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HomeMy WebLinkAbout15213 �C" V �r"� CITY OF DIAMOND BAR � � 1 °� ' --�-1��'-- DEPARTMENT OF COMMLJNITY dc DEVELOPMENT SERVICES �/✓,����,�� '� w, . ai�o E.c�iey��e s�c�i90 �/f�`" pRESS �����°��� BUII.DING PE (RMIT APPLICATION � v FIRMLY � -- . � JOBSITE p � �j �/ APPLIC �j PERMIT P/C o ADDRESS r /�� ��� � � �' '-^� DATE �� /i`� NUMBE�# r� ISSUE TYPE OCC APN L TRACT DATE CONST. GROUP °C OWNEF � " S J ZONING SETBACKS p ADDq.�S � C��,,/) FRONT RW ❑ f�� J REAR ❑ APPUCANi --�� G� _ SIDE/SIQE STREET RW ❑ � CONTRAC (,�r SIDE ❑ � ADD S � PROPOSED USE CI� ! EL. o ARCH/ENG/ � DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS = CITY ZIP TEL. � DESCRIPTION S(].FT. FACTOR PSF ADJ.ARE.ANALUATION � OOWNER-BUILDER DECLARATION SFR/ADD/REM � I HEREBV AFFlRM UNDER PENALiY OF PERJUflV THAT�0.M E%EMPT FROM THE CONTRACTORS LI- � Garage/Carport W CENSELAWWRiHEFOILOWINGREA50N(SEC.7031.58USINESSANDPROFESSIONSCODE:ANVCIiYOR CJ COUNTYN7iICHREOUIRESAPERMITTOCONSTRUCT,ILLTER,IMPftOVE,�EMOLISH,ORREPAIFANYSTRUG �W Patio/Deck WNRE.PRIOR tOITS ISSUANCE,ALSO RE�UIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W .� STATEMENT 7HA7 HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTMCTOHS U- � CENSE UW(CHAPTER 9{COMMENqNO WITH SECTION 7mo)OF�IVISION 3 0f THE BU51NES5 ANO Pfl0- � Pool/Spa FESSIONSCOOE)ORTHATHEORSHEtSEXEMPTTHERE'.ROMANDTHEBASISFORTHEALLEGF.�E%EMP- (� TION.ANYVIOLATIONOFSECTfON7037.6BYANYAPPLICANTFORAPEHMITSUBJECTSTHEAPPLICANTTO z Re-Roo( � ACIVILPENALTY OF NOT MORE TNAN fIYE HUNORED DCLURS(i5oo�.): � ❑I,ASOWNEROFTHEPiiOPERTY,ORMYEMPIOYEESWITHWA0ESA5THEiRSOLECOMPENSATION, Q COtllfflBfC13I WILL DO THE WOAK,AND THE STPUCTURE IS NOT INiENDED OR OFFEREO FOR SALE(SEC.7044,BUSI� J NE55 AN�PROFESSIONS COOE:THE CANTflACTORS LICENSE LAW DOES NOT qPp�Y TO AN OWNER pF � PPOPERNWFIOBUIL0.SORM1PqOVESiHEFEON,ANDWHDDOE55UCHWORKHIMSELFORHEFlSEIFOq � � THAOUGH HIS OFI HEROWN EMPLOVEES,PROVIDED THAT SUCH IMPROYEMENTS ARE NOT INTENDEO OF m � OFFEfiEDWRSALEIF,HOWEVERTHEBUIL0INGORIMPROVEMENTI550LDWITHINONEVFAROPCAMPLE- z �710N,THE OWNER�B�IIDER WILL HAVE THE 9URDEN OF PROVING THAT HE OR SNE DID NOT BUILD OR = IMFROVE FOR THE PURPOSE OF S�I.E�. O 1,AS O4MER OFTHE PROPERTY,AM EXCLUSIVELV CONTRACTING WITH LICENSED Cf1NTRACTORS a TO CONSTAUCT THE PR0.1EC7(6EC.7014,BUSINESS AND PROFESSIONS COOF:THE CONT0.ACTORS LI- V81U0fi0f1 __ _ADJ.AREA W CENSEUWDOESNOTAPPLY70ANOWNEROFAPROPERNWHOBUILDSORIMPROVE57NEREON,ANQ � NM1qCON7MCTSFORSUCMPRQIECTSWITHAC9NTMCTOR�SjLICENSEDPURSUANTTOTHECONTMG QunNrirv DESCRIPTION FEE � TORS UCENSE LAW.). o ❑I AM EXEMPT UNDER SEC. _B.8 P.C.FOR THIS REASON Q 3 — -- — � � LL' OATE OWNER V Z W Y UCENSED CONTRACTORS OECLARATION —� � W 1 HEREBY AFFIRM UNDEfl PENALTY 6F PERJURV THAT 1 AM IICENSED UNDER PROVISIONS Of CHAP'ER � e�S�i] � � e(COMMENCING WiTH SECTION 7o:q)OF DIVI510N 3 OF TNE AUSINESS At�PROFESSIONS CODE,AN� Z �" ��� MV LICENSE IS IN FU FOR E AND EFFECT. m o ���� ��7--��% � F. UCENS LAS �.�E LIC,NO._ � �" � V DATE�� �.,/� CONTRACiC���yL�:-�[�.�--����'"� d W � WORKER3'COMPENSATION DECLARATION a = U � I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF TNE FQLLOWING OECLARATIONS: � Z Q � _IHAVEANOWILLMAINTAINACERTtFICATEOFCONSENTTOSELF-INSUREFORWORKERS' 2 . � 001APENSATION.AS PROVIOED BV SECTION 3�0o OF iHE LABOR CODE,FOR THE PERFORMANCE W OF TFIE WORK FOP WHICH THIS PEAMIT IS ISSUcO. � � W _I HAVE ANO WILL MNNTAIN WORKEFS'COMPENSATION INSURANCE,AS RE�UIRED BY SEC7ION Q 370oOFTHELABOR�DE,FORTHEPERFORMANCEOFTHEWORKFORWHICH7HI5PERMITIS ISSUED.MV WORKERS'COMPENSATION INSUFANCE CARRIEF AND POLICY NUMBEA ARE: CONSTRUCTION _ jCAaPIER _ ^_ PLAN REVIEW � POLICVNUMBER ELECTRIC ___����1�� �{ � � / L1 Q (fHISSECTIONNE�NOTBE�'LEfEDCF7I+EPEPlMtSFaRONEHUPDfiEDDIX.,JfAS too�ORLE55j. „�UJlABiM6--- _�__ Z I CERTIFYTNAT IN THE PEPFORMANCE OF THE WO OR W CH T ERAA ISSUED.I MECHANICAL („� SHALL NOT EMPLOV AP1V PERSON IN ANY MANNE O AS TO E E CT TO TNE —� � WORKERS'COMPENSATIONLAWSOFCAI.IFOR A,AND EET SHOULDBECOME INSPECTION FEE ___.__._—__ _ SU&iEC�TTQ�TNE WORKERS'COMPENSATION ROV S OF SE ION 370o OF THE l4BOF S �E,I F�bJ91'ITH COMPLY WITH ROVISION ISSUANCE p DATE L_—� APPLICANT: SMIP � y ENERGY P/C WARNINO;FAILURE TO SECURE WOi7KERS'COMPENSATION COVEPAGE IS UN WFUL,A SHALL 6E � SU&IECTANEMPLOYERTOCRIMINALP[NAITIESANDCIVILFINESUPTOON HUNDREO OVSANO ENERGYPERMIT P��I � Il �nnn DOLLAflS(5700,DOOj,IN ADOITION TO THE COSTOF COMPENSATION,OAMAG AS PROVID D FOR IN � SECTION 3708 OFTHE IABOR CODE,MTEREST,ANO ATTORNE`fS FEES. RETENTION FEE: �j'� - 7�7� p�-� � CONSTRUCTION LENOING AGENCY PRE-ALT FEE: `-'+; A �F DIAMOI'liJ�h1.LC � IHEREBVAFFlRMUNOERPENALTYOFPERJURVTHAT7HEREISACANSTqUCTIONIENDINGAGENCY �3LTI�.,DING�1ND SAFETY d FOF THE PERFORMANCE OF THE WORN FOR WHICH THIS PEFMIT IS ISSUEO(SEC.30s7,CIV.C.). Z W � LENDEft'SNAME_ _ 1--� LENOER'SA�DRE55 � ICERTIFVTHATIHAVEREADTHISAP7LICATIONANOSTATETHATTHEABOVEINFORMATIONISCORRECT. TOTALFEES �� ` � � W I AGREE TO CAMPLY 1MTH ALL CITYAND COUMTV ORDINANCESAND STATE LAWS RELATING TO BUILDING � � � CONSTRUCT , D HEREBY AUTHOPI2E REPR56ENTATIVES OF THIS CDUNTY TO ENTER UPONTHE Z ABOVE-M K7N D PROPEHT`4fOR INSPECTIOtJPURPPSES. COMMENTS � � � ��:��� mryryry...,,, Q PEftMITTEE N � (PRIN) ' �� � G� � � SIGNAT E O FlMI7T � OATE = RECPT.NO. 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