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HomeMy WebLinkAbout16390 (23) �' • �'''� CITY OF DIAMOND BAR /� �— -�� -� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES , (/' w , 21660 E.Copley Drive Suite 190 `"� (909)860-3195 Fax(909)8b1-3117 PRESS •�.�.�..�.� FIRMLY "�"_ BUILDING PERMIT APPLICATION o ADDRESS ��(�'L G� ��L'�N�FL-� �� DATEICATION �� I �r� . NUMBER�L°��� �/C;,. _.,..... . .,:..,., � JOBSITE � � ISSUE TYPE OCC APN LOT TRACT 'J�����I DATE CONST. GROUP p OWNER � ' " ADDRESS U �,�' ZONING SEBACKS W cirv.�lZ-i✓oN ziP TEL. 7 FRONT RW ❑ � APPLICANT TEL. REAR ❑ � SI�E/SIDE STREET RW ❑ CONTRACTOR """' SIDE ❑ o� ADDRESS o CITY ZIP� TEL. PROPOSED USE � (� ✓Z w ARCHlENG! z DESIGNER���=��5-I SS c�L;-� w " —� NO.DWEL. NO. NO. d ADDRE � UNITS STOR�ES BEDROOMS y CITY Z P � �'"'TEL.7���y� cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER-BU�LDER DECLARATION SFFVADDlREM O I HEREBY AFFIRM UNDEfl PENALTV OF PERJURY THAT 1 AM E%EMPT FROM THE CONTRACTORS L6 GflfdJB/Cefp0li � CENSEUWFORTHEFOLLOWINGflEASUN(SEC.7o31.5BU51NE55ANDPROFESSIONSCADE:AN7C17YOfl (f� COUNTYWHIpiREWIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOUSH,ORREPAIRANYSTRUG W pg�i0/DBCk W TUHE,PHIOti TO ITS ISSUANCE,AL50 RE�UIRES THE APPLICANT WR SUCH PERMIT TO FlLE A SIGNED W STATEMENT THAT HE OR SHE IS IiCEN5E0 PURSUANT 7p THE PROVISIONS OF THE CANTRACTORS L4 S CENSE UW ICHAPTER 9(COMMENCINO WITH SECTION 70D0)OF DIVISION 30F THE BUSINESS AN�PR0- �'�' POOUSp8 �"�� JE FESSIONSCOOE�ORTHATHEORSHEISEXEMPTTHEHEFROMANDTHEBASISFORTHEALLEGEDEXEMP- � TION.ANYVIOLATIONOFSECTION7031.66VANYAPPLICANTFORAPERMITSU&IECTSTNEAPPLICANTTO Z R@-ROOf .„ ' " A GYVILPENALTV OF NOTMORE THRN FIVE NUN�RED�OLL4R5(SSoo),I: ���� ``'�' " ^ ❑I,ASOWNEROFTHEPROPERTY,ORMVEFAPLOVEESWITHWAGESASTHEIRSOLECNJMPENSATION, .. � YALL 00 THE WORK,AND THE STRUC?URE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7oa�,BUSI- � Commercial � NES9 AND PqOFE93lON3 CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF = PROPERiY WFiO BUIIDS OR MPROVES THEREON,l1ND WHO DOES SUCH WOFiK HIMSELF OR HERSELF OR Q TFIHOUGH HIS Oq HEFiONM EMPLOYEES,PROVIDED THAT SUCH IMPROVDAENT&ARE NOT INTENOE�OR m . .. 0 ,OFFEREDWRSPLEIF,HOWEVER,THEBUIIDINGORIMPAOVEMENTISSOLOWITHINONEVEAFOFCAMPLE- � TION,7HE OWNER-BUIIDER WILL HAVE THE BURPEN OF PROVING THAT HE OR SHE DI�NOT BUILD OR = IMPROVE WqTHEPl1RPo5EOF5ALE). W ❑I,AS OVMEROFTHE PROPEqTY,AA1 EXCLLISNEI_V CONTRACTIN[i WITH LICEtdSED CONTRAC70RS � TO CONSTRUCT iHE PR0.IECT(SEC.70U,BUSINESS ANO DROFESSIONS COOE:'fHE CONTRACTOPS Li- VdIilBilOn ADJ.AREA W CENSEUWDOESNOTAPPLYTOPNOWNEROFAPROPERTVWNOBUILDSORIMPROVESTtiEREON,ANO � WFIOCONTHI.CTSFORSUCHPqOJECTSWITHACqNTRACTOR�S)UCENSEDPURSUAN7TOTHF.CONTMG QUANTITY DESCRIPTION FEE Y TORSLICENSELAW.�. 0 ❑I M1 EXENPTUNDER SEC. B.8 P,C.FOA THIS REASDN Q � U w � DA7E OWNER U � LICENSED CONTRACTORS DECLAFATION W � IHEFEBYAFFIRMU�DERPENALTYOFPERJURYTHATIAMLICENSEOUNDERPRDVISIONSOFCHAPTER � i" d Y(COMMENCINp WIh13EC710N 7ao0)OF DIVISION 30F iHE BUSINESS AND PROFE3SION5 CODE,AND Z � X MY UCENSE IS IN FULL FORC AND EFFEGT. m � LICENSE CLASS� LIC.NO.,. �� _�__� � V DATE�y�+�N+ `�� CONTRACTOR_i�� ' ' " d W �a= a � WOFKERS'COMPENSATION DECLARATION —� � I HEREBV AFFIRM UNDER PENALTV OF PENURV ONE OF THE FOILOWING DE0.ARATIONS'� Z � �IHAVEANDWILLMAWTAINACEflTIFICRTEOFCONSENTTOSELF-INSUREFORWORKERS' _ ,� COMPENSATION,AS PROVIDED 8V SEC710M 3'!0o OF THE LABOR CODE,FOR THE OERFORlAANCE `U Q OFTHE WORK FOR WHICH THIS PEflAIIT{S ISSUED. � � I HAVEANO WlLLMARJ7AIN WOAKERS'COMPENSA710N INSURANCE,AS REOUIRED BY SECTIDN O 37000FTHELABORCODE,FORiHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS ISSUED.MY WO ERS'Cp1�PENaSATION INSURANCE CAHpIER rAyN�D�POLICV NUMBE�gJ}�aE: CONSTRUCTION � CAFRIER L— � 't ..L—�1Wf.,.fT. L'L7 `, PLAN REVIEW � rouCV NUMeER_��°1 , f� — ELECTRIC ¢ -/-� 0 (f1iI55ECilONNE�NOTBE�ETEDOFl1fPER1Nf1SFDRIXJEHIMDREDOCl1ARSR10D)ORLESS� /'�, __ 1_._a,_LJ W 1 CEHTIFY THAT IN THE PERfORMANCE OF T4E WOR1(FOR WHICH THIS PERMIT IS ISSl1ED,I N1GI�L ��' Z � SHALLNOTEMPLOYANVPERSONINANYMANNERSOAST00ECAMESUBJECTTOTHE � WORKERS'COMPENSATION LAWS OF CALIF-0RNIA,AND hGREE THAT�F 1 SHOULD BECOME INSPE�FE� _ SUBJECT TO THE WORKEflS'COMPENSATION PROVISIONS OF SECTION 3]00 OF THE LABOR �� � s COpE,15HALLFOflTIiWITHGOMPLYWITHTHOSEPROVISqNS. ISSUA E _ �� O �� ��� ���p p DATE: �' � pppIICANT: F.� SMIP � WARNING:FAILURE TO SECURE WOPKERS'COMPENSATION CAVERAGE IS UNUWFUL,AND SHALL BE 'F�['1^^"��P!C' — ---- �y SUBJECTANEMPIAYERTOCRIMINAI.PENALTIESANOGVIIFlNESUPTOONEHUNDREDTHOUSANO '�'� DOIURS�51oo,ao0),IN ADDITION TOTHE COST pF COMPENSATION,DAMAGES AS PROVIDED FOR IN � SECTION37a00Fh1ELABORCOOE,IN7ERE5T,ANDA7TORNEV'SFEES. RETENTIONFEE: O CONSTRUCTION LEN�ING AGENCY PRE-ALT FEE: m � 1 NEREBV AFFIRM UNDER PENALTV OF PERJURV TH THERE IS ACONSTRUCTION IEN�ING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHI THI PEqM1T IS ISS D�SEC.3D9'7,CIV.G}. � j�fJ/1,�;� �4�T�� W � LENDER'S NAME — F_- IEN�ER'S ADORE55 �.-� � 1 CER7IFY iNAT I HAVE REA�THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT TOTAL FE ES �� � ��J 1J W IAGREETOCOM.PLVWITHALICITYANDCAUMVORDINANCESANDSTATEIAWSRELATINGTO8U1lDING ��' � CONSTRUCTION,AND NEREBY AUTFIOFIRE REPRESENTATIVES OFTHIS COUN7Y TO ENTER UPON THE Z ABOVE-MENTIOHEDPROPERTYFORINSPE TpNPURPOSES. COMMENTS 0 -i-� � m PERMItTEENAME(PRWT) � ' �., �.Z�-c�/ � 51 UREOFPERMI DATE = FECPT.NO. 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