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HomeMy WebLinkAbout17185 CITY OF DIAMOND BAR ' T �-- �``' - DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � I � 21825 E.Copley Drive � ry+�` (909)860-3195 Fa7c(909)861-3117 PRESS �9���� BUILDINGPERMIT.APPLICATION FIRMLY � JOBSITE � �j �i.f:j s �C�i�� ' �C. S�L. APPLICATION PERMIT P/C o ADDRESS_ DATE C1 NUMBER�7I�S # °r APN LOT_ TRACT �SSUE TYPE OCC DATE CONST. GROUP p OWNER ti I p ADDRESS p� " ZONING SETBACKS z CIN ,�J- �= ZIP TEL. f '' FRONT R1�I ❑ o APPLICANT GYI��+►�'A�'�1 TEL!/� � �, REAR ❑ z -'�� SIDE/SIDE STREET RW ❑ m CONTRACTOR J�w �J SIDE � `� ADORESS �0.� � CITY L ' (.�fr ZIP y� �TEL. PROPOSED USE�� '� T� t'��e N'�V oARCH/ENG/ �� N M ' �z DESIGNER � NO.DWEL. � NO. NO.�I W. � � ADDRESS_� UNITS STORIES BED OOM �+� � = CITY ZIP TEL. cn -- cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BLIILDER DECLAFATION SFRlADD/REM O p I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI� Gff13J0/CB�POf[ W CENSELAWFOR7HEFOLLOWINGREFSON(SECJ031.SBUSINESSANDPROFESSIONSCODE:ANYCITYOR (n U COUNTYWHICHFEOVIRESAPERMITTOCONSTRUCT,ALTER.IMPROVE.DEMOLISH.ORREPAIRANVSTRUC� W P0t10/D2Ck W TURE,VRIOR TO ITS ISSUANCE.ALSO REQUIRES THE APPLICANT FOF SUCH PERM;T TO FILE A SIGNE� W � STATEMENT THAT HE OR SHE IS LICENSEO PURSUANT TO THE PROV:SIONS OF THE CONTRACTORS ll� CENSELAW�CHATER9(CAAAMENCINGWITHSECTION700D�OFDIVISION3OF7HE9USINESSANDPPO� LL POOUSPB � FESSIONSCODE)ORTHATHEORSNEISEXEMPTTHEREFROMANd'THE9ASISFORhIEALLEGEDEXEMP� (� V TION.ANVVIOLATIONOFSECTION7031.58VANYAPPLICANTFORAPERMITSl1BJECTSTHEAPPLICAMTO z Re-Roof ACIVIL PENALiV OF NOT MORE THAN FIVE Hl/NDREO�OLL4R5(5500).): � ❑I,ASOWNEROFTHEPROPERTY,ORMVEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSqTIDN, � COrt1(i1BfCl&i Z WILL 04 THE WOFiK,AN�THE STRUC7URE IS NOT INTENDED OH�C/Ff'ERED FOR SALE(SECJo44,BUSI- J � NE55 AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW�DOES NOTAPPLY TO AN OWNER OF PROPERTVNhi08UILD'$�OF�IMPROVESTHEREON.ANDIM-IODOE5SUCHWORHHIMSEI.FORHERSELF'oR � 2 THROUGHHISORHEROWN'EMPLOVEES,PRDVIOEDTHATSt1CNIMbROUEIAENTSARENOTINTENDF.D'OR m � OFFERE�FORSALEIF,HOWEVER,7HEBUIL�INGORIMPROVEMENTISSOLDWITHINONEVEAROfCOMPLE Z TION,THE�OWNER-BUILDER WILL HAVE?HE BURDEN OF PROYMG'TNAT HE OP SHE DID NOT OUILD,OR � IMPROVEFORTHEf'GRPOSEOFSALE). ''�-`'� -'- w ❑I,A90WNEROFTHEPROPERTY,AMEXClU51VELYCONTRACTINGWITHLICENSE�CONTRACTORS � TO GONSTflUCT THE PAOJECT(SEC.7oqa,BUSINESS AND PROFE$SIONS CADE�.THE CONTRACTORS LI� VeIt18ti011 � - ADJ.AREA W CENSELAWOOESNOTAPPLYTOANOWNEROFAPRO�ERTYWHOBUILDSORINPROVESTHEREON,AND � WHOCONTRACTSFORSUCHPROJECTSWIiHACONTRACTDR(S1CIL`ENSEOpURSUANTTOTHECONTRAC� QUANTITY DESCRIPTION FEE Y TORS LICENSE LAW.). � D I AM EXEMPT UNOER SEC. B.6 P.C.FOR THIS REASON Q � J U � � DATE a ,t� �� OWNER f � W � LICENSED CONTRACTORS DECLARATION W Q � I HEREBYAFPIRM UNDER PENALTY OF PEFJURY THAT I AM IICENSEO UN�ER PROVISIONS OF CHAPTEP �, • a. 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 0F THE BUSIN�SS�ANb`pROFESSIONS CODE,AND Z X MV LICENSE IS IN FUIL FORCE AN�EFFECT. �� � UCENSE CLASS �%�� LIQ NO.�]`�_�_�/ � j V DATE '�� Q�y CONTP,ACTOR OJ. W � WORKERS'COMPENSATION DECLARATION � � I HEREBV AFFIRM UNDEF PENALTV OF PERJURV ONE OFTNE FOLLOWING DEC'.ARATIONS: Z z _I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT 70 SEIF-INSLIRE fOR WORKERS' _ Q CAMPENSATION.ASPROVIDE�BYSEC710N37�OOP7HELABORCODE.FORTHEPERFORMANCE U Q OFTHE WORK FOR WHICHTHIS 7ERMIT IS ISSUEO. ,� �w _I HAVE AND WILL MAINTAIN WORKEFS'COMPENSATION INSURANCE,AS RE�UIREO BY SECTION 370o OF THE LA�OFI��CODE,FOR THE 7ERFORMANCE OF TFf�4VbRK FOb WHICH THIS PERMIT IS 'q �,C� J ISSUE�.!dY WORKEAS'COMPENSATION INSURANCE C0.RR(ER 0.N0 POLICV NUMBER ARE: CONSTRUCl1ON ��,(,,i � CARRIER PLAN REVIEW Z POLICYNUMBEF ELECTRIC Q �jr� - ISSE NEmNOTBE�OMPLE'EDOFTHEPERMffISFORIXJEHUNDReDDOLLARS(S10a10RLES5). PLUM8ING . ...._...'_'_"'__' Z ICEFTIFYTHATINTHEPERFORMANCEOFTHEWORKFORWHICHTMSPERMI7151SSUED,1 MECHANICAL *"�'"� I �� !�S SHALLNOT EMPLOV ANV PERSON IN ANY MANNER SO AS TO BECOIv1E SUBJECT TO THE � ' � �• � , WOFKERS'COIAPENSATION LAWS OF CALIFORNIA,AND AGpEETHATIF I SHOIJ�D BECOME INSPECTION FEE _ �' SUBJECTTOTHEWORKERS'COMPENSATIONGROVISIONSOFSECTION37000FTHELABOR CODE,I SHALL FORTNWITH COMPLY WITH TI'OSE PROVISICFIS: � ISSUANCE � � �y� . � .�� p �ATE: "� r�� APPLICANT: �✓ "�� SMIP � WARNING�fAIIURETO SECURE WORKERS'C041PENSATION COVEqAGE ISUNLAWFUL,AND SHALLBE ENERGY P/C � �^^ `��� __ � SUBJECTANEMPLOVERTOCRIMINALPENALTIESAN�CIVILFINESUPTOONEHl1NOREOTHOUSAND ENERGYPERMIT g''��—�"'"m'�`"-�.T'�-� � OOLLARS�51o0,00o�,INADDITIONTOTHECOSTOFCAMPENSATION,DAMAGESASPROVIDE�FORIN ��"`�""""'�" ��`��"�'"��'��"�'- � J SECTION 9708 OF THE LABOR CODE,INTEPEST,AN�ATTORNEY'S FEE9. �� �n p� fiETENTION FEE: OCONSTRLICTION LEN�ING AGENCY PRE-ALT FEE: � I NEREBVAFF�qM UNOER PENALTV OF PERJURV THATTHERE IS A CONSTRUCTION LENDMG AGENCY FOR THE PERFORMANCE OF THE W ORK FOR W NICH THIS GERMIT IS ISSUED(SEC.3097,CIV.C.). Z W � LENDER'S NAME F— LENDER'SADDHESS � TOTAL FEES � W ICERTIFVTHATIHAVEREA�THISAPPL�CATIONANDSTATETHATTHEABOVEWFORMATIONISCORRECT J�7„ � I AGREE TO COMPLV WITH ALL CITV AN�:AL'NiY OqDINANCES AND STATE LAWS RELATING TO BUI�OING � CONSTRUCTION,ANDHEREBVAUTHORIZEREPRESENTATIVESOFTHISCOUNT'TOENTERUPONTHE z ABOVE-MENTIONEDGROPERTYFORINSPECTIONPURPOSES. COMMENTS O ��F���v'X.+� 'V � QPERMIiTEE NAME�PRINT) a, ,,,�,. �o.._.�l_ J � SIGNA7URE OF P MITTEE DATE _ � � ��'�' ' RECPL NO. PAID BY VALI�ATION_� ~ ' �- � WHITE—Depsrtmen[Copy,YELLOW—Finance Copy.PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanYs Copy ; � � .. .., . . .. . .. ......� .:;,•,: ,..,,. , . � , . . � ., . ,. � . , , ,. ��..,�: �� � � �����,a�� .i� �� �;�;����� �o�� � ��*_ °� .�`m,�„� �.��';. �� ��� .�� ., � .� � ��M'';� s� , „;� �.: .�"'�� ��8;. 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