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Home My WebLink About16522 (22) �� CITY OF DIAMOND BAR � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �� , 21660 E.Copley Drive Suite 190 ,,.,_. (909)860-3195Fau(909)861-3117 r� Q PRESS ��. BUII,DING PERMIT APPLICATION�.r .._ � �Z � � FIRMLY y JOBSITE - • C � APPLICATION ��` �('}-�1�U B R � a��''�/ #/c � • �� o ADDRESS -.� 3 DATE V '� � issuE - rrP€ occ APN LOT TRACT �� OATE CONST. GROUP p OWNER , � ADDRESS ZONING SETBACKS 0 � CITY � ` ZIP��' (Q1Z TEL REART RW ❑ APPLICANT J TEL SIDE/SIQE STREET RW ❑ � CONTRAC70R SIDE ❑ ADDRESS PROPOSED USE � CITY IP T , � ARCWENG/ z DESIGNER NO.DWEL NO. NO. � ADDRESS UNITS STORIES BEDROOMS CITY ZIP TEL. "C�r7 � DESCRIPTION SQ.FT. CTOR PSF ADJ.AREAN UATION Q OWNER-BUILDER DECL4RATION SFR/ADD/REM � � 'U O p I HEREBY AFFiRM UN�ER PENALT'OF PERJURY THpT I AM EXEMPT FROM THE CONTRACiORS L4 � GaragelCarport � � W CENSELAWFORiHfFOLLOWINGREASON(SEC.7W7.66USINESSANDPROFESSIONSCODE:ANVCITYOR � C7 COUNTYWHICHHEIXIIRESAPERMRTOCON5iRUC7,ALTEfi.IMPROVE.DEMpLJSH.OPREPAIPFNYSTRUC- W PdtiO/DeCk �� `� � , � Z NRE,PRIOR TO ITS ISSUANCE,ALSO RE�UIRES THE APPLICNJT FOR SUCH PERMIT TO FILE A SIGNED LL� ST�TEMENT 1HAT HE OR SHE IS LICENSEO PURSUANT TO THE PROVi510N5 OF THE CON1'AAC70RS ll- W � CENSE UW(CHAPTER 8(COMMENCINO WITH SECTION"/000)OF DNISION 3 OF THE 6USME55 AND PRO- � Po0USp8 FESSIONSCWE�ORTHATMEORSHEISDCEMPT7HEREFROMANOTHEBASISFOPiHEAILEGEDEXEMP- (� TqN.ANVV10UT�ONOFSECTION7031.58VANVAPPUCANTFORAPERMIT&U&IECTSTHEAPPLICAN770 Z Re-Foof r ACIVILPENALTYOfNOTMOHEiHANFIVEHl1NORE�00lLAR5(E50a1J: � ❑I,ASONMEROF'MEPROPERT/.ORMVEAIPLOYEESWITHWAGESASTHEIRSOIECOMPENSATION, L7 CORImBfCl81 ' WILL DO TME WOFti(,MIO THE STRUCTURE IS N�T INTENDED OR OFFERE�FOR SALE ISEC.7044,&151- J NESSNA PAOfE6SIpNS CODE:THE CONTMCTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF � PPOPER7YWFiOBUILDSORIMPROVESTHEREON,ANDWHODOE55UCHWOHKHIMSEIFORHEFSEIFOR = � THFiOUQHHIS OR HER OWN EMPLOVEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENOED 6R � . � OfFEREDFORSALEIF,MOWEVERTHE9UILDINGORIMPHOVEMEN715SOLDWITHINONEYEAROFCOMPIE- ` � Z 710N,THE OWNEfl�BUILDER M�ILL HAVE THE�URDEN OF PROVIN�THAT HE OR SHE DID NOT BUILD OR = IMPROYEFORTHEPURPO5EOFSALE7. �yy ❑I,ASOWNEROfTHEPROPERtV,AMIXCLUSIVELYCONTRACTlNGWITHIICBJSEOCONTRACTORS � TO CONSTRUCT7ME PRQIECT(SEC.IOH.BUSINESS M70 PROFESSIONS COOE:THE CONTRACTOFS U� V91d18IIC!1 � ADJ.AREA W CENSEUWDOE6NOTAPPLVTOANOWNEROFAPROPERTVWH06UILDSORIMPROVESTHEREON,AND — � NTpCONTMCTSFORSUGHPROJEGTSWIiHACONTRACTOR�S;LICENSEDPUR5UAN7TOTHECONTRAG QUANTITY DESCRIPTION FEE Y TOqSUCENSELAW.). � J (" O�MI E%EMPT UNDEfl S�C._ _B.a P.C.FOR T'f115 REASON Q � � J y�� 3 OC �- /T��3J'G � � DATE OWNER_ � ' � � � LICENSED CON7RACTORS DECLARATION W �� /� � 1 HEREBY AiFIRM UNDER P�NALN OF PERJURY THAT I AA1 IICENSEO UNOER PROVISIONS OF CHAPTER Z t � �� , 0(�MMENCMk7 WITM SEl:T10N 7000�OF D�VISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND X MV UCENSE IS IN NLL FO AND EFFECT. u� �.y //�� m , � LICENSE GIAS __ .� LIC.NO.�.1� �� T �+� , u�. ,. � J 1. 7S W DATE CONTRACTOR,� d � •,�t R ✓� � "x � WORKERS'COMPENSATION DEGLAAATION Q = U � IHER�AFFIRMUN�ERPENALTYOFPER1UflVONEOFTHEFOLLONANG0ECUIRATIONS: �'� � � pr�� Z 0 v I HAVE/JA)VJILL MAIN7AIN RCERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS' _ - '��\ Z �COMPENSATKKJ,ASPROVI�EDBYSECTION370oOFiHCI.A80RCO0E,FORTHEPERFORMANCE U �� OF 7NE W�JRK FOR WHICH THI6 PERMIT IS ISSUED. � �/ � � I HAYEAND WiLL MAINTAIN WORKERS'COMPEM5AT70N INSURANCE,AS REWIRED BY SECTION � .f� -^� ` � 37aoOFhIELABORCODE,FpRTHEPERFORMANCEOFTHEWCRKFORWH'CHTHISPERMfTIS I�/� \ �1 l� ISSUED.MYwq{�f'-i7KF.flS'G7�4CPENSAT!OItlIMSURANCECARRIERMI�POLICYNl1MBERARE: CONSTRUCTION '�j�_ �� y �� CqRRIER—C_�_ _ � PLAN REVIEW � Z �,��r'�ru�R ELECTRIC �� L" � (IHSSEC%7NNEmrarBE�nPttrEooGniEPEPAHiISWRadEralnoRED�:1Mslbiao)caLEssl. PLUMBING `' � /�� W � I CERTIFY NAT IN THE PERFORMANCE OF THE WOPoC FOqNMICH 7HI5 PERIAff IS ISStIED.I MECHANICAL �S �•�� ` SHALL NOT EMPLOYANY PERSON INANY MANNER SOAS TO BECOM[SUBJECTTO THE � � � WORKER5'C,OMPFNSATIONIAWSOFOALIFORNIA.ANDAGREE7HATIFISHOULD6ECOME INSPECTIONFEE I/ SU&IECT"L�THE WORKERS'COMFENSATqN PpOVI510NS OF SECTION 37oC OF THE LABOF 7� ' l � e,i sr+ut ORIHW�TN COMPLY WITH THOSE PROVISIONS. �p�,�s ISSUANCE O ��L./ e� O �...�� ►/ri-_�_ 9MIP p OATE: APPLICANT: ._ JENERGY P/C ' �� Tw� WARNINO:FAILURE TO SECUP.E WORKERS'COMPENSATION COVERAGE IS UNLhWFVL,AND SHALL BE �—y SU&IECTANEMPI.OVERTOCRIMINALPENALTIESAN�CIVILFINESUPTOONEHIJNOREDTHOUSAND ENERGYPERMIT DIX.URS(5700,00�),�N A�DITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIOED FOR IN � SECTION3ToeOFTHELABORCJDE,INTEREST,ANDATTORNEVSFEES. �tC� " ' r�^'�q �('� RETENTION FEE: � � + +J d CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � O � � I HEREBV AFFIflM UNOER PENALTY OF PEliJURV THAT THERE IS A CONSTRUCiION LENDING AGENCY FOF THE PERFORMANCE OF 1'HE WORK FOF WHICH 7MI5 7ERMIT IS ISSLiED(5 C.3off7,CIV.C.). ' . � ��—� �� -�-�''� ��. I�C :_----- W __._ _ _ _.__._... ..�.__. �ENDER'S NAME �-� 1� 1— LENDER'SADDRESS / � ICEflTIFYiHATIHAVEREADTHISA7PUCATIONANDSTATETHATTIEABOVEMFORMATIONISCARRECT. TOTAL FEES �,�J��J I AGFEE TO CAMPLY MATH ALL CITY AND CqUNTY OROINANCE5AN0 STATE LAWS'REYATING TO BUILDING y� �J -S � CONSTRUCTION,lYDHEREB�AUTViORREREPRESENTATIVESOF'fHISCOUNTVTOEN'rERUPONTHE ABOVE-MENTIONED PROPERTY FOR INSPECTION PURVOSES'. COMMENTS_ � �� _ m PERMITTEE AME(PPINT) f ¢ �.C8 -- � � uJ SIGNAT EOFPERMITTE �A /° ' = FECPT.NO. PAID BY VALIDATION ~ WHITE—De artment Co YELLOW—Finance Co PINK—Assessor Co GOLDENRO�File Co GREEN— IipnPs Co P PY. PY. 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