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HomeMy WebLinkAbout16527 (23) ��` CITY OF DIAMOND BAR � DEPARTMENT OF COMMUr1ITY&DEVELOPMENT SERVICES 21660 E.Copley Drive Suite 190 (909)860-3195 Faa(909)861-3117 PRESS , . . �"��°'��' BUILDING PERMIT APPLICATION `�����"Y . ..,.�. ..,. u . , .W�.,.,�. �, , ,... �.... .,, y JOBSITE ^ ` APPLICATION h✓ (� PERMIT � P/C o ADDRESS - 1 � � DATE `-' ' �'" � NUMBER � # � ISSUE TYPE OCC APN OT � TRACT �"� DATE CONST. GROUP p OWNER `p ADDRESS ZONING SETBACKS � CITY�,�� ZIP��„TEL. - Z-�(�, FRONT qyy � APPUCANT � . TEL. REAR � � SIDE/SIQE STREET RW ❑ CONTRACTOR SIDE ❑ ADDRESS g CITY_ ZIP EL. PROPOSED USE �w ARCWENG/ q�-y^y, DESIGNER � c � � ~ NO.DWEL. NO. NO. ADDR S I •���� ���� � � UNITS STORIES _ BEDROOMS N CITY ZIP�,�,�`y TEL. ' ' v� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADD/REM O p I HEREBY AFFIRM UNOER PENQTY OF PERIURY iHAT I MI E%EMPT FFOM 7NE CONTRacTORs u- Gara !Ca rt W CENSEUWKORTHEFOLIOWINGqEASON(SEG7031.59USINESSAN07POFESSIONSCCi�E:ANVCINOR (n � � � COUNTYWHICHREQUIRESAGEqMITTOCONSTRUCT,ALTER,IMPRDVE,DEMOLISH,ORREPAIRANYSTRIJC- Z 7URE.PRIOR TO IiS ISSUANCE,ASO RE�UIRES THE APPLICANf FOR SUCH PERMIT TO FIIE A StONED W Pello/DBCk � STATEMENT hiAT HE OR SHE IS llCENSED PURSUANT TO THE PROYISIONS OF THE CONTRACTORS LI- CEN9E UW(CH�PTER e(COMMENCINO WITH SECTION 7000)OF D�VISION 3 OFTHE BUSMESS ANO PRO- u' POO�Spa FESSqNSCODE)ORTHATHEORSHEISEXEMPTTHEHEFROMANpTHEBASISFORTHEALLEQEDEXEMP- (� V TpN.ANVVpLAT10NOF5ECTION7031.59YANYAPPLICANTFORAPERMITSU&IECiSTHEAPPUCANTTO � R8��R001 F ACML PENALTY OF NOT MORE YHAN FIVE HUNDRED DOLLARS(5500).): � ❑l,ASOWNEROFTHEPROPERTV,ORMYEbiPIOYEESWITHWAGESASTHEIRSOLECOMPENSATION, C� COmRIBfCIdI - WILL DO hIE WORK,AW THE STRUCTURE IS NOT INTENDED OR OFFERED FON SALE(SEC.70�6,6USI- J � NESS AND PROFESSIONS CDOE:THE CONTRACTORS LICENSE UW DOES NOTADPLV TO kN OWNEH OF � PROPERTY NM1iO BUILDS OR IIJPROVES THEFEON,M1D WHO DOES SUCH WORKHIMSELF oR HERSELf OR � THROUGHWSORHEROWNEMPIOYEES,PROVIOE�THATSUCHIMPROVEMENTSARENOTINTENDEDOR m — OFFERED FORSALE IF,HOWEVER�E BUIIDING OR IMPROVEMENT IS SOLD WITHIN ONEYEAR OF COMPLE- Z TION,THE QWNEH-BUILDER WILL HAVE THE BURDEN OF PFiOVING 7HA7 HE OR SHE DID NOT BUILD CH � IMPROVE FORTHE PURPOSE OF 5P1E). W OI,ASOWNEROFTHEPROPERTY,AME%CLUSIYELYCAN7fl.4C71NGWITHIICENSEDCONTRACTORS � TO CONSTRUC7 THE PHQIECT(5EC.70s4,Bl15WES5 AND PROFESSIONS CADE:THE CONTRACTORS LI- V01u8Si0n ADJ.AREA W CENSEUWDOESNOTAPPLVTOANOWNEROFAPROPERT'WHOBUILDSORIMPFOVESTHEREON,ANU � WFIOCONTMCTSFORSUCHPROJECtSWI7HACONlRACTOR(5)LICENSEDPUPSUANTTOTHECONTRAC- Q�JqN71TY DESCRIPTION FEE Y TORS LICENSE IaW.). O ❑�AME%EMPTUPDERSEC._ _B.&P.C.FORTH;SREASON Q ^ '�y U � DATE_ OWNER_� _ U �t[ UCE�USED CONTRRCTORS DEGLAFATION w CC I HEflEBYAFFIRN UNOER PENALYY OF PERIURY THAT I AA1 UCENSED UNDER PROVISIONS OF CHAPTER � � Y(COMMENCINO VJITH SECfIOk 1000)OF DIVISION 3 OF THE BUSINESS AMD PROFESSIONS COOE,AND Z LL� MY UCENSE IS IN FULL FOFlCEAFJD EFFECT. m � UCENSE LAS� LIQ NO.� 6 � � V DATE_� �_ CONTRACTOR _ _� d � �x r ' WORKERS'COMPENSATION pEC!_ARATION a � I HEFlEB fFIRM IINUER PENhITY OF PE0.IURV 4NE OF THE FOILOWINO OECLAAPTION9: Z � HAVE ANO WILL MAIN7AIR A CE�tFICATE OF r.pNs"ENT 70 SELPaNSUPE FOR WORKERS' 2 � � PENSAi ION,AS PFOV7�ED Bv SECTION 37d�OF THE LABOR COCE,FOR THE PERP6RMANCE U Q �F THE WOAN:-0F WHI(YI THIS PEFMIT IS ISSUED. � w MAYEANQYYiLIMAINTAINWORKeRS'COMPENSA710NINSURpNCE,ASRFqUIREC�BYSF.CTION � 37000F7HELABqRCOCE,FORTHBPERFORMANCEOFTHEWORKFORWHICHTHISPERMl1'IS ,/ �''��J ISSUEA.MYWORKERS' PE/N�SAI'ION INSt1RA E CAFlRI"cR AND P ICY M6E ARE: CONSTRUCTION ��N/ CJ✓ � CARRIER -�� t.a p''`�9J �,7 ���_ PLAN REVIEW � POLICV N MBER- - - ��!.L:��=��_. ELECTRIC ✓ i p Cni�s . Nci E , OFThEPEWvYfISFORONEHU�DfiEDD011l31S(StoojORLESs� PLUMBING Z ICERTIFYTHATINhiEPERFqqtaANC"cOFTHEWORKFORWHICHTHISPERMI7151SSIJEqI MECHANICAL (s SHALL NOT EMPI OY PNV PERSC�N IH ANY A4ANNF_R 50 AS TO�FCOME SUBJECT TO THE � WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOUID BECOME INSPECTION FEE r SUBJECT TO THE WORKERS'COMPENSATION PROVI.SIONS OF SECTION 3700 OF TNE LA60P. = CO ISH�j.FOflT�H.,WfITHCOM{'LYWITH7HO5EPROVI"IONS. , �o�' ISSUANCE O --[�+�s�k—L/W ��-t-^��' i C.J SMIP 1'T �i=:�, m DATE: PPLICANT: ����� wWAfiNING:FAiLLFE TO SECURE WORKERS'COMPENSATION cbVERAGF IS UNLAWFU�,AND SHALL BE ENERGY P/C " r LL St10JECTANEMPIOYERTOCRIIAINALPENALTIESANOqVIIFWESL'PTOONEHUNDREDTHOUSAND ENERGYPERMIT OOLLARS(S�00,000).IN ADOITION TO THE COST OF COMPENSATION,OAMAGES AS PROVI�E�FOR IN � J SfCTtON��oeqf'THELABORCODE,INTEREST,ANOATTORNEV'SFEES. . �a -. � � AETENTION FEE: OCONSTRUCT�ON LENDING AGENCY PRE-ALT FEE: � � I NERE9V AFFIR61 UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY _ � ' ' ' � -��- FOR THE VEFIFORSAANCE OF THE WORN FOR WHICH THIS�ERMIT IS ISSUEO(SEC.3097,CIV C.). V � '"� W -�--�- C.�t�- tit��� _.- ..,__r_.�___.�_.. _ � LENDER'S NAME . h LENDER'SAOORE35 w ICERTIFYTMATIHAVEAF_MTHISAPPLICATIONAN�STATETHATTHEABOVEINFORMATIONISCORRECL TOTA�FEES . � . � � a I AGREF TO CAMPLY WITH AL�CITV AN�CDUNTV�RDINANCES ANO STATE LAWS REL4TING TO BUIIAING � CANSTRU�ION,AND HEREBY AUTHORIZE RECRESENTATIVES OF THIS COUNTY TO ENTER UPON THE Z. ABOVE-MEMIONED PqOPERTV FOR INSPECTION PVRPOSES. COMMENTS � _� ��rrelS m . — Q PERMITTEENAME(P . � �, � ., --f� r � SIGNA EOFP OATE = FlECPT.NO. .._ �PAID BY �� VALIOATION_ _ ~ WHITE—Department Capy,YELLOW—Finance COVY�P�NK—Assessor Co GOL�ENROD--File Co GREEN— PY. PY. ApPlicaoPs CoPY ..� :�.���.�: ..�. ...�, �n ,�... 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