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HomeMy WebLinkAbout15990 (22) _. _ .� � ���,�,��� _ CITY OF DIAMOND BAR /U�-0 G I -. . --��-- DEPARTMENT OF COMMUI�TITY&DEVELOPMENT SERVICES / a 21660 E.Copley Drive Suite 140 PRESS �'.�%�.� �BU)II.DINGSPERMIT APPLICATION FIRMLY . � JOBSITE X� APPLICATION PERMIT � P!C o ADDRESS��5�2- lr 4Q�-'9' L�1 � DATE � �� �` � _NUMBER�� # - c� ISSUE f r� TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER R• K�Nn+�� � ADDRESS �'�'Z �+ �-� � ZONING SETBACKS "' CITY G���- Z P��7� TEL�j�i-59�P�2'�3 Y FRONT RW ❑ � APPLICANT TEL. REAR ❑ SIDE/SIDE STREET RW ❑ � CONTRACTOR � f� � 1 �-S oV C SIDE ❑ � ADDRESS � vf �'' PROPOSED USE a CITY �� ZIP 7!Z TEL. SZ7-��6•:Ct'// wo ARCH/ENG! z DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT: FACTOR PSF ADJ.AREANALUATION � � OWNEii-BUILDER DECLARATION SFR/ADD/REM O � I HEREBY AFFIRM UNDER PENl�TY OF PERIURY THAT I 11M E7(EMPT fROM THE CONTMCTORS LI- Gflfd9B/Cd�Oii l!1 CENSEUWFORTHEFOILOWINGREASON(SEC.7031.SBUSINESSANDPROFE5519NSCODE:ANYCITYOR (n SJ COUNiVNMICHREWIPESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANYSTRUC- W pgti0/DBCk WNRE,VRIOR TO ITS ISSl1ANCE,ALSO HEQUIRES THE APPLICANT FOR SUCH PERMIT TO FlLE A SIGNED W � STATEMENT THAT HE OR SHE IS IICENSE�PURSUANT 70 TNE PROVISIONS Of THE CONTRACTOflS LI� � CENSE LAW�CHAPTER 9(COMMENCINO WITH SECTION 7a0o)OF OIVISION 30C THE BUSINESS AND PRO- � POOUSPB FESSIONS ODOE�OR THAT HE OR SHE IS EXEMPT THEREFqOM ANO THE BASIS FOR THE ALlEOED E%EMP� TION.ANYVIOUTIONOFSECTIONT031.58YANYAPPLICANTFORAPEHMITSU&IECTSTHEAPPLICANTTO z R2-ROOf � A GVIL PENALTY OF NOTMORE THAN FIVE HUNDPED DOLLAfiS 15500).�: � ❑I,ASOWNEROFTHEPROPERTY,ORMVEMPLOYEESWITHWAGESASTHEIRSOLECAMPENSA710N, C� COfI1ff19fC13I Y/ILL DO THE WORK,AND THE STRUCTIJRE IS NOT INiENDED OR OFFERED FOR SALF(SEG.704a,BUS!- J NESS AND PROFESSIONS CODE:THE CONiRACTORS UCENSE LAW DOES NOT APPLY TO AN OWNEF OF � PROPERTYWFiOBUIIDSORIMPROVESTHEREON,ANOWHODOESSUCHWORKHIMSELFORHERSELFOR m � 1HROUf3HHi50RHEFlOWNEMPLOYEE5.7qOVIDE07HATSUCHIMFROVEMENTSARENOTINTENDEDOR 0 OFFEREDGORSAIE.IF,FIOWEVER'ME9UILDINGORIMPROVEMENTISSOI.OWITHINONEYEAROFCAMPLE- Z 710N,THE OWNER�BUILDER WILL HAVE THE BUR�EN OF PROVING 7HAT HE OR SHE DID NOT BUIL�OR = IMPROVE FORTNE PURPOSE oF SALE). W ❑I,ASOWMEROFTHEPROPERTY,NME%CLUSIVELYCQNTRACTINGWtTNLICENSEDCONTqACTOPS � TO CONSTRUCT lHE PRQIECT(SEC.7644,BUSINESS AND PROFESSIONS CODE:7HE CONTPACTORS LI- V8IUH110f1 ADJ.AREA W GENSELAW�OESN07APPLYTOANOWNEROFAPROP'cflTfWHOQUILDSOAIMPROVESTHEREON,AN� � WHOCONTNACT5FORSUCHPROJEC75WITHl.CONTRACTOF(S�LICENSEDPURSUA�NTTOTHECONTRAG QUANTITY DESGRfPTION FEE Y TOHS LICENSE UW.J. g ❑IAM EXEM7T UNDEF SEC. B.8 P.Q FOR THtS REASON � � � � � DATE O6YNEfl V � IICENSED CONTRACTOFS DECLARATION �y � 1 MER£BY AFFIRM UNOER PENAITY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPiER � � y�a `• .�Q� d Y(COMMENCINO WITH SECTION 7000)OF OiVI510N 3 OPTHE HUSINE55 AND PROFESSIONS CODE,AND z �� �.� MY UCENSE i5 M FUIL FORCE AND EFFECT. m Q UCENSE CLASS �� LIC.NO._ '� � z Z"/ � V DATE , 3• n'�. CONTRACTOR�+"� `_�'j��G d W � WOAKERS'COMPENSATION DECL4RATION Q � I HEREBYAFFIRM UNOER PENALTY OF PERJURY ONE OFTHE FOLlUW1NG OECLARATIONS: U � Z Q C] I HAYE ANO WILIMAINTAIN A CEqTIFICATE OF CONSENT TO SFf_FJNSURF FOFi WORKERS' _ � �COMPEN9ATION,A5 PROviOED BY 3ECTION 370o PF THE IABOR CO�E,FOq THE PERFORMANCE `U OFTHE WORK FOR WHICM?HIS PEAMIT IS ISSUED. .� O w i HAVE AND WILL MA�NTAIN WORKEPS'COMPENSATION INSURANCE,AS REOl11RED BY SECTION Q 37000FTNE IABOR CODE,FOR 7HE AERFORMAkCE Of 1HE WOHK FOR WHICH THIS PERM!T IS ISSUED.MY WORKEII^u'COMPENSATION WSURANCE CARRIER AND POLICV NUMBER ARE: CONSTRUCTION jc,wAiEq _ � PLAN REVIEW z Pa.ICV NUMBER _ ` _ ._ ELECTRIC � �' d � � ((HISEECiK:NNEEI7PIOTBEWh+PI.fTFDOFTHEPEF?A71SFOi?ONEHUNDfiE�DOIll+RSrytoo�ORLE55J. PLUMBING +� � w -y ` ��1 � ICERTIiVTHATINTHEPERFORMANCEOFTHEVJORKFORWHICHTHISPcRMITI5ISSUEO,I MECHANICAL B��T� 1 Z ��y;'d'r (} SHALL NOT EMPLOv ANY PEFISON IN 1WV MhNNER SU AS TO BECOME SUB:ECT TO THE °S � WORKEiiS'CAMPENSATIONLAWSOFGALIFtN1NIA,RNDAGREETMATIFISHOULDBECOME INSPECTION FEE � SU&IEC7T0 T11E WORKERS'COMPENSATION PROVISIONS OF SEC710N 37a0 Of THE UflOR ,y'� �y�' �i��-yy`ylrfl•�� � y'" ,¢ - CODE,I SHALL FOHiHW17H COMPLY WITN iHOSE PROVI510N5. �SSUANCE "�..+�A d �+ a-.u-��1���� t� Q SMIP ��������� ua e.s.:. p DATE: APPLICP.NT: _. ___.__—_ . W ENERGY P!C J WAflNIN�:FAILURETO SECURE WOFKERS'COMPENSATION CAVERAGE IS UNIAWFUL,AN�SHALL 8E � SU&IECTAN EMPLOVER TO CRIMINAL PENAlTIES AIJ�CIVIL FINES L1P TOONE HUNDRED THOUSAND 'cNEAGY PEAMIT DOLL0.RS(5100,Ooo).W AD�ITIONTO THE COST OF COMPENSATION,DAMADES AS P{70VIDE�FOR IN � SECTION 3708 OF THE LABOR CODE,INTEFEST,AN�ATTOPNEYS FEES. RETENTION FEE: pW_, CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � I MEREBV AFFIFM UNDEH VENALTY OF PERJURY THAT THEHE IS A CONSTPUCTION LENDMG AGENCY n- FOR THE PERFOflMANCE OF THE WOFK FOR WHICFI THIS PERMIT IS ISSUED(SEC.3097,CIV,C.). Z w � LENDER'S NRME_ - F- LENDER'SADDRESS __ f � {.. �n w ICERTIFVTHATIHAVEREADTHISAPPLICATIONANDSTATETHATTHEABOVEINFORAIATIONISCARRECT. TOTAL FEES `�(,° "� � � � I AGREE 10 COMPLV WITH ALL CITY AN�COUNTV ORDINANC[S AND STATE LAWS RELATINC TO BUILOING CONSTRUCTION,AND MEREBY AUTHOPIZE REPRESENTATIVES OF THIS COUNT'TO EMER UPON THE Z11BOVEMENTIONEO PflOPERTY FOR INSPECTION PURPOSES. COMMENTS � s���- � �r — aPERMITTEE 1 PAE(PRINI')l _ � �/ N SI NAT RE OF PERMITTEE� �� �� ���-- = FiECPT.NO. 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