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HomeMy WebLinkAbout17285 (23) �� CITY OF DIAMOND BAR �J � DEPARTMENT OF COIvIlvfi_JNTfY 8c DEVELOPMENT SERVICES / 2I82S E.Copley Drive (909)860-3195 F�(909)861-3117 PRESS ��'�y���� BUILDING PERMIT APPLICATION FIRM Y � JOBSITE �e ¢ ADDRESS �-��"IS 1 PGA�� ,�����_ APPLICATION (�; �'/� PERMIT (�� �,�/C o DATE � �`' NUMBER I / Yi (.D � ISSUE TYPE �� y OCC APN LOT TRACT � ' � p OWNER 1 � .� DATE. CONST. GROUP o ADDRESS ZONING SETBACKS z CITY Q • �_e--�,_ ZIP����"TEL.y�B,�� FftONT q�n� � � APPLICANT TE�, REAR � z SIDE/SIDE STREET RW ❑ Q CONTFiACTOR �"?..�-��-�--- SIDE p � ADDRESS � CITY ZIP TEL. PROPOSED USE o ARCH/ENG/ z DESIGNER a ADDRESS NO.DWEL. Np. Np. cn UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION p SFR/ADD/REM � I NEREBY AFFIflM UNDER PENALTY OF PEPJURY THAT I AM E%EMPT FROM THE CONTRACTORS LI- G2f8 ft�CB OfS W CENSEUWFOHTHEFOL�OWINGREASON(SEC.703t.5BUSINE55ANDPROFES510NSCO�E:ANYCITYOF (n 9 � U COUNTYWHICHREqU1RE5APERMITTOCONSTRUCT,qLTER,IMPROVE,OEMOLISH,ORREPAIRANYSTRUC- W 7URE,PRIOR TO I75 ISSUANCE,AL50 REDUIRES THEAPPLICANT FOR SUCH PERMITTO FILE A SIGNEO W Pa}io/DeCk � STATEMEM THAT HE OR SHE IS LICENSEO PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI� CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIV:SION 3OF THE 9uSINESSAND PRO� � PooUSpa O FESSIONSCADE)ORTHATHEORSHEISEXEMPTTHEREFRDMANDTHEBASISFORTHEALLEGEOE%EMP� (� U TION.ANYVIOLATIONOFSECilON7031.98YANVAPPLICANTFORAPEPMITSUBJECTSTHEAPPIICANTTO Z Re-Roof A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDPED DOLLARS�f5oo).)�. 0 ❑I,ASOWNEROGTHEPROPEFTV,ORMVEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, � COfiIRIBfC18I Z WILL 00 THE WORK,AND THE STRUCTURE IS NOT INTENOED OR OFFERED FOR SALE(SEG,7044,BU51� J � NESSAND PROFESSIONS Cq�JE:THE CONTRACTOfiS LICENSE LAW DOES NOTAPPLY TO AN OWNER OF � PflOPEPTV VJHO BUILDS Oq IMPROVES THEREON,AN�WHO DOES SUCH WORK HIMSELF OR HERSELF OR � THROUGHHISORHEHOWNEMPLOVEES,PROVIOE�THATSUCHIMPROVEMEMSAqENOTINTEN�E�OR m � oFFERE0FOR5AlE.IF,HOWEVER,iHEBUiLDINGORIMPROVEMEN71S50LDWITHINONEYEAROFCOMPLE� Z 710N,7HE OWNER-BUILDER WP,L HAVE THE BURDEN OF PPOVMG ThIAT HE OR SHE DID NOT BUILD OR = IMPROVE FOR THE PURPOSEOF SALE). - �yJ ❑I,ASOWNEROFTHEPROPERTV,AMEXCLUSNELVCONTPAC7INGWITHLICEN5E000NTRACTOPS � TO CANSTRUCT THE PFOJECT(SEC.7oA6,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- V8IU8110f1 ADJ.AREA W CENSEUW�OESNOTAPPLVTOANOWNEROFAPROPERTVWHOBUIIDSORIMPROVESTHEREON,AND — � WHOCOMTRACTSFORSUCHPROJECTSWITHACONTRACTOR(5)LICENSE�PURSUANTTOTHECONTRAC- QUANTITY DESCRIPTiON FEE Y TORS LICENSE LAW). 0 ❑I AM IXEMPT UNDER SEC. B.8 P.C.FOHTHIS REASON Q � � 1 � � �" c OWN F– __ V � LICENSED CONTR W ¢ _._. � I HEREBYA RM UNDER PENALTY OF PERJUqY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER � � 9(COMMENCINGWITHSECTION7oao)OFDIVISION9OFTHEBUSINESSANDPROFESSIONSCODE,AND z `X MY LICENSE IS IN FULL FORGE AND EFFECT. m � LICENSECLASS LIC.NO. � V DATE CONTRACTOR d W � WORKERS'COMPENSATION DECLARATION Q � I HEREBV AFFIRM UN�ER PENALTV OF PERJURY ONE OF THE FOLIOWING DECLARATiONS: Z Z _IHAVEANOWiLLMAINTAINACER7IFICATEOFCONSENTiOSELF�INSUREFORWORKERS' _ ¢ COMPENSATION,AS PROVIDED BV SECTION 3700OF THE LABOR COOE,FOR THE PERFORMANCE U Q OF TNE WOfiK FOR WHICH THIS PEflMIT IS ISSVED, � W _I HAVE ANO WILL MAINTRIN WORKERS'COMPENSATION INSUFANCE,AS REO�'IPED BV SECTION 0 37000F THE LA90R CODE,FOR THE PER�ORMANCE OFTHE WORN FOR WHICHTHIS PERMIT 15 ISSUED.MV WORKERS'COMPENSATION INSl1RANCE CARRIER AND POLICV NUMBER ARE: CONSTRUCTION J j CARRIEa PLAN REVIEW Z POUCVNUMeEa ELECTRIC ,¢ �,. � (iHISSECTICNNEmNDTBECClAREfE00F11iEPEflMITISWFONEHUFDRED00l1AR5(5100�ORLESS). PLUMBING Z I CEFTIFV THATIN THE PERFORMANCE OF THE WORK FOR W�-11CH THIS P'cRM1T IS ISStIED,I MECHANICAL C�S SHALI.NOT EMPLOY ANY PEFSON IN ANV MANNER 50 AS TO dECOME SUB�ECT TO THE � WORKERS'COMPENSATIONLAWSOFCAUFORNIA,ANDAGREETHPTIFISHOUL�BECOME �NSPECTIONFEE � SUBJECTTO'HE WORKERS'COMPENSATION PROVISIONS DF SEC�'ION 37a00F THE UBOR � COOE,I ShIALL FOFTHWITH COMPLY WITH THOSE PROVISIONS. ISSUANCE 0 p DATE: APPLICANT: SMIP � WARNING FAIWRE TO SECUPE WORKEFS'CAMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE ENERGY P/C � SUBJECTANEMPLOVERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUN�REDTHOUSAND ENERGYPERMIT DOIURS(5100,OOD),IN AODITION TO THE COST OF COMPENSATION.DAMACES AS PFOVIOED FOR IN J SECTION37oBOFTHELABORCODE,WTEREST,ANDATTOR?lEY'SFEES. Q RETENTION FEE: OCONSTAUCTION LENDING AGENCY PRE-ALT FEE: � I HEREBV AFFlRM UNDER PEf.'ALTV OF PERJVRY'HAT THERE IS A CONSTRUCTION LENOING AGENCV FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3a9],CIV.C.). Z W — � LENOER'S NAME 1— LENDER'SADDRESS ,� TOTAL FEES �+ , � ¢ I CERTIFY THAT i HAVE REA�TNIS APPLICATION AND STATETHAT iHE ABOVE INFORMATION IS CORRECT. � I AGREE TO COMP�Y WITH ALL CITYAND COUNTV ORDINANCES AND STATE fAWS REIATMG TO BUIL�ING � CONSTRUC710N,AND HEREBY AUTHORIZE REPflESENTATNES OF THIS COVNTV TO ENTER UPON THE Z ABOVE-MENTIONED PROPERTY FOR INSPECTION Pl1RPOSES. COMMENTS � –J e 1 � �����7.�'__'____— m PERM EENAME�P'r�NT) � Q �n � 1(/l ,�,J � SIGMATUREOFPERMIT�EE D0.E = FECPT.NO. 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