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HomeMy WebLinkAbout13902 (7) CITY QF DIAMOND EIAR - ---�'��' -- DEPARTMBNT OF COMMUNITY&DEVELOPMEN'I'SERVICES 2i�o E.coP1�y��e s�ce 190 PRESS ��^��W B DING PERMTT APPLICATION FIRMLY � JOBSITE ' � (� �'} � j,�,0���./ APPLICATICIN Q���.,�7 C� PERMIT ���U�PJC��r� � ADDRESS�_E'����a� DATE tf f � NllMBER_ # r r � --- ISBUE TYPE OCC APN--�� LOT TRACT DATE CONST. GROUP p OWNER c.�/� !.�' a ADDRE��1= ZONING SETBACKS �'" CITY�/__��� ZIP �( TEL. ��,�__ FRONT RW ❑ � APFLICANT _._ r� �E�� — SiDE1StIIE STREET _ RW ❑ � CONTRACTLI SIDE ❑ AQQRESS - pR4POS€D USE �-^�-u"L� Csj - I 14 �'�� g CITY{�{Dv`ti�- ZI TEL � U. t��.+ ARGHtENGt 9'� —� � DE5IGNER NO.DWEL. NO. NO. � ADDRESS � UN4T5 STORIES SEQRdC3MS_ � GtTY _ Z!P _ TEL. - � DESCR�PTION SQ.FL FACTdR PSF AdJ.AREANALUATtON <,r� � OWNER-BUtLDER DFGLAFiAT10N SFRIADDIREM (' 14{fREBY AFFlF9d I�ER PENAl7Y OF PEftRlRY TNAT i AM EXEMf7 FftGRA TNE CANTF7ACTORS ll� {a`gr8ggf�..`g�Oti µJ CENSEUWfORTNEFOLL9WIMGREASONiSEC.70.31.5BUSiNESSANt�PROFE55iONSCODE:ANYCtTYOR (J) - (,� ppUNTyWh{ICHREQUIRE&AP6RMRTOCONSTRUC7,ALTER,IMPROVE,pEMOlISH,ORFEPAIRANYSTHUP W Pa110/D6Ck WTURE.aR7OR Ta ITS iSSUdNCE,,+154 REQUtRES THE APPLICANT FOft SUGN PEftMiT TO FILE R S�IE9 � .� STATEMEN7 THAT ME Ofl:iHE IS UCENSED PVRSVANT TO THE PROVISIONS OF TNE CONTRAC10R5 t�� pqOUS 8 � CENSE UW{pUPTEfl 9(c%MIMENCNi6 WITIi SEC710N 1900)pF OIVISION 3 bF THE 9USINESS AN�PFO� � P , FESS�ONS CODE)OR 7HAT ME Ott SNE t5 EXEMPT TNEREFftOktANO THE BASi$F�R THE ALIEfiEO£%fMP� TION.ANVVIOLhTpNOFSECTIQN7a31.5BYANVAPPLICANTFORAPERMITSU&IECTSTHE0.PPLICANTTO z R6-Root � ACtViIFHiAtFYOFNOTiv10RETltANfiVEt1UNDRED441.1,AR5{f5o0},): � I]IASOWNEROFTFiEPR9PERTV,ORMVEMPIOYEESWiTHWAGESASTFiEiR50tECOMPSltSATKNb. CI GOtTtme�Ciel WILL DO THE WORK,AND TNE STRUGTURE IS NO7 INTENDEO pp O'rFERED FOR 5ALE(SEC.7pA4,BU51- J ryE$$AND ApDFES510NS C�CIE:TME C6NTflAC70R5 IiCENSE t/iW OOES NOT APPIY TQ PN OWNEN OF � PROPERTVYh106UILO5QRIMPROVESTHEREON,ANDVMODpESSUCHWPRKMiMSEIFpRHfRSEIFOR m (= THpOU[iHHI50RHEHONMEMPIOYEES,7ROVILIEDTHA75UCNIMPROVEMENTSARENOTINTENDEDpq QOFFEAEDFORSN..EIF,NOWEYEH.7}iE9VWD�NGIXiiMPR4VEMENTiSuOLDWITHiNt7NEYEAft�WMPIE- Z TION,THE 4WNER•BUILpfR WILL H�VE THE BURDEN OF PROVING THAT HE OR 5HE Dip NOT BUILD pfl ������� � H6PROYEFORSHEPUPo'+a5EOF5ALE). ❑1.AS ONTIER OF THE PflQPERTY,MA EXCLUSNELY CONTRAC1lNG WITN UCENSEJ C�tiTflACT4flS Q TO CANSTIiUCT THE PqCJECT(SEC,70N,BUSINE55 ANO PRbFE�SfONS GIJDE THF_CpNTPACTORSII� VBIUflllOfl ApJ.AREA tl! CE?7SEUWDOESNOTAi'PIYTOhNC1W{9EftOiRPROPEflTYWkO8Ut1ASORIMGFqVES7HEREON,AND ZVhIC?CONTRACTSFORSU�qiPRQiEC75WtTHACQNTRACTOA(5)UGEN9EDPVflSUAM7SDTHEC�NTRAG QUANTITY DESCRiPTION FEE � TOR5UCENSELAW.). ❑1 M/EXEMPT UNq�ER 9EC.��.��-......._-...._.B.8 P.C.FGR TN�5 REASflN � � �' ��„ � �� 1.i 3 -- -- a 7 LL DATE ___'_ OWNER ._—_ . - CM.) J J 2 ti1 F LICENSED CONTRAGTORS DECLAqATInN � __ � I H6REBV AFFIRM UYDEFI PENALN OF PERJURY TNAi IAM I�CENSEU UNDFR PR�YISIc�NS O�CHAPTER � � � � d Y{CQMMENCING WITH RI_CTK}N 7a00)Of DIVISION 7 OF 7HE BUSIM�55 ANO VROFESSIONS COfJE,ANO � X MY ttCENSE IS!N F4R.l FGRC6 AND EFFECT. m — LJJ � � IiCEFtSE CtAS5_...� .,_.- UC.Nc7._ .-_.— J � OATE .-_......- CONTf4AGTtiR-..,-._��...._._, a .. ; , . ...; tZJ � � WOHKEN5'CQMPENSA7ION pECLARA710N Q - � � tn � � 1 MEREBY AFFIqM UNOE'9 PENALN Oi PERJUfiY ONE CF THE FGLLOWING pECLARA�IONS: Z .. . . _ Q � _I NAVE ANO WII,i.MiR�NTA�N A GERTIFlCATE OF C6NSENT TO 5ELF-INSUAE FOR VX}RKEft5' S " - CC7MPENSATKNI,AS pPOVIDEO BY$ECTION 3]00 OF THE UBOR COOE,FOR TNE PERFpRMANCE C,) Q Of TtiE WC�RK F OA WHICH THIS AER4AtT IS ISSl7E0. � , ^ w `�'"'� �_ � U W i HAYE AN�WIIL MNNTAIN WORNCPS'COMPENSATIpN IN511HANCE.AS REdUIRED 0Y SECTIpN '� t � AN � i' Q 3700 OF THE LA60R t�OE.FOR TriE RER%ORMANC'c OF THE WOAN F4R WM{`N THIS PERMiT IS _ ISSUEa.AAY .r '�yp-M�PyE�N,'S'�,�TION INSUfjpp�GE CARRIEP ANO POL'�.CY NUMBER ARE: GONSTRUGTION .� _. �.....� � ,�����fL-l-y-,-, c�� �- PIAN REVtEW .__���..-�.x.��— � ,.LI r"_ . ..- CMRIfR._._. - �. .��'� G1 aa.�cvNuraetH_ � ��' ���—�._-_._ - EIECTRIC .__....—_'-....._�— __'��_-L�!-�' a ____�/ -- --- � tTtiFssecrr�dnr�or+��reec:z�n.e'tIDo�i�r�w�rr�wuc�Efn��Wi.�a1'isgiuoloa�tss�. �LUMBING ._ �..__ �.... ----. � I CERTICI THA^'iN TNE PERFOflMANCE OF THE WORK FOR WHICN THIS PCRMIT IS ISSUEC,1 MEGHANICAL y.t..1}-- Z -�.�.-._.. -.....-...._ (,�j wiULLtAT EMPI�Y ANY PERSON INANY MANWER SUAS Zq BEGbME SUl3JECT TQ TNE �-(!G�� � WORKERS'COMVENSATION LAWS OF CALIFONNfA 0 AGREE TMAi IF t S OvtO BEGOME INSPECTION FEE _ _. __1� SUBJECT TO 7NE WORKEqS'COI.APENSATION P �IONS SE fION o0 oF TNE LAOOR � (:OOE I SNALL i/�/�' p7�iW3TN CtzMPtY Wf7H 7 PROVt N ISSUANCE _..� _..._ ... -._. p DATE.���11.� APi1fCAN2 SMIP ._. . .. -_.....--_ _..._-.._- W ENERGY P!C ..... J WARNINf#:FAR.VRE Tt1 SEGURE WOFKENS' MPENSA'fiON COV�' GE IS UNLAWFUL,AND SHALL BE ���J � SU&IECTANEMFIOY�RTOCRtAiMAIPENALT4ESANpqVi�� UPTOCNYEHUNOftEOTNOUSAND ENERGY.PERMYt _ IX:1lUR5(51oo,OW7.UM ADDITION TO THE COST OF COMPE ION,DAMAGES AS PROYI�ED FOF tN ,�] "-� '--"""-- � SECTH?N37fl8GlFTHEIABORC04E,INTEREST,ANDA1"i NErsFEEs. RETE�fIONFGI� �i�� .___�_.�... _.._.....—..._.._ ., � CONSTRUGTION IENDING AGENCY PRE-/�LT FEE'. � � �.._.�......-_�.- ..- C7 � 1 HEREBV AFFIflM UNI)ER PENALTV OF PERJIJR�THAT THERE�5 A CONST%UCTtON LENDWG Al3ENCY �, ..__. 0- FC7R FME P[RFORMnNCE Of THE WORN FOR WHICH'fH15 PERMIT IS ISSUEO(SEC.3oe�,cIV.C.). � � � LL! . _ -.._ ._.� ���^ � IENDER'S f1NAE_�. _—._--_.___. ',r I-�,' LENDER'SADORESS � . - »- T �{/{ C / W1 CERTIFY iHAT I NAVE READ TH1S APPLICATION AND 5TATE THAT TNE A&'JVE�NFORMA'f10N IS CORRECi. I O I f"l�F�C� � ��� t � � i AGf1EE TO fQMPLY WITH AlL GITV ANP COLINTV OFpI'JANCES ANp STATE LAWS RELATING TO BUILbING t�' � C;ON57RVGTipN,RN1}µfR`cIIYAUTHORi2EFEPHESfiNTATiV6S0lTHISCOUNTYTOENtEftUt'OHSME �-- ABOVE•M TICiNED I'ROPERN FtlRINSPECTIUN PUAPOSES. COMMENTS � �..��(/ __. � � �- � PER��RiNi) �"-"�'__ , v �.._ _...__..._. � .._......._-._.-.,,_.._.. CI} �- � IGNATUREOFPEWNITTEE DATE ,��� RECPT.N . P�` �' � �ALIDATIO�� � WHiTE-Oepariment Copy,YE�LOW-Finance Copy.P�NK--Asssssor C , R4D---File Gopy,GflEEN--t4�licanYs Copy __._--...�'-� - �1�"� �►F ��� �� �� �P���E�"CIC�. ���C� �3 i' p� A � M b t,�..�r�i. 4 � Y � � � 1 � �} }� �'�4��y, � �' ,�i F t . � P . .. .. 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Y __ _ . , __. _. �' �4�p ; . � .. . ._..._ .. . _ . ._.... __... ...... . ...... .. ._ . ... ... ... .. .. .. r�� E , � . .�_. _ .. —__.. . _..._ .._ _.. ._.. _,.... . ..._ f, .i. '; . _.. .. _.. .. . .. ,,i +dji � � ? ._ . _...... ......... . ...... ... .. ...... ._ ..... _... ....._ . ......... ... . . ... . . .. ! � . ... . , _....._ ....._ ..,._ __. ..... ...... ...... ..._ .._..... .. . ... F, , € . � .. � ._..._.. , ._..._. , .._. _ _.._ ._.:_ .. ._... .;...... ...... .... ... . ... . .. .. _. . . � � `p � _ .. _ �, ..__. .. . .,..._ .,._._........,�,...�_..,..�. a.....�....m.,....,.�.U..,�.,..�,..._m._�,m,,.._..e.._a.... _...,.�._ __._� ..... ._ .. . ..._ . ._. _ _ ... . ..,. .... . i......�....._...._ m....,:..,.._. . __ . .. .. . . . � CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVE�OPMENT SERVICES 21660 E.Copiey Drive Suite 190 (909)860-3195 Faz(909)861-3117 BUILDING PERMTI'APPLICATION PRESS FIRM�Y JOBSITE� �f,�p�p C��' ADDRESS LOT TRACT APN Ltd OWNER]� ADDRErSC' CIl'Y�-/�'r ZIP TEL. 6 APPLICANT TE�. CONTRALTO ADDRESS CITY dLUrA-ZI TEL ARCH/ENG! 9G DESIGNER ADDRESS CITY ZIP_TE�. OWNER-BUI�DER DECLARATION I HEREBY AFFIRM UNDEA PENA�TY OF PERIURV THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSE IAW FOR THE FOL�IrVING REASON(SEC. 7031.5 BUSINESSAND PROFESSIONS CODE:AIVY CITY OR OWNN WHICH REWIRES A PERMRTO CONSTRUCT,ALTER,IMPROVE, DEMO�ISH,OR REPAIR ANY STRUC. TUBE, PRK)R TO ITS ISSU/WCE.ALSO REQUIRES THE APP�ICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR;iHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRP,CTORS LI- CENSE�AW(CHAPTER D(CX)NIMENCING WITH SECTK)N 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- FESSK)NSCODE)ORTHAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE A�LEGED EXEMP- TKNI.ANV VIOI.ATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUB]ECTS THE gPP�ICANT TO A CIVIL PENA�TY OF NOT NK)RE THAN FIVE HUNDRED DOLLARS(f500).): �I,AS OWNER OF THE PROPERTY,OR MV EMPLOYEES W ITH WAGES AS THEIR SOLE COMPENSATION, WI�L DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SA�E(SEC. 7044, BUSK NEBS AND PROFESSK3NS CODE:THE CONTRACTORS�ICENSE lAW DOES NOT APP�Y TO AN OWNER OF PROPERTY WMO BUILDS O�R IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THROUGH HIB OR HER ONM EMPLOYEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE IF, HOWEVER,THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE V EAR OF COMPLE- TION,THE OWNER-BUI�DER WIL�HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUI�D OR IMPROVE FOR THE PURPOSE OF SALE). ^I.AS OWNER OF TI�E PROPERTY,AM EXCLUSN ELV CONTRACTING WTM LICENSE)CONTRACTORS TO CONSTRUCT THE PROJECT(SEC. 70N, BUSINESS AND PROFESSIONS IX)DE THE CONTRACTORS LI� CENSE�AW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUtI-DS OR IMPROVES THEREON,AND WNO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PVRSUAN'T 1'0 THE CONTRAC- TORS�ICENSE UW.). ^ I AM EXEMPT UNDER SEC. .. B.A P.C. FOR THIS REASON DATE .OWNER LICENSED CONTRACTORS DECIJaRATION I HEREBY AFFIRM UNDEFI PENA�TY OF PER]URY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER D(COMMENCING WITH Sf_CTKN17000j Of DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND MY LICENSE IS W FUL�FORCE AND EFFECT. LICENSE C�P,SS - - LTC. NO. DATE ^.�CONTRACTOR- WORKERS'COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE GF THE FOLLOWING DECLARATIONS: I NAVE AND WII I-MAINTAIN ACETiTIFICATE OF CONSENT TO SE�F-INSURE FOR WORKERS' COMPENSATOV,AS PROVIDED BY SECTION 3700 OF THE�ABOR CQDE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I HAVE AND WIL�MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION 37000E THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY YyCi R'MPEN TION INSUfjGOlCE CARRIER AND PO�ICY NUMBER ARE: CARRIER,�/\� POLICY NUMBER--.-- (I}y,S SFCDOFINEED NOT BF.00NIPL.EITD OF 1HE PEFAYT IS FOR ONE MJM]REO VOLLARS{f100)OR LESS). 1 CERTIFY THA"iN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN ANY MANNER 50 AS TO BECOME SUB]ECT TO THE WORKERS'COMPENSATION (AWS OF CALIFO�NIA,J�yD AGREE THAT IF I S OULD BECOME SUBJECT TO THE WORKERS'COMPENSATK)NP 61SK)NS SE TK)N OOOE THE tABOR �CODE,I SHAL�F T WITH COMPL.Y WITH T PROVI N 1 DATE: � APP�ICANT: I j WARNING FAILVRE TCI SECURE WORKERS'MPENSATION COV GE IS UN�AWFU�,AND SHAL�BE SUBJECT AN EMPLOYf_R TO CRIMINA�PENALTIES AND CIVI�FI UP TO ONE HUNDRED THOUSAND DOLIARS(f100,000),IN ADDITION TO THE COST OF COMPE ION, DAMAGES AS PROVIDED FOR IN I SECTK)N 3708 OF THE�ABOR CODE,INTEREST,AND ATf NEWS FEES. 1 CONSTRUCTION �ENDING AGENCY i 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LEND{NG AGENCY FOR THE PERFORMANCE OF THE WORN FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV. C.). I LENDER'S NAME LENDER'S ADDRESS �I CERTIFY THAT I NAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATKK]IS CORRECT. I AGREE TO COMPLY WITH AL�CITY AND COUNTY ORDIYANCES AND STATE�AWS RE(ATING TO BUI�DING 5 CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE�M TIONED PROPERTY FORINSPECTKJN PURPOSES. 3 IL� { 0 PE RINT) C� �IGNATURE OF PERIMII-fEE DATE WHITE-Department Copy,YE�LOW-Finance Copy, PINK-Assessor Cbpy;'GOC9ENROD--File Copy,GREEN-Applicant's Copy_ �E— �— +-�-mot�� �_�,v<, i� G3G .