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HomeMy WebLinkAbout16389 (23) �� , �� `';, _�� CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � 21660 S.Copley Drive Suitc 190 1'iAdd u w (909)860-3195Fax(909)861-3117 PRESS , BUQ.DING PERMIT APPLICATION �- � FIRMLY . . . .. y JOBSITE �7� f --7� �� ��y `=�,� ��� APPLICATION � „ ,7� PERMIT �+ -�� P/C �i_ ( o ADDRESS � (c� G DATE u NUMBER ���x q � � ISSUE TYPE OCC APN LOT TRACT � ��G?JI DATE — '' CONST. GROUP °C OWNER J�fF.� O ADDRESS �"L � �3 fLc i�' .C� ZONING SETBACKS � CITY .�i�-G�e°.L/1� ZIP Z�/Z TELt��G�'?[�t� C) FRONT * RW ❑ APPLICANT TEL. REAR ❑ � SIDE/SIDE STREET RW ❑ CONTRAC70R SIDE ❑ Q ADDRESS ._____ � CITY IP TEL. PROPOSED USE w ARCHIENG/ � DESiGNER '�� �'-� �`���� NO.DWEL. NO. NO. a ADDRESS I'��`f i / �� UNITS STORIES BEDROOMS N CITY -T ZIP TEL"')/��j��'7 cn DESCRIPTION SQ.FL F CTpR PSF ADJ.AREANALUATION O OWNER-BUILDER DECLAHATION SFR/ADD/REM Z '"' � L i� I HEREBV AFFIRM UNDER PENPLTY OF PERJURY THAT I AM E%EMPT FROM THE CONTRACTORS LI� 1 W CENSELAWFORTHEFOLLOWINGfiEA50N(SEC.7031.SBUSINESSANOPfiOFESSIONSCODE:ANYCITYOR � Garage/Carport � L ( C� COUNTYWHICHREWIRESAPERMITTOCONSiRUCT,A�TER,IMPROVE,�EMOLISH,ORREPAIRANYSTRUP �.LI pyfio/Deck Z,. L.. �� � �. l � L TUpE,PRIOR TO ITS 13SUANCE,AL50 REQUIPES THE APPLICAN7 FOR SUCH PERMIT TO FILE A SI6NED W STATEMENT THAT HE OR SHE IS LICENSEO PURSUAN7 i0 THE PROVISIONS OF THE CONTRACTORS LI� W � CENSE UW(CHAPTER Y(COMMENCINO WI7H SECTION 7ooa)oF OIVISION 3 OF THE BUSINESS AND PRO- � PooUSpa FESSpNSCODE)ORTHATHEOFSHEISEREMPT7HEREFROMAN�TNEBASISFOqTHEALLEGEDEXElAP- (� TKKJ.ANVVqLATIONOF6ECTION7031.58YANYAPPLICANTFOPAPERMITSUBJECi57HEAPPLICANTTO z Re-ROOT � ACIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLURS(SSoo).): � ❑I,ASOWNEROFTHEPROPERTY,ORMVEMP�OYEESWITHWAGESASTHEIRSOIECOMPENSATION, � Commercial_.. - WILL DO THE WORIC,AND hiE STRUCTURE IS NOT IN7ENDED OF OFFERED FOR SALE(SEC.7aa,BUSI- J � NESS AND PIiOfE5510N5 CODE:THE CAN7RAGTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF � `,p�J! { PROPERTYWFIOBUILDSORIMPROVESTHEREON.ANDWHODOESSUCHWORKHIMSELFORHERSELFOR ���� ( � TIROUGH HIS OR HER OWN EMPLOVEES,7ROVIDED THATSUCH IMPROVEMENTS AqE NOT INTENOED OR m � OFFEREDFORSKEF.HOWEYER,hiEBUlLDINGORIMPROVEMENTISSOIDWITHMDNEYEAROFCOMPLE- Z TION,THE OWNER$LIILOER WiLL HAVE THE 9UR�EN OF PROVING THAT HE ON SHE DID NOT BUILD OR = IMPROVEFORTHEPURPOSEOFSALE). W ❑I,IISOWNEROFTHEPFOPERTY,PMEXCLUSIVELYCONTRACTINOWITHLICENSEDCONrRACTORS � � TO CONSTRUCT THE PRQIEC7(SEC.'lo.i4,BUSMES&AND PROFE6SIONS CADE THE CONTRACTORS LI- V31U8IIOf1 -� ADJ.AREA W CEMSEUWDOESNOTMPLYTOANOWNEHOFAPROPERTVWHOBUILDSORIMPROVESTHEREON,AND WFIO CONTMCTS FOR SUCH PRQIECTS WfTH A CONTRACTOR(S)LICENSED PUpSUANTTO THE CANTRAG roesuceNseuw.�. QUANTITY UESCRIPTION FEE � � � ❑I AM EXEMPT UNDER SEC. B.&P,C.FOR THIS REASON Q 3 � � � — cc DATE OWNER`_ U Z W � LICENSED CONTRACTORS DECLARATION W � I HEREBV AFFIHM UNDEP PENALTY OF PERJURY THAT I AM UCENSED UNDER PROVISIONS OF CHAPTER � Y(COMMENpNO WIT11 SECTION 7000)OF DIVISION 30FlHE BUSINESS AND PROFESSIONS CODE,AN� 7 � - �� MYUCENSE IS IN FUILFOftCEANO EFFECT. m r� � � LICENSE C-LA-3_5 �j' �,'f!'T" LIC.NO. _ � ' W DATE��`J�./���, CON7RACTOR '� Cl. ^ � 1 [17 " " � d WORKERS'COMPENSATION DECLARATION Q f,x�.C'i1 ��L��4� � 1 HEHEB AFfIRM!UNDER PENALTY OF PE0.IURV ONE OF7HE FOLLOWING DECLARATIONS: Z ( j (, V � !✓��HAVEANPWILLA4AINTAINACERTIFICATEOFCANSENTTOSELF-INSUREFORWORKERS' _ � .\ �� COMPENSATION,ASPpOVIDEDBYSECTION3]o00FTHF.tA80FlCODE,FOFlTHEPEftFORMANCE W V OfTME WORK fOR WHICHTNIS PERMITIS ISSUED. � G 7 0 W IHAVEANDWILLMAINTAINWORKERS'COAAPENSATIONINSUtiANCE.ASREWIRE�BVSECTION - � Q ' 37000FiHELA80RCODE,FORTNAEPERFORMANCEOFTHEWORKFORWHICNTHISPERM1T15 � I r�,(`�f � I� I�` � I�.f"� „ ) ISSUED.MY WOR flS'COMPENS,TION INSURANCE CARRIER AN�POIICY NUMBe��E: CONSTRUCTION l \/ 4 l 1..� r r�� �^ � � CARflIER �' �/ � ` �-/✓�7 •'- � � Z POLICY NUMBER �,d,�I� -L- � 11 A/ rl'�T . _ Q �,{,� J � p (R95SECiICNME�NOTBEWMR.EfIDOFhffPERRYTI5i.7fiqJEF0.MDREDDOLL�ASI510D)ORLESS: �LC.TMFrNN� J ,/ d ( � z lCERTIFYTHHTINTHEPERFORMANCFOFTNEWORKFORWHICHTHISPERMI7ISISSUE�,1 H IC L '^�0 Lj' SHAIL NOT EMPLOY ANY AERSON IN ANY MANNER SOAS TO BECOME SUBJECT TO THE Uj WORKERS'COMPENSATIONLAWSOfCALIGORNIA,ANpAGREETHATIFISHOULDBECOME INSPECTIONFEE = SUBJcCTTOTHEWORKERS'COMPENSATIONPROVISIONSOFSECTION37000FTHEL4BOR -- � COUE,ISHALLFORTHWITFtCOMP�YWITH'fyqSEP VISIONS. `C%: ISSUANCE '�.� ,� +J 'f l% Y7 a�� •/ . p �ATE: ..%✓� `'�r I APPUCANT: � � �� L J WARNINO:FAILUftE T09EGJRE WORKERS'COMPENSAT70N COYERA6E IS UNLAWFUL,AN�SHALL 9E ENERGY P(C _ _ _, �y SUBJECTANEMPIOYERTOGRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT � DOLURS(L700,000j,IN ADDITION TO THE COSTOf COMPENSATION,DAMAGES AS PROVIDED FOR IN � SECTWN37080FTHELABORCODE,MTEREST,ANDAITORNEV'SFEES. RETENTIONFEE: ��,� �1 OCONSTRUCTION LENDINGAGENCY PRE-ALT FEE: � I HEREBY AFFIpM UNDER PENALTV OF PERJURY TH THERE IS A CONSTRUCTION IEN�ING AGENCv FOR TME PERFORMANGE Oy�F THE WOPK FOfl WHIC ^IS PERMIT IS ISSU (SEC.309�,CIV.C.). � LENDEWSNAME 1 "'n��� f/ ���"'�-� ' F- LENDER'SADORESS W� TOTALFEES C ICEPTIFVTHATtIi�VEREAOhIISAPPLICATIONANDSTATETHATTHEABOVEMFORMATpNISCORRECT � � � 1 AGREE TO CAMPLV WI7H ALL CITV AND COUNTY OflDINANCES AND STATE LAW3 RELATWG TO BUILDING � CONSTRUCTION,PNDHEREBVAUTHOqIZEREPRESF.NTATIVE50FTHI5LOUN1'(TOENTERUPONTYE 11�� Z ABOVE-MENTIONED PROPERTY FOR INS ECTION PURPOSES. COMMENTS � ."'� � m PERMITTEE NAME�P ) �� cn _��5��� �.�Y' � � SIGN F PERMITTE OATE � � � = RECPT.NO. 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