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HomeMy WebLinkAbout16149 �����. CITY OF DIAMOND BAR /`G/�.s3c�,�0� _ ~� ---�� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �='2� w 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS �'� BUII.DING PERMIT APPLICATION _y FIRMLY . , _ � .,._ ,,:.,. � JOBSITE i r DATE CAT�ON t PERMIT P/C o ADDRE55��C�L` �`1 lQ� Y�,,,,• �. � J �1 NUMBER .. � � APN LOT TflAC7 �SSUE��� ��` TYPE OCC p fOWNER t��` ���- , DATE CONST. GROUP IADDRESS� ""� S. lr 20NING SETBACKS �o l` RW ❑ CITY i�. �GY t�:t�t-�� ZIP�'��TEL. G `r FRONT APPLICANT TEL. REAR ❑ � SIDE151QE STREET RW ❑ �ONTRAGTOR�G�'�{..bY����� ;�� SIDE ❑ o pDRESS�7�rC� f�F�'7�G1'�`P_C�i;I� ��� T PROPOSED USE rCITY �1'�I�.l�-e�tt11,. ZIP�� �, TEL�Ir��y�5'� c�L7�S o 'ARCFVENG/ Z DESIGNER w NO.DWEL. NO. NO. a AdDRESS � CITY ZIP TEL. UNITS STORIES BEDROOMS � t/� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADD/REM O p I HEREBV AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CON7RACTORS LI- GBfd B/C0 0 11J CENSELAWFORTHEFOLLOWINGREASON(SEC.7031.SBUSINESSAN�PROFESSIDNSCAOEANYCITYOR (n 9 �'P rt (J COUNTYNMICHRE�l11RESAPERMITTOCONSTRUCT,AL7ER,llAPROVE,DEMOLISH,ORREPAIRANVSTRUC- W Patio/Geck � TURE,PRIOR TO IT$ISSUANCE,ALSO REW IRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNEO W STATEMENT THAT HE OH SHE IS LiCENSEO PURSUANT TO THE PROYISIONS OF THE CONTRACTORS Lb � CENSE UW�CHAPTEfl 9 f�MMENCIN�WITH SECTION 7000)OF DIVISION 30F TNE BVSINE55 AND PRO- �'1' POOUSpe FESSpNSODDE�ORTHATHEORSHEISE%EMPTTHEREFROMANDT6IEBASISFORTHEALLEGEDEXEMP- (� TION.ANVVIOIATpNOFSECTIIXJ7n31.5BYANYAPPUCANTFORAPEFMITSUBJECTSTHEAPPGCANTTO Z Re-Roof F, A GML PENALTY OF NOT MORE THAN FNE HUNDRED�OLLARS�5509).�: � ❑I,ASOVJNEROFTHEPROPERTV,ORMVEMPtAYEESWITHSVAGESASTHEIRSOLECAMP[NSATION, 0 CommBfCial - WILL DO THE WORK.AND THE STRUCTURE IS NOT INTENDED OR OFFEiiE�FOR SALE(SEC.7046,Bt151- J � NESS AND PROFESSIONS CO�E:THE CONTFACTORS UCENSE LAW DDES NOT APPLV TO AN OWNER OF � ViiOPERiV Yh10 BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK FIIMSELF OR HERSELF 6R � THROUGH HIS OR HEFiOMM EMPLOtlEES,PROVIOED TNA7 SUCH IMPROVEMENTS ONE NOT INTENDFDOR m QOFFEREOFORSAI.EiF,HOWEVERiHEBU1L01NdORIMPROVEMENTISSOIDWRHINONEYEAROfCOMPI.E- Z TION,THE OWNER-BUILDER WIIL HAVE THE BURDEN OF PROVWG THA7 HE Oq SIIE PID NOT BUILD OR = IMPROVEFOHTHEPURPOSEQFSALE). � ❑I,ASONTlEROFTHEPRO�ERTV,lW1 E%CIUSIVELY:ANTRACTING WITH U^ENSED(XINTRACi0fi5 � TO fANSTRUCT TNE PROJECT(SEC.7041,BUSINESS AND PROFESSIONS CADE:TkE CONTFACTOflS�I� ValUBtbn ADJ.RREA W CEhSEUW�0E5NOTAPPLYTOANO`AMEROFAPPOPERTYWHORUI:DSORiMPqOVESTHEREON,ANO — � WFIOCONTMCTSFORSUCHPRQIECTSWI?HACONTRACTOR(S�LICENSEDPURSUANTTOTNF_CCNTRAG QUANTlTY DESCRIPTION FEE � TORS LICENSF�AW.J. ¢ O I AM EXEMPT UNDER S�C. _8.8 P,C.FOR THI i R£ASON Q � O� ----- V � � DATE OWNER ^ � F- Z — —_ (.� W �q LICENSED CONTRACTORS DECLARATIpN W fL I HEREBY AFFIfiU UNOER PENAI.TY OF PERJURY TNAT I AM UCENSED UNDER FROVISIONS OF CHAPTER � y ;s ,+� p� Y(COMMENCINO WITH SECTION 7000)OF 07VIS�ON 30F THE BUSINESS AND PHOFr'SSIONS COOE,ANO Z 1 "�_�.F. -��%.5�y�]�j�' X MV IICENSE IS IN FlAI FORCEAND EFFECT. LLI /� � J Q LICENSE CLASS �-��J F.+ �{C.NO_ ��I I � ��'• � U �ATE_����/ �� CONTRACTOR ��'✓�L4� ��. d W � � WORKERS'CdMPENSATION DECLAFiATION q i � 1 HEREeV AFFIRM UN�ER PENALN OF PERJURY ONE OF THE FOLLOWING DECLARA770N5: � Q _IHAVEANDW�LI.MAIN7AIkACEFTIFICATE�FCONSENTTOSCLF-INSUREFORWORKERS' Z Q CAMPENS0.TION,AS PPAVIDFO 8V SFCTION 3700 OF TFiE LABUR CO�F,FOR THE AERFORI.IANCE IU Q /OF TFIE WORK FOR WHICH TiIS PERMIT IS ISSUED. � w � � r� IMAVEANOWILLMAMTAINWORKEflS'COMFE.NSATIONINSUFqNCE,ASREOUIREDBYSECTION Q 7)OaUFTHFLA80RCO�E,PoRTHEPERWRMA.NCEOFTHE5Y0RKFORWHICHTHISPERM1T15 ISSl1E�.MY YIORKERS'IX)MpEN5AT10N�I-NrS�UR�ANCE CAfpHIER AND POL.ICY NUMAEF ARE CONSTRUCTION j cnaaieA_�,�'t.��'t Cl�� PLAN REVIEW � POI.ICY NtIMBER_�.'r�'��,L�,�.��,} ELECTRIC Q Q �r�ssti.�N�norsEcx�E�oc�r.�pEqr.aisro�onEriuwaEooaups�E�w}oa�Fss�. PLUMBING � I CF_PTIFY TkAT IN THE PEftFDR1AANCF_OF THF.WORK FOR WHICH THIS PERMIT IS ISSl1ED,I MECHANICAL � SNALLNOT�MVLOYANYPEHSONINANYMANNtRSOASTO�ECOMESUBJ'cCTTOTHE (n WORKEPS'COMPENSATIONlAW50fCA�IFORhIA,ANDACREETHATIFISHOVl.DBECOME INSPECTIONFEE r SUBJEC?'O TF!E WORKERS'C00.1PENSATION PpOVI510NS OF SFCTION 370o OF THE LA20R � CUOE,I SHALL FORTIiWITH COMPLY WITHTHOSE PROVISION. � ISSUANCE � p DATE�'A�� APPUCANT.�� _ __ SMIP _�, J WARNING:FAiLURE TO SECVRE WOPIiERS'COMPENSATION COVERA IS UNLAWFUL,AN�SHALL BE ENERGY P/C _ __ 11 SUEJECTANEMPLOVERTOCqIMINALP'eNALTIESANOCIVILFINESU TOONEHUN�REDTHOUSAND ENERGYPERMIT DOlURS(5100.000�,IN ADDITION TO THE COST OF COMPCNSATIIXJ.DAMAGES AS PROVIDEO FOR IN � SECTION37oeOFTNELA80flCODE,IfJTEREST,ANDATTORNEYSFEES. FETENTIONFEE: a CONSTRUC710N�ENDING AGENCY PRE-ALT FEE: O � IHEREBVAFFIflMUNDERPENAITVOFPERJURVTHATTHEREISACONSTPUCTIONLENDINGAGENCY _ FUR THE PERWRMANCE OF THE WORK FOR WHICH THIS PERM17151SSUE0(SEC.3DB],dV.C.�. Z W -- � LEN�ER'SNAME _____" ___v -- F—' LENOEfl'SADOflE55_ __ ' � I CERTIFV TMAT I HAVE PEAD�HIS APPLICATION AN�STATE THATh1E ABOVE INfaR{AATION IS CAPRECT. TOTA�F E ES �I I at � I AGREE TU COMPLY WITN ALL CITV ANO COUNTY ORGINANCES 0.ND STATE LAWS RELATING TO BUILDING �� { � � CONSTRUCTlON,ANDNERE&VAUiHORIZEREPRESENTATIVESOFtH15COUNTYTOENTERUPONTNE L A804E-MENTKKJEDPROPERTVFORINSPECTIONPURPOSE6. COMMENTS � r y J \ �y p .^°y m --1-�t�4-�--1`��_—_ _—_—___—'_ _— _ Q PE.iMI�EE NAME�PRINT � �� rjjj`yyy�''''jjj � flE0 PERM(YT � DATE� = RECPT.NO. 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