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HomeMy WebLinkAbout16386 (22) �� CITY OF DIAMOND BAR �� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �""'^ _ 21660 E.Copley Drive Suite 190 w (909)860-3195 Farz(909)861-3117 PRESS �y�''� BUII,DIIVG PERMIT A1�PLfCATION _ - . , FIRMLY �'�/0 �y��,�,�s� .c��" , _'� _ .._ m . . , . ,, .�. ., ..w ..,. � JOBSITE � J�, �.--- APPLICATION _�) PERMIT I__� P/C o ADDRESS /�� " DATE NUMBER # � ISSUE TYPE OCC APN LOT TRACT ���C*� DATE � � CONST. GROUP p OWNER �%'IFL o ADDRESS l-.�/C- - ZONING SETBACKS � CITY .��-C"//� ZIP� TEL./��R�7�'17�C flEART RW ❑❑ APPLICANT TEL. SIDElSIDE STREEf RW ❑ � CONTRACTOR SIDE ❑ � ADDRESS �� � - 8 ARCIi/ENG/ IP TEL. PROPOSED USE z DESIGNER G- r.� � -r'S��• � ADDRESS NO.DWEL. NO. NO. � UNITS STORIES BEDROOMS � CITY` ZIPG�'"�'�t^'TEL. tn � ��Y� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION ¢ OWNER-BUILDER DFCLARATION SFR/ADDlflEM O I HEREBY AFFlRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FHOM THE GONTRACTOPS ll- G3f298/CefPOfl � CENSELAWFORiHEFOLLOWINOREA50N(SEC.7o31.5BU51NE55ANDPROFE5510N5CODE:ANVCITYOR (n COUNTYMMICHREOUIRE511PERMfTTOCOiJSTRUC7,ALTER,IMPROVE,DEMOLISH,ORREPAIRANYSTRUG W P8ti0/D6Ck W NRE,PRpR TO ITS ISSUANCE,ALSO RE�UIRES THE APPLICMIT PDR SUqi PERMIT TO FILE A SIGNED W � STATEMENT THAT HE OR SHE IS UCENSED PURSUANT TO THE PROVISIONS OF THE CANTRACTOfiS ll- � � (�1SE LAW(CHAPTER 9(COMMENCINO WITH SECTION 7000)OF�IVISION 3 0F THE BUSINESS AND PPO� POOI/Sp8 FESSIONSCOOE)ORTHATHEORSHEISEXEMPT'fNEREFROMANDTHEBASISFORTHEALLEOEDEXEMP- � TION.ANYV�OUTqNOFSECTION7031.5BYANVAPPIICANTFORAPERMITSUBJECTSTHEAPPIICAhT70 Z Re-RooT � ACIVILPENALTVOFNOTMORETHANFNEHUNDREDOOLUIRS(t500�.): � ❑I,ASOWNEROFTHEPpOPERTI,ORMYEMPLOYEESWITHWAGESASTHEIRSOIECAMPENSATION, � COffIf118lCI81 � WILL DO THE WORK,AN�THE STRUCTURE IS NOT INTENDED OR OFFEtiEO FOR SALE(SEC.7014,BUSI- J � NESS ANO PNOFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF = PFiOPEHTYVY}IO BUIL�S OFi IMPHOVES THEREON.ANO VA10 W ES SUCH WORK HIMSELF OF HERSELF OR � T7q0UGHHiSORHEROVJNEMPLpYEES,PPOVIDEDTHATSUCHIMPROVEMENTSARENOTINTEN�E�OR m QOFFEREOWRSALEIF.HOWEVERh1EBUILDINGORIMPROYEMENTISSOLOWITHINONEYEAROFCAMPLE- Z TqN.THE OWNER$111L�ER WILL HAVE THE BUROEN OF PqOVINO?HAT HE OR SHE OID NOT BUIL�OR = IMPROVE FOR THE PIJHPOSE OF SALEJ. W ❑I,/S OY/NER OF THE PROPERTV,AM E%CLUSIVEIY CANTflACTING WITN LICENSEO CONTRACTQRS � TO CONSTRUCT THE PRQIECT(SEC.7014,BUSINESS AND PROiESSIONS CODE:THE CONTqACTORS LI- VdIUellOfl ADJ.AREA W CENSELAWDOESNOTAPVLYTOANONMEHOFAPROPERT/WH06UILDSORIMPROYESTNEREON,AND � WHOCOMMCTSfOR3UCHPROJECTSWITiACONTFiACTOR(9)LICENSE�PURSUANTTOTHECONTRAG QUANTiTY DESCRIPTION FEE � TORSLICENSEUW.). � ❑I AM E%EMPT UNDER SEC.___ _._B.6 P.C.FOR THIS REASON � � U � — � �ATE OWNER_ U 0 W � UCENSED CONTRACTORS DECLARATION W � 1 HEREBY AFFIRM UNDER PEN,iLTY OF PERJURYTHAT I AM LICENSED UNQER PROVISION3 oF CHAP7ER Z � p� 9(ODMMENqNOWITNSECTIONiaOo)OFDIVISION3OFTNEBUSINE55ANO�ROFESSIONSCODE,AND ,,-� X MY LICENSE I5 iN FVI.I FORCE AN�EFFECT. m LLl '''�� �� 0 UCENSE CLASS_,�_LIC.NO.__��,��� _�.,,�_ � W DATE��"y��rJ,/ COPITHACTOR 3/C��� 4- / � WORKERS'COMPENSATION DECLAP.ATION Q � I HEN V AFFIRM UrDER PENNSY OF PERJURY ONE OF TNE FOLLOWING DECLARA?IONS: Z Q � IHAVEANOWILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSIIREFORWORNERS' _ COMPENSAiION,ASPROVIDEDBYSECTION3�OPOFTHELABOPCODE,FORTHEPERFORMANCE U � OF THE WORN FOH WHICH THIS PERMIT IS ISSUED. � � F IHAVEANDWILLMAMTAINWORNERS'COMPENSATIONINSURANCE,ASREQUIREDBVSECTION Q 37000F THE LABQR CODE,FOR THE PERR7RMANCE OFTHE WORN FOq WNICH THIS PERMIT IS ISSUcU.MY WO KERS•COMPENSATION yINS�URA�NCE CAPRI�ER�AN,cD�POLICY NU �EqRARE: CONSTFUCTION jCARRIER����g�/_��"[�" �� ��'1/ PLAN FEVIEW � POLICYNUMBER--`AS�I6^/�—. '(.�2 n BB�i"�J ELECTRIC T� ,_. ' - 5 / /�' � - .Ti t--7C— 0 (niSSEcncrvN�nbraE�E�oF7r�rEanarsF'oaor��Eooa�ws�EtaloRLEss� PLUMBING �"� •.�1 1 .S�i� w � I CERTIFY THAT IN THE PERFORMANCE OF THF WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL �P R 1 _ �- SHALLNOT EMPLOV ANY PERSON IN hNY MANNER SOAS TO BECOME SUBJECT TO THE Vj WORKERS'COMPENSATION LAWS O:CAIIFORNIA,AND AGREE THA7 F I SHOULD BECOME INSPECTION E SU&lEC7TOTHEWORKEAS'COMPENSRTIONPROVISIONSOFSECT N3�o00FTHELABOR —���" OCOOE,ISHAU.f-0HiHW�THI:OMPLYWI7HTNOSE?ROYISIONS. ISSUANCE �� ��) �,3�a p DATE:M��APPLICANT:. � SMIP J WAflNIN6:FAllURETOSECUREWOftKERS'COMPENSATIONCOVERAGEISl1NUWFUL,ANDSHALLBE ENERGYPIC _ _.__.______ � SU&IECTANEMPLOYERTOCRIMINALPENALTIESANOqVILFINESUPTOONEHUNDREDTHOUSANO ENERGYPERMIT DOlLAFS(f1o0,o00).IN AD�ITION TO THE COST OF COMPENSqT10N,DAMAGES AS PROVIDED FOR IN � SECTION97080FTHElABORCOOE,INTEREST,AN0AT7DRNEY'SFEES. RETENTIONFEE: d CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � 1 HEREBYAFFIRM UNDER PENALTY OF PERJURV iHATTHERE IS A CONSTRUCTION�ENOING AGENCY FOR THE PERFORMANCE OF THE WOFK FOR W CHTHIS PERMIT IS IS UED(SEC.3D87,CIV.C.). . , W /`-�� � LENDER'S NAME_��„" � ____ F— LENDER'SADORESS � I CERTIFV THAT I HAVE READ THISAPPUCATION AND STATE TNAT THE ABOVE MFORMATION IS CORRECT. TOTAL FE ES ����J ..S� W IAQREETOCOMPLVWITHALLCITYANDCAUNTYORDINANCESANOSTATEUWSR[LATINGTOBUILDING � CONSTRUCTION,AN�HEFEBY AUTHORIZE REPRESENTATIVES OF THIS COUNTV TO ENTEH UPON THE z ABOYE-MENTIONEO PROPEHT/FOR I SPECTION?URPOSES. COMMENTS � �� � � PERMITTEE NAME(PR Tj � +1���� - � � � y SIGN FEOFPERMI E DATE = RECPT.NO. 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