWGRER50N{SEC.7031.5BUSIIYESSANDPPOFESSIONSCADE:ANYqTYOR (f, � U ,C'aUN7YNPr11CHFE0UIRE5APERMIT�TOCOY5TRUCT,ALTER,IMPflOVE,DEMOGSH,ORREPAiRANYSTflUC- W Patio/Deck � ��� .TURE:PRqP 7d 1T5 ISSUANCE,14LS0 REaUIRES THE APPLICANT FOR SUCH PERMIT TO Fl�E A SIGNED � � ' 'W �.STATEMENT THAT HE OF SHE ISI LICENSED PURSUANT TO THE PRCVISIONS�OF THE CONTRACTORS LI- W . ��. "� 'CB!7SE LAW(CHAPTER 9(COMM€NCINO fNfTH SECTION 7000)OF�IVISIOId 3 OF THE'BUSINESS AND PRO- � PO�I/SP9 '� ''FESSipNSCODE}ORTHATHEOFiSHE{SE%EMPTTHEREFROMAN�THEBASISFORTHEALLEGEDEXEMP- (� �, ��;;, 'TION.kN`fVIOLATIONOFSECTl0�17037.5BYANVAPPLICANTFORAPERMiT5U0JECTSTHEAPPLICANTTO Z, Re-Roof �- � �,,, �'ACIYIL'PENALTVOFNOTMOREl}IANFIVEHUNDREDDOLL4R3(E500).J: _ , -'�,',�.�, C�,AS�VIfJEROPTt1EPROPEFTY,ORMYEMPLOVcESWITHWAGESASTHEIRSULECOMPEiJSAiION, 0 (.`Off1ff18iC18I .. -- ' ��WILL OOTHE WOHK.At3D THE ST�IC7URE IS NOT INTENDED OR OFFER�D POR SpLE(SEC.7044,BUSI- mJ .,� �.'�.NCSS AFD PqOFESSIONS CADE:�ITHE CANTRACTORS LICEN$E LAW�OES NOT APPLY TO AN 6WNER OF � . � � ''.PpOPERTY MMD BJILDS OR IMP&�O�JES TFSEREON,ANO WHO DtlES Sl1CH WOFK HIMSELF OR HERSELF OR ' "i �(_: �THi10UGH HiS OR HER OWN EMPLOVEES,PROVIDm THAi SUCH ItAPROVEMENTSARE NOT INTENDFA OR m ',;�', ,'�iOFFEREDFORSALEIF,HOWEVEF�,Th{EBUdlD14GORIMPROVEMENTIS&OIDWIT.HINOIJ[YFAFOFCAMPLE- ,� "�,TIOPI,Yf£OWNER$UBLDER Wlil HAVE THE BURDEN OF PR06'ING THAT HE DR SNE DID NQT BUILD OR IMPROVEPOflTMEPURPOSEOF�,SALE). ' I '[��p, C I,AS OWPiEROFiHE PROPEHBV,P�.L9 E7tGLU51VELY CONYRACTING YYITH LPCENSE�CCNTRACTORS . ,pC TO CbNSTRUCT THE PR0.JECT(SEC,70d4,BUSINESS AND PpOPESSIONS CODE:THE CONTRACTOfiS LI- V8lGe:i00 � ,4DJ.AREA � '�.111 '�,CEN5EUWDOFSNOTAPPLYiQ�AN�OWNEROFAPRDPEHNWH09WLO50RIMPAOVESTHEREON,ANe '� _'�: '.I��CONTRRCTSFORSUCHPq.TJF.CTSWITNACAMTRACTOii(5)LICENSEDPURSUANTTOTHECNJNTRAP � � �`� ����rowsucEassuw.�. � ' � QUANTITY DESCRIPTION FEE� . . ',o� . �I AM EXEMPT llNDER S�C� B�8 P.G fOR iH15 REASON Q � � ��, .���.. . . U , ,. �, C'i ',, ���.., ��.DATE �� oWNER U � LICEPlSED CONTR4CYORS'DECLARATIOF � �G ��IHEflEBYAFFIRMUNDERPEMAIT!OFPERJIlRY7HATIAMLICENSEDUNDERPROVISIONSOFCNAPTEA � '�p„ 9(COAiMENC{NGWITFiSECTIONYOD�)�FDIYISi9N30FTHE6U51fVES5ANDPFOFESSIONSCODE,AND Z ' ' ,9� MYlICENSE IS 1N FULL'FORCEAAID EFFEC'C � � '� 'Q..����P__— ���'�✓�J � 'Lf� LICENSE CLA55 UC.NO. V DATE ,��--'�' ^' v � CDPlTRACTOR �- Lil. �'�� WOFiK�RS'COMP�NSATPOiV DECLARATIOId ¢ � � � IHEREBYAFFIRMUPiDERPENdLTYOFPERIURYONEO�TMEFOLLOWING�ECLARATiONS: � . �,, �IHAVEANDWILLM�9INTP.INACERT@FICATEOFCANSENT705ELPdNSUREFORWORKER"o' S CAMPENSATION,AS?flC.7ViDEGBVSECTfD�W37o06FTHELAEQRCDDE,FOPTHEPc'RFORMANCE C, � OFTHE WOpK FOR WHiCH THIS PERMli PS ISSU'cD. g ', � �I HAVEM/U WILLNAAINTRiN WORKERS'COMPEEVSATIOH INSURANCE,RS REQUIRE�BY SEC710N � �� 37000.tTHELA60R�qE.fRfl'NEPERFDEMAttCeOF'HEWORKFORWHICHTHISPERMIiIS ISSUED.MY�v�OqyK..E�RS'G�O�MPENSATIONINSURANCE ARRIERANDPOLICYNUMBERARE: CONSTRUCTION � � car���En �tJ 1�6.�i C�. �lsl Y9.� PLAN REVIEW � �'�� POtICYNUMBER����� �F C��.� EL'sCTAIC . --- � (tH�SECT6yNNE�NDT9E�EfEDOFTHEPEF�,4TISF7�RONFiilIPDFiF.D�OIIARS(590D)ORLESSF PLUMBING � Z ICERYIFYTHATINTHEPERFORMANCEOFTHEWORKFORWMCHTHISPEflMITISISSIJED,I MECHANICAL _ �� frHRLLkOTEMPIOYANV�iPER50N�NFNYMAt3t3ERSOAST08ECAMESUBJECTi07HE �� �!_ ' ('n WORK�RS'COMPENSATIpNLAWSOFCALIFORNIA,AN�AGREETMATIFISHOUL�6ECAME IfVSPECTIONFEE d���^� " "-'` ' � ��'--�^_-'�-^') � SUBJECTTOYHEWORKERS'COMPENSATIONFROVlSIONSOFSECTION37oDOFTNEIABOR $ / ISHALLFORTHW`IYrHC MPLYiNI iHOSERROVISlO ISSUANCE C a L✓� P p��y, � � p DA'fE: ��`T ^ qPPLtCANT. �Ls�{ 6C�YI � SMIP '� .J�.. WARNING FARURE TQ SECURE 1VORKERS'CAMPENSAT:OR OOVERAGE IS UNLAWFUL.AND SHALL BE �NERGY P/C I y� S�BJECT AN EMPLOYERTO CRI�IIPIAL PENALTIES AND CIVIL FINES UP 70ONE HUNDRED THOUSANO ENEflGY PERMIT �.=4�Te '. DOILARS�E1Co.c0o),INADDIT�ONTOTHECOSTOFCOMPENSATION,DAMAGESASPPOVI�EDFORIN �-�--�---- J' SECTION 37o80F hiE 3.ABOR CdOE,7NTEREST,AND ATTOiiNEYS FEES. � E�-•.'-..-�.�-.-.----.�----�----� � p�� RETENTION PEE: OC(DfJSTRUCTION LENDING AGENCY PRE-ALT FEE: �., I NEREBV AFFIRM UNDER PENALTV OF PERJURY THAT THEPE IS A CONSTRUCTION LENDING AOENCV FORTH¢PERWRMANCE OFTHE WORK FOR WHICH TNIS PERMIT IS ISSUED(SEC.3oe],GY.C.). � U! �S LENDF.R'S NAME ' ' ;i^-� IENDER'SFDDRESS � � ICEflTIFYTNRTIFiAVERER�THI6APPLICAFIONAND5TA7ETHATTHEA80V'cINFORMA710NISCARPECT, TO�AL FEGS �r �, I AGflEE TO CAMPLV WITH qLL C4T1'AND CDUNTV ORDINANCES AND STA7E LAWS REIATING TO BUILDING ' . ,�'', CAWS?RUCAIOt�l,AND HEREBYAUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE Z, ABOVE-MENTIONE�Pfl9P'cRTY FOR 6hSPECi60N FURPOSES. 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