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HomeMy WebLinkAbout16503 (23) ��� CITY OF DIAMOND BAR DEPARTMENT OF COMMiJ1VITY&DEVELOPMENT SERVICES � . 21660 E.Copley Drive Suite 19U (909)860-3195 Fax(909)861-3117 PRESS ���^� BUILDING PERMIT APPLICATION FIRMLY _ ..< ., .,. JOBSITE »^ �� "- � ,��q APPUCATION PERMIT �`'��l P/C o ADDRESS �'��'4� ���(�..-(�� �--� DATE �y � �_�� NUMBER�vv�# e� ISSUE TYPE OCC APN LOT TRACT K����T_ DATE CONST. GROUP p OWNER �- " ADDRESS � E" ZONWG SETBACKS � CITY , ZIP�j`�-TEL R I k FRONT RW ❑ APPLICANT TEL. REAR ❑ SIDE/SIDE STREET RW ❑ � CONTRACTOR SIDE ❑ � ADDRESS � Q � CITY ZIP TEL. PROPOSED USE � - »� a DESIGNER,___1Z�11L�'/, �li�"l'�.� ��56 G✓ ADDRESS "'Z� ' NO.DWEL. NO. NO. ����-- — UNITS STORIES BEDROOMS � CI y f ZIP��fEL. � R DESCRIPTION SQ.FL FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFRlADD/REM O p I HEiiEBV AFARM UNDER PENALTV OF PERJURY THAT I AM E%EMP'T fROM THE CONTRACTORS ll� � GafagB/C0fp01t W CENSEUWFORTHEFOI.LOWINOREA50N(SEC.703758USINESSANOPROFESSION9CODE:ANVCI'1'1'OF U COUMYWH7CHqEQUIHESAGERMi7TOCON5TRl1CT,ALTER,IMPROVE.DEMOLISH,ORREPAIRANY57AUC� 'W PatiOlDBCk W TURE,GflWR TO IT3 ISSUANCE,AL50 REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNEO � STATEMENT THA7 HE OR SHE IS LICENSED PUqSUANT TO TME PROVISIONS OF THE CONTRACTORS LI- CENSE LAW(CHAP7EP 71COMMENCING WITH 6ECTION 7DDo)OF DIVISION 3 OF THE BUSINESS AND PRO- V'" PooI/Sp2 FESSION&CODEI�RTHAT HE OR SHE IS EXEMPT TMEREFROM AN�iHE BA515 FOP THE RLIEG ED E%EMP- TION.ANYVIOUTIONOFSECTION7037.SBYANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO � Re-Root r ACIYIL PENALTY OF NOT MOREh1AN FNE HUNORED DOLLARS(S50o)J: p � ❑I,ASOWNEROFTNEPROPERTV,ORMVEMPLOYEESWITHWAGE5AS7HEIfiSOLECOMPENSATION, COBltllelClal - WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDEO Oi1 OFFERED FOR ShLE(SEG 7oN,BUSI- J NESS ANO PROFESSIONS CODE:THE CONTRACTOFS UCENSE LAW DOES NO7 APPLY 70 AN OWNEP OF � PqOPERNWFiO8U1LDSORIMPROVESTHEREON,ANOWHODOESSUCHWORKHIMSELFOAHERSELFOR � CL THROVaNH150RHEROYMEMPLO7EES,PROVIDEDTHATSUqiIMPROVEMENTSARENO7INTENDEDOR � . . , QORFEREDFORSALEIF,FIOWEVEi4THE6UILDINGORIAIPROVEMENTISSOLDWRHINONEYEAROFCOMPLE� Z TION,THE ONlNER�BUILAER WILL HME iHE BURDEN OF PROVING THAT HE OR SNE DID NOT BUIfA OR � IAIPROVEFORTHEPURVOSEOFSALE). W ❑I,ASOMMlEROFTNEPFOPEFCTY,AMEXCLUSNFLYCONTRACTINCWITHLICENSmCONTRACTORS � TO CONSTRUCT THE PHOJECT(SEC.704�.BUSINESS AND PROFESSIONS CODE',THE CONTMCTORS LI- VHIl12110/I ADJ.AREA W CENSELAWDOESNOTAPPIYTOANOWNEROFAPROPERTYWHOBU1LO50qI1APpOVESTHEREON,AN� � WHOCONTRACTSFORSUCHPR0.1ECT5WITHACONTRACTOR(5)4CENSEDPURSUANiTOTHECON7RAG Q�OANTITY DESCRIPTION FEE � TORS LICENSE UW.). J Q �1 AM E%EMPTUNDER SEC. __ B.&P.C.FOR THIS REASON � � � � DATE , OWNER_ ~ � � LICENSEQ CONTRACTORS DECLARATION i j � I HEREBYAFFIfiM UN�ER PENAITY OF PERJURV YHAT I AM LICENSED UNDER PROVISIONS OF CHAPTER � '� p'� D(COMdENCINOWISHSECilON700D)OFGIVISION30F7NEBUSINESSANDPROFESSIONSCADE,RND Z MV IICENSE IS W NLL FORCE D EFFECL a� � � LICEN5E CLASS ���',/ LIC.NO. �/ �7���a% � � V DATE- � �""`� �_ CONTRACTOR-a��€���7� � a W r z'' D � WORKERS'COMPENSATION DECLARATION a N U N I HER V AFFIRM UNDE(i PENALTY OF PEFJUqV ONE OF THE FOLLDYJING DECLARA710N5: Z d A I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SLLF-INSURE FOR WO�NEFS' y Z COAiPENS�TION,AS PROVIDEO BV SECT.ON 3700 OF TME LABOR CODE.FOR THE PERFORMANCE U � f OFTHE WORK FOR WHICM 7HI3 P£FMIT IS 153UED. � W I HAVE MID WILLMAINTAIN WOAKEFS'WMPENSATION INSURANCE,AS REOL'IP,F.pBYSECTiON � . 37000FTHE LABOH COOE,f-OR THE PERFOHMANCE OF THE WORK FOfl WHICH THIS PERMIT IS � �55UE�.MYYv'OR 'COMPEN6ATIONINSUPANCE HflIE�NDPOLIGYNUMBERAflE: CONSTRUCTION �j. GARR�ER � PIAN REVIEW _ � caicvNuue/eq P EIECTRIC ` Q ��FCiKINNF�NOT6ECQF�IEiFDOF77-IE FVN7'ISFORONEMUI�[)REDOd.W,S(5900)ORLESS} PIUMBING � �l Z I CERTIFY THAT M THE PERFORMANCE OF THE WORK PoR WHICH THIS PEP�IIT IS ISSUED,I MECHANICAL (� SHALLNOTEMPLOY/WYPERSONINANYMANNERuORS70HECOMESUe.:ECTTO'HE � WORKERS'COMPENSATIONlAW50FCALIFORNIA,ANDAGREETHATIFISHOU�DBEWME INSPECTIONFEE r SV&lEC?TOTHEWORNERS'COMPENSATIONPROVISIONSOFSE TION31000FTHElABOR � CADE,ISHALL OqTHWITHCOMPLYWRNTHOSEPROVISqNS,� ISSUANCE U ' ���-j� ' Zq.�-� � DATE:�,�-���__L�fAPPLIGANT: � .- . SMIP J WARNING FAIIURE TO SECUHE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHAU.BE ENEPGY P/C �y„ SU&IECTANEMPLOYERTOCRIMINALPENALTIESANOqVIIFINESUPTOONEHUNDREDTHOUSAt� ENERGYPERMIT DOLLAPS(5100,000),IN ADDITION TO THE COS7 OF COb1PENSATION,OAMAGES AS PROVIDED FOR IN � SECTIDN3]WOFTHEIABORCODE,INTEREST,ANDA7TOFNEYSFEES. F�ETENTIONFEE' d CONSTRUCTION(.ENDING AGENCV PRE-ALT PEE: ___ O � IHEREBVAFFIqMUNDERPENALTVOFPERJURYTHATTNEPEISACONSTRUCTIONLENDINGAGENCV ____ fOf7 THE PERFORMANCE OF THE WORK FOR WHICH S PERMIT IS ISSl1ED(SEC.�097.CIV C.). w �"�.i��__-_ � LENDEFI'SNAME__y. � �N" F— IENDER'SADORE55 W ICEfiTIFYTHATIHAVEFEAO'NISAPPUCATIONANDSTATETHAT?HEA90VEMFORMATqNISCARRECT. TUTAL FEES � I AGREE TO COMPLY WITH ALL CITY ANO COUNT'!OROINANCES ANO STATE LAWS REUTING TO BUILDING CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS CAUMV TO ENTEfl UPON THE 2 ABOVE�MENTIONED PROPERTY FOR INSPECTION PVRPOSES. COMMENTS � —i�t7��� ot✓� a QPEFMITTfE NAME(PRIN� .y.�, �//f� _ (!J • �V �/��..� � SIG flEOFPEftMfR -- DATE = RECPT.NO. 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