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HomeMy WebLinkAbout16593 , CITY OF DIAMOND BAR ,,.,''��`,, --��` -- DEPARTMENT OF COTvIMUNTI'Y&DEVELOPMENT SERVICES /,�°� � 4� — �,��,�,, - 21825 6.Copley Drive �''" (909)860-3195Fax(909)861-3117 l � PRESS '�'<v�ry'��' , BiTILDII�G PERMIT APPL�CATION FI MLY � JOBSITE � APPLICATIO. PERMIT P/C o ADDRESS��wJ !'� ������^�-��''� �-� DATE ���� / NUMQER # � oro ISSUE ^ �" : TYPE OCC APN LOT�_ TRACT J`Zrl�..�� DATE � CONST. GROUP p OWNER �"��1-��-1lI� ADDRESS����� C CO�1jlJafy S'�' ZONWG SETBACKS z CITYPA�AL- �ir ��F ZIP9/� TE�'�yZ�s FRONT RW ❑ o APPLICANT"Z� YYI�.�I TEL���'��,'i�('� S DE/SIDE STREET RW ❑ z Q, CONTRACTOR ' SIDE ❑ ADDRESS p C�N � Z�P TE� PROPOSED USE o ARCHJENG/ iz' DESIGNER NO.DWEL. NO. NO. a' ADDRESS UNITS STORIES BEDROOMS � CITY 21P TEL. c�i� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION 'p� O�NNER-BUILDER DECLARATION SFR/ADD/REM ,O i I HEREBY AFFIRM UN�EFi PENALTV OF PERJURV THAi I AM EXEMPT FROM iHE COMRACTORS LI- G&f2gB/CefPOff �'��'W'. CENSEL4WFORTHEFOLLOWI�GIREASON(SEC.7031.5BUSMESSANDPROFESSIONSCD�E:ANYCITYOR (/� �.'U .COUNTVWHICHRE�UIRESAPERMI7TOCONSTftUCT,ALiER.IMPftOVE,DEMOLISH,�RREPAIflANVSTRUC� W patia/Deck w. 'TURE,PRIOR TO ITS ISSUANCE,ALSD REQUIRES iHE APPLICANT FOR SUCH PERMI i TO FILE A SIGNE� w �STA7EMENi THAT HE OR SHE I5�ICENSED PURSUANT TO TNE PROVISIONS OF THE CONTRACTORS U� ' ���. �. CENSE LAW[CHAPTEA 9(COMME CING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO� V" POOUSpa � FESSIONSCODE)OATHATHEOF HEIS�IXEMPTTHEflEFROMANDTHEBA5ISFORTHEALLEGEDE%EMP- (� ',,� iION.ANYV104ATIONOF5ECT10t�1o31.5BYANY0.PPLICAldTFORAPEftMITSUBJECTSTHEAPPLICqNTTO Z Re-Roof ACIVILPENA�TYOFNOTMORET ANFNEHUNOREODOLLARS(f5oo)J: ❑I,ASOWNEROFTHEPROP�FTY,ORMYEMPLOVEC-SWITH�NAGESASTHEIRSOLECOMPENSATION, ' � �,O � . 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QUANTITY DESCRIPTION FEE '�� ❑I AM ExEMPTUNDER SEC�.II B.S P.Q FOP THIS REASON Q r� -� /7I�� �.,�;�' i U .. � � DqTE ' OWNER U • ;'.Z' , � '. W . "����a; � LICEN�E�CONTRACTOflS DECLARATION � r.Q, ''"���i��: ,IH�REBI"�AFFIRMUNDERPENALT�'OFPERJURYTHATIAMLICENSEDUNDEPPROVISIONSOFCHAPTER '� ',��',�����. .�.y.�COMMENCWGWITHSECT10N7iP�)OF�7IVISION30FTHEBUSINESSANDPROFESSIONSCODE,AND Z �,��;�,'X„',, I:AV LICENSE IS IN FULL FORCE'AN6 EFFECT m ��� UCENSECLASS � LIC.NO. .� � J �'�ATE CONIRACTOR a W I �������, WORKERS'�OMPENSATION DECLARATION a '�.'��','-1HEREBYAFFIRMUNDERPENALT'�OFPERJURYONEOFTHEFOLLOWINGDECLARATIONS: Z �,'.,2 _iHAVEANOWILIMAINTAIt�ACERTIFICATEOFCANSENTTOSELF�INSUREFORWORKERS' _ CAAIPENSATION,ASPP�IOED6YSECTION3]ooOF7HELABDqCODE,FORTHEPERFORMANCE U �'¢ OFTHEWORKFORWHICHTHIS�,PERMIYISISSUED. � ��'"�'.�IFIAVEANOWILLMAINTAINWOR ERS'COMPENSATIONINSURANCE,ASREQUIREDBYSEC710N �I��Q�, 37ooOFTHELA90RCOD�,FOR EPERFORlAANCEOFTHEWDRKFORWHICHTHISPERMITIS ISSUED.MY WORKERS'CdMPE�ATION INSURANCE GA IER AN�POLICY NUMBERNiE: CONSTRUCTION R .�'� CAFRIER��� � PLAN REVIEW / �,,Z.,.„ PoucvNUMeed�+" � -� �. ELECTRIC � f�,y, ¢"' I �'.0,� (I}iISSE(:T10NNEFDNOTBE�iCOMPLETE�OFThEPERMITFSFORONEHUNDHm�OLtARS�$iC0)ORLESS). PLUMBING � ��~"1`".� ,�;, � .� . ..,�,.<„'.� ,Z � ICERTIFYTIIATINTHEP=RFOR�y1RNCEOFTHEWORKFORWHICFITHI5PEFIMITI5155t1ED,l MECHANICAL � � '.,ff � SHALL NOT EMPLOYANY P`E'R5�6�IN IN ANY MANNER SOAS TO BECOME SL18..'ECT TO THE '.��j , WORKEfiS'COMPENSATIOryLAwSOFCALIfORNIA,ANDAGftEETHATIFiSHOULDBECOME INSPECTIONFEE SUBJECT TO THE WORKEFIS'CO PENSATION PROVISIONS OF SECTION 3�ao OF THE LABOR �''�,� ,, CODE,ISHALLFORTHW17�HCOMIPLYWITFITHOSEPROVISIONS. ISSUANCE d '�.p �,DATE: � A,�PLIC�NT: SMIP ��_�,'-- � , IJ WARNING:FAILURETOSECUREW RKERS'COMPENSATIONCOVEfiAGEISIJNLAWFl1L,ANDSHAlL6E ENERGYPIC --�� - �W SUBJECTANEMPLDYERTOCRIMI�JALP�NALTIESANDCIVI_FINESl1PTOONEHUNDREDTNOUSAND ENERGYPERMIT pOLLARS'',�51oo,o0a),INAOOITIpNTOTH C�STOFCOMPENSATION,DAMAGESASPROVIDEDFORIN '�J SECTION37060FTHELABOqCOtlIE,IN?REST,ANOATTORNEV'SFEES. RETENTIONFEE: ''���,���P"�' � CONSTFIIUCTION LENDING AGENCY PAEAL7 FEE: ��'�� '�,�IHEREBVAFFIRMUNDERPENALTVOFPERJURVTHATTHEREISACONSTRUCTIONLENDINGAG'eNCV „FOR THE PERFORMANCE OF THE Y.'ORK�iFOR V/NICH THIS PEflM1T IS ISSUED(SEG J09],CIV.C.). . ;W.':'. I .:S'.'. LEN�ER'SNAME ' � ������.�'�,�,LENDEA'SADORESS ��I _' '_._ .. . ��� �,ICERTIFVTHATIHAVEREADTHISpPPL16ATIONANDSTATETHATTHEABOVEI�FORMAT10NI5CORRECT. TOTAL FEES �w '�I AOREE TO COMPLY WITH ALL Cf(°(AND�COUMV ORDINANCES AND STATE LAWS RELATINO TO BUILDING �� 'iCON5TRL1CT10N,AN�HEREBYAUfHORIZEREPRESENTATNE50FlHI5CGUNTI'TOENTERUPONiHE �'�� �ABOVE-MENTIONEP PROPEFTV FOR INSQECTION PURPOSES. ��¢� � IZ � COMMENTS - �K� r - p �����-���,-� -���'z� � - - - --- -- �PERM E � E�PRINT� I ` ;� ��' �II ��'i ���!�� �.� ;',SI��A REO EflM EE '��.� �ATE � � '�'�;;.� � � '� . RECPT.NO. 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