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HomeMy WebLinkAbout16391 �, _ CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY d�DEVELOPMENT SERVICES w 21660 E.Copley Drive Suite 190 ,,,_A�,v._ (909)860-3195 Fa�c(909)861-3117 PRESS BUII.DING PERMIT APPLICATION ,� � e FIRMLY _ y JOBSITE / �°� /�„F� � � /�J 4 APPLICATION M,0�.��PERMIT � -� #/� ¢ ADDRESS l�'� �%' G� � o DATE NUMBER $ ISSUE ,� TYPE OCC APN LOT TRACT__�j�7-�'J. DATE CONST. GROUP p OWNER � .:.- o ADDRESS � � ZONING SETBACKS "` ` `" �W CITY � �/� Zlf� /�' TEL.`��f� ,Z�7�� � REAR Rw ❑ APPLI ANT TEL. SIDFJSIDE STREET RW ❑ � CONTRAGTOR ' SIDE ❑ ADDRESS �-- � CITY IP TEL. PROPOSED USE o ARCH/ENG! .. ��,, DESIGNER ��- sa�'� NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEORpOMS � CI ZIP TEL. � v� DESCRIPTION S .FT. FACTOR PSF ADJ.AREANALUATION � OWfJER-BUILDER DECLARATION SFR/ADDlREM ,(~ O I HEHEBY AFFIRM UNDEFl PENAL7Y OF PERJURY THAT 1 AM EXEMPT FAOM 7HE CON7RACTORS LI- G2f8 J01C3fpOf[ W CENSEUWFORhIEFOLLOWINOREASON(SECJo31.5BUSINESSANDPROFESSION3CODE:ANYCIttOR (f� � COUNTYWHICMHEOUIRESAPERMITTOCONSTRUCT,ALTER,IMPROYE,DEMOIISH,ORREPAIRANY5IAUG W paii0/D6Ck L. W NRE,PRIOR TO ITS ISSUANCE,ALSO REW IRES TME APPLICANT FOR SUCM PERMIT TD FILE A SIGNED w � STATEMENT THIIT HE OR SHE IS LICENSE�PURSUANT 70 THE PROVISIONS OF THE CONTRACTORS LI- CENSELAW(�HAPTER i(COAAMENCINO WITH SECTIDN 70�0)OF OIVISION 3 OF iHE BUSINESS AND PRO- � POOUSpfl � - � FESSIONSCODE)OHTNATHEORSHEISEXEMPTTHEHEFROMANDTHEBASISFORTHEALLEGE�E%EMP- (� TqN.ANYVIOLATNNJOFSECTION7031.58VANYAPPUCANTFORAPERMITSUBJECTSTHEAPPLICANTTO z Re-Roof � ACIVIL PENAITY OF NOT MORE THMI FIVE HUNDRED DOLIARS�S600).�: � ❑I,ASOWNEROFTHEPiiOPERTY,ORMVEMPLOVEESWITHWAGESASTHEIR50LECOMPENSATION, � Commercral - � - WILL DO THE WORK,AND THE STRUC7URE IS NOT INTENOED OR OFFERED FOR SALE(SEC.7oM,BUSI- J . � NE39 AND PROFESSIONS CODE:THE CONTMCTORS UCENSE lAW DOES NOT APPLY 70 AN OWNER oF = PROVERTY MR10 BUILDS OR MAPROVES TIEREON.AND WHD DOES SUCH WORK HIMSELF OR HERSELF�R Q 7HF10VOHHISORHEHOWNEMPLOYEES,PFOYIDEOTHA75UCNIMPROVEMENTSARENO7INTENDEDOR m 0 ,OFFEAEDFORSALEIF,HOWEVER'�HEBUIL�INGORIMPROVEMENTISSOLCWITHINONEYEAROFCOMPLE- z TION,THE OWNER�BUILDER VALL HAVE THE 9URDEN OF PROVING THAT HE OR SHE DID NOT 0UIL0 oR = IMPROVE FOR 7HE PUFPOSE OF S.LLE). W ❑I,ASOWNEROFTHEPROPERTV,AMEXCLUSNELYCONTMCTINGWITHUCENSEDCOMRACTORS Q TO CONSTRUCT THE PR0.IECT(SEC.�a4I,BUSINESS kN�AROFESSIONS CO�E:THE CONTRACTORS U- VdIUd[ID11 ADJ.AREA W CEt�E1.�IWDOE&NOTAPPLYTOANOWNEROfAPROPERTY`MIOBUILDSORIMPROVESTHEREON,AND � NR�IOCONTMCTSFORSUCHPR0.IECTSW�THACOMRACTOR(5)LICENSEDPURSUAhT?0?HECONTRAG QUANTITY OES RPTION FEE Y TORSucENSEuw.). -� � ❑I MA EXEIIPT UNDER SEC. B,8 P.C.FOR THIS REASDN Q � ± 3 � , �� f. �..- ,� — � - � DA7E OWNER_ V � LICEN5ED CONTRACTORS DECIARATION W � J � I HEREBY AFFIRM UNDER PENA�TY OF PERJURV THAT I AM UCENSED UNDER PRpViSiONS OF CHAPTER � ��` /` � 9(COMMENCIN6 WI7H SECTION 7000)OF DIVISION 3 OF THE 6USINE55 AND PROFESSIONS CODE,AND z M rL�J �� AIY UCENSE IS IN FULL FORCEAND EFFECT. m s � LICENSE CLA55 f� UC.NO, � �� �. J , � ' V DATER" 'd ' � --L� GONTRAGTOR r L1. �rv . i , ,.� W � WORKERS'COMPENSATION DECLARATION Q �] , �a L_.. � IHEREg7Y�AFPIRAIUNDERPENALTYOFGERJURYONEOFTHEFOLLOWINGDECLAMTIONS: Z y�-�� � �.--1H.IHAYEANOWIILMANTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' a , 2 (� �� � COMPENSATION,AS PfiOVIDEO BY SECTION 370o OF TME LABOR CODE,FOR THE PERFORMANCE C.) � �J � Q �OFTHEWORKFORWHICHTHISPERMITISI5SUE0. � .r- ` ^� LL! � I HAVE.WD WILLMANfTAIN WORKERS'COMPENSATION INSURANCE,AS REIXIIRED BV SECTYJN / Q 37000FTHELABORCODE,FORTHEPERFORMANCEOFTNErWQPoCFOPWHICHTHISPEflMITIS ��� ,�1 ( (I��-� ISSUF_O.MY WO EF5 COIqPENSATION INSURPNCE CARRIEflAND 70lICY BERARE: CONSTF3UCTION J� � '� � CARRIER - �' PLAN REVIEW . � PouCY NUMBER - ELECTRIC a � 0 (I}i15SECTqNNF�NaTBEGX�IPLE1'mOF1HEPERMITISt�RCNE4NrAREDDOLIAFiS(5100)ORLESSF PLUMBING �� '�J � W " Z I CERTIFY THAT IN THE PERFOFMANCE OF 7 HE WORK FOR WHICH THIS PERMIT IS ISSUEO,I MECHANI AL � v Lj 5HALlNOTEMPLOYANVPER50NINANYMANNERSOAST08ECOMESUBJECTTOTHE � ��(�7� � YVOPKERS'COMPENSATIONLAWSOFCALIFORNIAANDAGREETHATIPISHOULDBECOME INSPECTI NFEE L)11�/ � � SUBJECTTOTHEWbRNERS'COMPENSATIONPROVISIONSOFSECTION37000FTHELA60R � — � ` �- CADE,ISHALLFOflTHWl17/COMPLYWITHT SEPROVISIONS. ISS�JANC 1 � p DATE:���=o� APPLIGANT: U� F SMIP ��'t�.. _ � � -�._.�` ' .. r' ''".,,.. -� WARNING FAILUFIE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNIAWFUL.AND SHALL BE ENERGY P/C �..-._._ . J p �y SU&IECTANEMPIDYERTOCRIMINALPENAlTIE5/W�CIVILfINES1IPTOONEHUN�REDTFIOUSAND ENERGYPERMIT � DOLtARS(Z1oU,0oo),IN AD�ITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN J SECTION37080FhIELABORCODE,INTEREST,AN�Ai'TORNEV'SFEES. � '��i-�. p� RETENTION FEE: ���.� OCONSTRUCTION LENDING AGENCY PRE-ALT FEE � I HEREBV AFFIRM UNOER PENALTV OF PERJURV TNATTHERE IS A(`ANSTRIICTION I.ENDING AGENCY I FORTHEPERFORMANCEOFTHEWORKFOR ICHTHISPERMITI ISSUED(SEC.3087,CIV.G). W /� � LENDER'SNAME 'V���' G/��� H- LENDER'SADORE3S � ICERTIFYTHATIHAVEREA�THISAVPLICATIONANDSTATETNATTHEABOVEINFORMATIONISCAHRECT. TOTAL FEES � � �� W IAGREETOCOMPLVWITHALLCITYAN�CAUNTVORDINANCESANDSTATEUWSRELATINGTOBUILDING � CONSTRUCTION,MJD HEREBY AUTViORI REPRESENTATIVES OFTHIS COUNT`/TO ENTER UPON THE I Z A80VE-MENTIONEO PROPERTV FOR IN ECTION PURPOSES. COMMENTS � L /L��Z� � m PERMITTEE NAME(PRI � � L� �2`'7— �l � SIO REOFPERMITT DATE � RECPT.NO. PAID BY VALIDATION WHITE—Department Copy,YELLOW—Finance Copy,PWK—Assessor Copy,GOL�ENROQ-File Copy.GREEN—Applicant's Copy ....� , „-, , ,>,.. � . ��T� � ��������? � � ��� � .�: . ., � � � � � � � �, � �^�� �� .� � � ��� ����� � � ' � .:� ..:. � �: . .. -�z>. r. �_ r_, ��" ri�� �,���, .'_ ... � ..����,�,.��_ A a� . p g �- � j ( ? � .� �� -� � 8 �°i �r�`�.�., •. .. . .. } ��.t ....... .�.-. �. . -- .. � . ...___,_......._..._._....�..,.,_._ _.. L .�. __ ---{ _ ___ ______ �.._ _L__ fi -:^-- �.. { I°V ��, I'...7 L:. 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