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HomeMy WebLinkAbout13659 CITY OF DIAMOND BAR � f��� �----��---� DEPARTMENT OF COMMUNYTY&DEVELOPMENT SERVICES .�' ~� � ' �� 2t660 E.Copley Drive Suite 190 '��--''��'y PRESS (909)860-3195 Fax(909)861-3117 ��p�'�,� BUILDING PERMIT APPLICATION FIRMLY � JOBSITE / f�oG APPLICATION/ PERMIT� PlCC�q_2v ¢o ADDRESS II(9 /" k�IVE12 �� DATE b I� NUMBER # 1 c� ISSUE � TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER _�2 zf Mti� �'Et.FEK a ADDRESS ,rpMf As �eJ� _ 20NING SETBACKS w FRONT ___ RW Ll____ CiTY t �..onr> gA.� ZIP�C ,� TEL. � ��_(�tJ �j APPLICANT _ �,o.J ��N�%�l TEL.714-R"!1-�fF75 REAR I.I SIDElSIDE STREET RW fl � � CONTRACTOR L�1M.�Sr u.r�� l�/X� i�I't�n s _ SIDE L_ ____ � AODRESS '�7�5 S. STs9r�c !'�_�� tt.k�� �Z pROPOSED USE C � �pP�� .1CR o p CIIY �!II{af.(vn ZIP�� 7EL. � _�c��SS,l�_� �3 �, ARCH/ENG/ � G3� Ar�i.wvc� 7l��87i-�f/FoS' �— q z DESIGNER — NO.DWEL. NO. NO. � ADDRESS — — UNITS __ STORIES BEDROOMS_ _ � � CITY — ZIP TEL. y DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREr1NALUATION � � OWNER-BUILDER�ECLARATION SFRlADD/flEM : O � � I HEfiEBY AFFIRM UN�EIi PENALTY OF PE0.IURV THA7 I AM E%FlAVT FROM THE CONiRACTOqS LI- GflldgB/CafPOfl 1 W CENSEUWFORiHEFOLLOWINGREASON(SEC.7037SBUSINESSANDPROFESSIONSCODE:ANYCIT'OR (n U CWNTYWHIGHREWIflESAPEflMfTTOCCySTflUCT,ALTGR,L41PflOVE,DEMOLISH,ORREPAiflANYSTAUC� �j,� (�y�i0/Ded( � W TI1RE,DRIOR TO I751SSl1ANCE,ALSO REOUIRES 7HE APPLICANT FOR SU(k{pERMIT TO FILE A SIGNED W 1 � STATEMENT 7HAT HE OR SHE IS LICEN6E�PUR6UANT TO THE PflOVISIONS OF THE CONTRACTOR5 LI- � ���SSS CENSE LAW(CHAPTEfl 9(COMMENqY6 WITH SECTION 7000)OF[lIVI510N 30F il1E BUSINE55 AND PHO- LL Po0USP3 — � � FESSIONS�E)ORTHATHEORSHEISEXEMPTTHEREFFOMAN�THE�ASISFORTHLALLEGEDEXEMP- (� - TION.ANVVIOLATIONOFSECTION70.91,SBVANYAPVLICANTFORAP'cPMITSUBJECTSTHEMPLICANTTO � Re-Roof r � AGIVIL PENALTY OF NOT MOHE THAN FIVE HUNDRE[7 OOLUIRS($5tl0)): � � uI,ASONRJEROFTHEPROPERTY,ORMYEMPLOYEESWITHWAGESA57HEIR50LECAMPEN5AT10N. � CommefCial _ W1LL DO 7HE WORK,AN�THE STRUCTUkE IS NO7IN7[NOFD OR OFfERED FOH SAI�(SEC.704e,BUSI- J--- NESSAND PROFESSIONS CODE:THE CONTRACTOfiS LICENSE LAW UOES NOi APPLV Tn AN OWNER OF j 7 � PROPERTYYAfOBU1LDSORIMPFOVESTHF.REON,ANDVRiO�OESEUCMWORKHIMSELFORHEP.SEIFOH _ � TNRd16HHISORHERONR.IE/AVLOYEES,GFOVIDEUTHATSUCNIM7ROVFMENTSAR[NOTINTENUFDOfi m � � �FFEREDFORSALE.IF,HOWEVER,TiEBUILAINOORIMPROVEMENTI550LOW11'HINONEYFAflOFCOMPLE _ __ _ TION.YHE OWNEH�BUILIIER WILL HAYE TME tlUR�EN OF Pf10VING THAT h1E OR SHE DID NOT BWtD OR } = IMPROVEFORTHEPURPOSEOFS�L.E� g W �7�,ISOWPIEIYOF7HF.Pfl6NER1Y,AMEXC�U61�lELYCOMRACTINGWITHLICENSEUCOhTRACTOHS � ��� D � TO CONSTRUCT TME PR0.IECT(SEC.7oM,BUSIhE55 PND PROFESSI0Y5 CDDf::THE CUN7R�CTOR5 LI� V8W2110l1 AOJ.AREA 3 s CEN3EUWQOESNOTAPPLYTOANUWNEROFA7ROP'cRTYWH08UILDSORIMPfiOYfiSTHERCQN,AND � � WFIOCAN7RACTSFORSUCHPPQIECTSWITHACONiRACTOR(S)LICENSEDPUI75U.'�VTTqTHECOMRAC- QUANTITY DESCRIPTION FEE Y TORSUCENSEUW.). _ . �-- � � _ -____ � Q �I AM EXEMPT UNDER SEC.__�___ B.8 P.C.'roA 7HI5 HEA50N � U ��+ �.�TS 3 - - � ___� S � � onre _owneA-------._....------ ---- _� 5 tu w �L �' LICENSED CONTFACTURS DECLARA710N W I � � IHEREBYAFFIRMUNDEFlPENALTYOFPER.IURYTHR"IAMUCEtr5E0'JN�EFiPROV15iGY50FGItAP1ER t— j �d- B(WMAIENCWC�WITHSECTION700a)Oi01JIS!ON30FTHEBUSINESSANUPHaFE5510N5CODF.AND ��_ � >G MV UCEN3E IS IN FULL FORCEAN�EFFECi. m� �j ua ia" O UGENSE CLASS_ � LIC.NO.���7��_._____ � t V DATE�� r� __ CONTI�ACTOR.�M(}.LkA/� Nf � � 4. a W � ' � �� WORKERS'COMPENSA710N DECIARATION � � = U --- $ � I HEFEAV AFFlPM UNDER PENhLTY OF P'cPJUHY O4E OF THe fOLLOWING DECLARATIDNS: � � a O IHAVEANDWILLMAIN'fAINACEHTIFlCA7EOFC04SF.NTTOSELF-INSUREFORV✓ORKERS' 7'�- � � COIAPFNSATION,AS PROHI�FD 6Y SEG?ION 3]�Of TNE LAB09 CODE.FOR THE PFRFORMANCE U ________.___ — a' OFTHEWOPKFOHWHICHTHISPERA9ITISISSIJE�. W W �IHAVEANDWILLMAIMAINWOHKEHS'COMPENSAiIOVINSUflAVCE.ASREQUIFtEDBV£ECT:qN �� � Q 37oaOFTHElA60RCOUE,FORTHEPERFORMANCEOFTHEWORKFOAWHICHiHISPERMITIS ' � 0. ISSUED.MY WORKERS'COMPENSATION INSURANCE CARRIEFi AN�POLICV NUMBEH ARe: CONSTf�UCTION ' _ ., , ,_.__ ._ � �'=L�� �_ ��-e_" � s'� ti PLNN HEViEVJ �,-�-�---�.- - - ---- -. � CAFRIER._._"' jq� S��n-_"'_-..""_.----- .."_' "__'___' '- z POLICY NUMBEH_"7—KEJ�S�'7--�—�JI --.....-----.---....._.__.. /� � -�-�� ELEC7'RIC ----�—� � ---— —�L�� Q -"l---- ( �. (iH155ECTpNNFfDNOTBE�RSr3fTmOFh+EPLf4ATIStURONEF+UrYMEDDOLIARS(57001Q`1L�5} PIUMBING _______ ._ ..Z: ICERTIFYTHATIYTHEPEflFOFMANCEOFTHEWORKFORWHIf.HTHISPERMITISISSUED,I MECHANICAL __ ...______ �(}�. SHALLNOT EMPLOYANY PFHSO4IN ANY MA4NER SO AS TO BECOMf-5:!!3JF.CT TO T � �� � WORKEflS'COMPENSATIONLAWSOFGLIF(�RNIA,ANUAGREETHATIFISHOULD ECOME IN5PECTIONFEE __ ______._.� � SU&IECT TO THE VIUHKEflS'COMPEN5ATION PHOVISI(NJS OF SFCTION 3l0o OF THE LABOF O COOE.1 SHALL FORTHWITH L'OMPLY WITH "F'HOVISIONS. IbSUANCE _ � _._..._ � DATE:�p�C_(- 11PPLICNNT. � ` SMIP L "''—'_'_-'__ -_ J � � ENEFGY P/C _..._... . _ .I J WARNING:FAILUR[TO SECURE WOflKERS'COMPENS�TION CAVEIiAGE IS VNLAWFUL,AND SHAIL BE '--"' " " '- -- ""'--"- �y SU&IECTANEMPLOYEHTOCNIMINAI.PENALTIESANDCIVILFINE.SUPTOONEHl1NDRE0THOU5AN� ENEHGVPERMIT DOLLAFlS(i10o.o00),IN ADDITION TO THE COST O�COMPENSATION,DAMAGES AS PROVIDE�FOq IN -- -� �� � -- ------- --� ---�-------1-��-��-J—�] ¢ SEClION37080FTHELA60FiCODE,INTEREST,�NDATTORNEYSFF.ES. AETE YIONFEE: _.__ „ ._ _,� --.-...,......__. 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