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HomeMy WebLinkAbout12169 (6) _ 1�� CITY OF DIAMOND BAR . DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 216b0 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 � ��� PRESS "*" BUILDING PERMIT APPLICATION FIRMLY �� JOBSITE !!��►�% �. �I�r J ��r�� APPLICATION� � 7 PERMff� I/�� P/C ADDRESS t� � v 4— G • � DATE �A' � NUMBER a-•✓1 1��� # $ ISSUE E ' TYPE OCC APN LOT RACT DATE CONST. GROUP � OWNER O — � ADDRESS /' � ZONING SETBACKS � CITY ZIP - TEL. '� FRONT Ry1/ ❑ __ APPLICANT TEL. REAR ❑____ � SIDElSICE STREET RW ❑ __ � COtdTRACTO SIDE ___ ❑___.,____ � ADDRESS � CITY ZIP TEL. PROPOSED USE w ARCHlENG � z DESIGNER — — W — NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � � CITY ZIP TEL. <n DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � p� OWNER-BUILDER DECLARATION SFR/ADD/REM O I HEREBV AFFIRM UNDER PENALTY OF PERJUHY THAT I AM EXEMPT FROM THE CONTMCTORS LI� GHf898/CBfPOfi » W CENSELAWPORTHEFOLI.OWINGRE0.SON(SEC.7031.581J51NESSANOPROfESSIONSCADE:ANYCITYOR (n � C.) COl1NTVNMICIiREWIHESAPERMRTOCON5TRIICT,ALTER,IMPROVE.OEIAOLISH,ORREPAIqANY57AUG �J,f pgI10/DQCI( W TUflE,PRIOfl TO IT6 ISSUANCE,ALSO REOUIRES THE APPLICANT FOR SUCH PEFMIT TO FILE A SIGNED W SiATEMENT TMqT ME OR SFIE IS LICENSED PURSUANT TO TME PROVISIONS OF TME CONTRRCTOflS LI- � CENSE UW(CHAPTEH B(COMMENCINO WITH SECTIDN 7000)OF DIVISION 90F THE 61151NES5 AND PR0- V' POOVSP3 — �� FESSIONSCODE)ORTHATHEORSHEISEXEMPTTH[flEFflOMANUTHEBASISFOflTHEALLEGEDEXEMP- (� V TKKtl.ANYVIOLqTIONOFSECTION7o31.5BYANYAPPLICANTFORAPERMITSUfUECTSTHF.APPLICANTTO Z Re-Roof � ACIViLPENALTYOFNOTMORE7HANFNEHUNOREDDOLLARSIS500).): � UI,AS0Y4NEROFTHEPROPEiiN,OqMVEIAPIOYEESWITHWACESASTHEIRSOLFCAMPENSATION, 0 COfiIfflBfCi81 YIILL 00 iHE riK7RK�ND TME STHUCTURE IS NO7 INTENDED OR OFfEREO FOR SALE(SEC.70M,BU51- J � NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWMEH OP ? PqOPERTY WHO BUILAS OP IAiPROVES THEFF.ON,AND WHO OOES Sl1CH WORK HIMSFLF OR HEHSELF OR � 7Hq0UpH11150RHEROWNEMPLOYEES,PROVIDEDTHA7SUCHIMPROVEMENTSM1FENOTINTENDEDOR m O ,OFFERE�WRSALEIFHOWEVEfl,iHEBUIIDINGORIMPftOVEMENTISSOLDWITHINONEYEAROFCAMPLE- Z TION,7HE OWNERAUILDER WILL MAVE THE AUflDEN OF PROYING THAi HF OR SHE OI�NOT BUILO OR � IMPROVEFOftTHEPURPO5EOF5ALE�. W C71,ASOWNEROFTHEPROPEHTY,AMEXCIUSNELVCANTRACTINGWITHLICENSEDCAMflACTOqS � TO CONSTRUCT TH[PRQIECT(SEC.7W<,BUSINESS AN�PROfES510N5 CADE THE CANTRACTORS LI- V8I11£111011 ADJ.AREA________.._._,__ WS CEN&EUWDOESNOTAPPLYTOPNOWNEROFAPROPERTYWH00UILDSORIMPROVESTHEREON,AND - F WFIOCONTMCTSFORSUCHPR0.IECTSWITHACONTflACTOR(5)LICENSEDPURSUANTTOTMECANTRFG QUANTITY DESCHIPTIDN FEE � 7DNSLICENSEUW.). u 1 AM EXEMYTUNDER SEC._______,_______,_ B.8 P.C,fOR THIS REASON Q � —_--- _'_ ---__'__"_ U !t_ � �ATE ONMER U W O LICENSED CONTRACTOAS DECLARATION W � � � ._.�._ �r '� I HEREBV AFFIN/A IIN�ER PENALTY OF PE0.1l1RYTHAT 1AM LICENSED UNDEfl PROVISIONS 0F CHAPTER � ' / ' � �Q� 8(COMMENqNf3 YYI7N SECTION 7000)OF DIV1510N 90F THe BU5INESS AND PHOFESSIONS COUE,ANU /' X MYLICENSE IS IN FULL FORCEAM1D EFFLCT. lL .�'° � 0 LICENSEC�6p��� LIC.NO. � � x J V DATE__,y CONTRACTOR d W � WORKERS'GOMPENSA710N DECLARATION a � IHEREBYAFFIRMUNDERPENALNOFPERIURYONEOFTHEFOLLOWINGOEGUflATIONS. � vj Z Q � IHAVEANDWILIMAM1�TAINACEHTiFIChTEOFCONSENTTOSELF-INSUHEFORYIOHKEfiS' � � COMPENSATKKJ,ASPHOVIDEDBYSECTION37000FTHELA90FCWE.FOPTHEPERFORMANCF W n� OF THE WOFK FOR WHICH THIS PERMIT 19155UED. � � .A. IHAYEANDWILLMAINrA44WORKERS'COMPENSATIONINSURANCE,ASREOUIFEDBVSECTION � 7T 37000FTHELABORCOOE,FORTHEPERWRMANCEOFTHEWORKFORWHICHTHISPERMITIS 0 ISSUED.MY WOP ERS,�'ryCO PEN ATION INSURANCE CARRIER I POUCY NUMOEfl ARE: CONSTRUCTION J __—__..... _ � CARRIER (! � �� PLANREVIEW ----,------.--.-- � VOLICVNl1A18EN EIECTRIC j( J-�gf}� � (MISSECTpNhE�NDTBE00A1P1E7E�OFTVEPEP1JnISfOi1�NEMMAiEDDOL1Ni5(St0010RLESS). PLUMBING _ __._—"'—�° '� �✓ Z ICER7IFYTHATINTHEPEHFORMANCEOFTHEWORKfORWHICHTHISPEFiMITISISSUEO,I MECHANICAL � .._____.___-�____, ('}' SHALLNOT EMPLOYANY PERSON IN ANY MANN[R SOAS TO BECOM[SIJBJF.CTTO THF �(n WOFKEHSCOMPENSATIONLAWSOFCALIf-ORNIA,ANDAGREETHATIFISHOULOBECOME INSPECTIONFEE __ __.___ ,��" ej.� � r Sll&IEC770THEWORKEHS'COMPENSATIONPROVISIONSOFSECTION370DOFTHELABOR �f/� � �,DE, SHALL FO THWITH COMPLV WI7H THOS'���P/r�JnS N5. ISSUANCE ,,.,____. ___�_G % a/ _ �� �� :�/ //����. SMIP �p DATE: AP%.ICANT: __� s --�-� '—"��-�---� �' ENERGY P/C ---,--.- -,-,--- � WAPNING: AILURE To SECURE WOFKERS'COMPENSATION COYERAGE IS UNLAWFUL.AND SHALlOE '�" SUBJECTANEMPLOYERTOCFiIMINALPENAITIESANOCIVILfINESUPTUONEHUNDPEDTHOUSAND ENERGYPERMIT DOLLARS�570o.a0o).�N ADDITION TO TiE COSTOF COMPENSATION,DAMAGES AS PROVIDEU FOR IN — --�-----�-- ------�---�-- J SECTION3]oBOFTH[�ABOfiCO�E,INTEREST.AN[7ATTOHNFV'SFEES. RETENTIONFEE: �. _"'_"--__'_"_'— O CONSTRUCTIDN LENDING AGENCY PHE-ALT FEE: �� __ � +°'�T, r� '� ;� I HEREBY AFFIRM UNDER PLNFLTY OF PEflJUHY THATTHERE IS AGONSTflUCTION LENDING AGLNCY f d ____ FORTHE PERFORMANCE OFTHE wORK fOR WHICH THIS PEHMIT IS ISSUED(SGC,3097,CIV.C.). Z � W :�• LENDER'SNAME _ ._'___ __ �'_' _ _ __"__ _"�i F— LENDER'S1D�RE55___ _._—__._--_-- �� ICERTIFYTHATIHAYEREADTMISAPPLICATIONANDSTATETHATTHEABOVEINFORMATIONISCORflECT. 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