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HomeMy WebLinkAbout17245 __ _. CITY OF DIAMOND BAR /'�� --�-- �'�`' � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �� � 21825 E.Copley Drive (909)8603195 Fax(909)861-3117 PRESS "%��^�� BUILDING PERMIT APPLICATION FIRMLY y JOBSITE . APPLICATIQN n �/ PERMIT U �/C o ADDRESS'��✓�Q���I��ajj4M,/��- DATE " l [.' � NUMBER �!' # � r � ISSUE TYPE OCC � APN LO TRACT DATE CONST. GROUP p OWNER p ADDRESS ZONING SETBACKS Z CITY � ZI TEQ FRONT q�ry ❑ � APPLICANT TEL. REAR ❑ z SIDE/SIDE STREET RW ❑ ¢ CONTRACTOR SIDE ❑ ADDRESS � CITY ZIP TEL. PROP D SE� �� �z� ARCH/ENG/ �J� ' DESIGNER NO.DWEt. NO. a ADDRESS � � CITY ZIP TEL. UNITS STORIES BEDROO � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADDlREM O p I HERE9Y AFFlRM UNDEF PENPLTV OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI� Gdf19B/COfPOfI W CENSEIAWFOR7HEFOLLOWINGREASON(SEC.7a37.5BUSINESSANDPROfESSIONSCODE:ANYCINOq (n U COUNTYWHICHREOUIRESAPERMIiTOCONSTRUC7,ALTER,IMPROVE.DEMOLISF,OpREPAIRANYSTRL�C� w TURE,PRIOR TO ITS ISSUANCE,ALSO REOl11RES THE APPLICANT FOR SL1CH PERMIT TO FIIE A SIGNEO W Patio/Deck STATEMENT THAT HE OR SHE IS I ICENSED VUiiSl1ANT TO THE PROVISIO��S OF THE CONTRACTORS U� � CENSE LAW(CHAPTER 9(COAAMENCING WITH SECTION]000)OF DIVISION 3 OF THE BUSINESSAND PPO- � POOVSpe O FESSIONSCODE�ORTHATHEORSHEISE%EMPTTHEREFROMANOTHEBASISFORTHEALLEGEDEXEMP- (� U TION.ANVVIOLATIONOFSECTION7o31.5BYANYAPPLICANTFORAPERMITS'JBJECTSTHEAPPLICANTTO Z Re-Roof ACIVIL.PENAL7Y OF NOT MORE THAN FNE HUNDRE�OOLIARS(E5o0).): Z ❑I,ASOWNEROFTHEPROPERTV,ORMY'eMPIOYEESWITHWAGE5A5TNEIR50LECOMPENSPTION, � COR1rt18fClel WILL�O THE WORK,ANO TH`c STRUCTUflE IS NOT INTENDED Ofl DFFEREO FOR SALE(SEC.7044,BU51- J N NE55 ANO PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY 70 AN OWNER OF � PROPERN NMO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK NIMSELF OR HERSELF OR � THROUGHHISOqHEROWNEMPLOYEES,PROVIDEDTHATSUCHIMPROVEUENTSAFENOTINTENDEDOR m � OFFEREDFORSALE.IF,HOWEVERTNEHUILOINGOftIMPROVEMENTISSOLDWITHINONEVEAROFCOMPIE- Z TION,THE OWNER-BUILDEF WILL HAVE THE 9URDEN OF PqOVING TNAT HE OR SNE DID NOT BUILD OR = IMPROVE FOR THE PURPOSE OF SALE). w ❑I.AS OWNER OF THE PROPERTV,AM EXCLUSIVELY CONTRACTING WITH LICENSEO CONTRACTORS � TO CANSTRUCT'HE PROJECT(SEC.�044,BUSINESS AND PROFESSIONS CODE.THE CONTRACTORS LI� V8IU8IIOI1 ADJ.AREA W CENSELAWDOESNOTAPPLYTOANOWNEROFAPqOPERTVWHOBUILDSORiMPROVESTHEREON,AND � WHOCONTRACTSFORSUCHPROJECTSWITHACONTRACTOR(S)LICENSE�PURSUANTTOTHECONTRAC� QUANTITY DESCRIPTION FEE Y TORS UCENSE LAWJ. � ❑i AM EXEMPT UNOER SEQ _._._.____.____. _8.&P.C.FOR THIS REASON U �i ¢ � DATE OwNER F- O w � LICENSED CONTRACTOR5 DECLARATION W ¢ � I HEREBYAFFIRM UNDER PENALTYOF PEiiJURV THAT IAM LICENSED IJNDEF PROVISIONS OF CHAPTER � � 9(COMMENCMGWITHSECTION70o0)OFDIVISION30FTMEBUSINESSANDPRO�ESSIONSCDDE,AND Z W MV LICENSE IS IN FULL FOPCE AND EFFECT. m � IICENSE CLASS LIC.NO. � V DATE� I CONTRACTOR�jy� d W � � WOFiKERS'COMPENSATION DECLARATION Q � IHEREBYAFFIRMUNDERPENALTVOFPERJURYONEOFTHEFOLLOWING�ECLARATIONS: Z Q Z _IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' _ ¢ CAMPENSATION,ASPROVIDEDBYSECTION37�OOFTHELABORCODE,FORTHEPERFORMANCE U Q OFTl7E WORK FOR WHICH THIS PERMIT IS ISSUED. � W I HAVE AND W�LLMAIN7AIN WORNERS'COMP'cNSATION INSURANCE,AS REOt11RED BV SECTIok Q 3�0o OF THE LA90R CODE,FOR THE PERFORMANCE OF THE WORK FOR NMICH THIS PERMIT IS /j'y },T ISSUEO.MV WORKERS' �P S'A/TI��N INSURA CARRIE POLICV NUMBER ARE: CONSTRUCTION (r� � � CARRIER ���{/�`• '�� PLAN REVIEW r Z POLICV NUMBER Q �� � � ELECTFIC _ Q � (IHISSECTIONN"cmNOTBECOAu'LETEDOFT}�PERMfTISFOFQVEHUNDRED00lt.ARS(blao)ORLESSI PLUMBING Z I CERTIFV THAT IN THE PERFORMANCE OF THE WORK FOq WHICH THIS PERMIT�S ISSUED,I MECHANICAL (3 SHALL NOT EMPLOV A�'V PERSON IN ANY MAYNER SO AS TO BECOME SUBJECT TO THE Uj WOflKERS'COMPENSATIONLAWSOFCALIFORVIA,ANDAOREETHATIFISHOUL�BECOME INSPECTIONFEE � = SUBJECTTO THE WORKERS'GOMPENSATION PROVISIONSOF SECTION 370o OF THE 1A80R CO�E,I SHALL FORTHVlITH COMPLY WITN THOSE PROVISIONS. ISSUANCE 0 .�J p OATE: APPLICANT. SMIP r / l J WARNING:FAILURETOSECUREWORK[RS'COMPENSATIONCOV[RAGGISUNLAWFUL,ANDSHALLBE ENERGYP/C � Sl18JECTAN EMPLOYERTO CRIMINAL PENALTI'c3 AND CIVIL FINES UP TO CNE HUNDREDTHOUSAND ENERGY PERMIT DOLLARS(3100,000�,IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN r /�) � SECTION 3708 OF THE LABOF CO�E,MTEREST,AND ATTORNEY'S FEES. RETENTION FEE: / �(�A OCONSTRUCTION LEN�ING AGENCY PRE-ALT FEE: � I HEREBVAFFIflM UNDER PENALTV OF PERJUflY TMATTHERE IS ACONSTRUCTION LENDING AGENCY �-- FOR THE PEftFORN�ANCE OFTHE WORK FOR WHICH THIS PEflMIT IS ISSUED�SEC.3oel,qV.C.�. Z W � LENDER'S NAME I— LENDER'SADDRESS � ICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTAiETHATTHEABOVEINFORMATIONISCORRECT. TOT/"1L FEES � � �� w 1 AGREE TO COMPLV WITH ALL CITY ANO COUNTY OR�INANCES AND STATE LAWS RELATING TO BUILDING � � CONSTflVCTION,ANDHEREBYAUTHORI2EREPRESENTATIV��E,50FTH15COUNTVTOENTERUPONTHE Z ABOVE�MENTIONED P ERTV F INSPEGTION PURPOSI E$ 7l � COMMENTS o � �r�f%�� � PERMITTEE NnME(Pftl � � � �� � Q � t� — � SIGNA7 ITTEE DATE ' = RECPT.NO. 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