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HomeMy WebLinkAbout14264 (15) .% --____ � CITY OF DIAMOND BAR � DEPARTMENT OF COMMUNTfY dr.DEVELOPMENT SERVICES � ' 21660 E.C le Drive Suite 190 � aP Y (909)8603195 Fax(909)861-3117 PRESS ��'^�� BIJII.DIN PERMIT APPLICATION FIRMLY oN JOBSITE �` APPLICATION PERMIT � L P/C ADDRESS DATE NUMBER M $ ISSUE TYPE pC� APN � O TRA T DATE CONST. GROUP � OWNER � p ADDR SS r ZONING SET6ACKS W CITY Ar __ ZIP EL. F�ONT RW ❑ APPLICANT TEL. FiEAR p SIDE/SIDE STFiEET RW ❑ CONTRACTOR-� L-- �, � SIOE ❑ � CITI( EL'a�l b ZIpYI�I� TEL. D PROPOSEDUSE �� ` ARCHlENG! � DESIGNER NO.DWEL. NO. NO. � CIT1f E� ZIP TEL. UNIT6 STORIES �_BEDROOMS � OwNEFi-BUILDEA DECI.ARATION DESCRIPTION SQ.FT. FACTOR PSF AW.AREANALUATION d SFRfA��/REM 1 MEREBY AFFlfOA Ul�ER VEWLLTY OF PERRIRY THAT I AM EXEMPT FFpM THE OONTMCTOHS ll� GBlE9B/Cel'poR CETISEUWFORTMEFOLL0IMINOREA90N(SEC.'l0.91.68USINESSANDVROfESSION5CO0E:M1YqTYOH (n COUNTYNMICFIREQMRESAVEIiMRTO00NS7Rl1CT,ALTEq,MPpONE,�EMOlJSH.ORREWURANVS7RUC- W Pqtlp/DBCI( 7URE�RIOR TO 1T6 ISSl1MlCE,ILSO REWIRE9 7HE APVLICMR FOq SUCH VERMIT TO FIIE Il SIGNED W iTATEMEM TNAT NE OR SHE IB{JCENSED PUR6UAHT TO TNE PiIOVISIONS OF 7HE CONTMC70H3 11- CENSEtAW�CFIAPTERi�COMMENCINOYMTF/6ECTON7Wo)OFDIYISION00FTHEBUSINESSANDPRO� LL POOIISPH FESSqN500DE)ORIFUITMEDRBHEISEXENM711EREFROMANOTHEBASI9FORTHEALLEOEDEXENP• (� TION.ANYVIOUTIDNOFBECTION7a71.6BYMIYMPLICANTFORAPERMIT5U8JECT5T/1EMVLICANT7� Z Re-Rool � ACIVR PENN.i�'OF NO7 NORE T/1AN FIYE MtMDRE��OLURS(i5a0j.�: OLASONMEROFTNEPqOPERTY,ORMYEMPLOYEESMlITHWAf3ESA5THEIR90LECOMPENSATION, O CommBfCiel WILL DO TME YWHK M7D THE 9TRUCNHE IS NOT MITEIOED OH OFFEREO FOH SALE(9EC.70u,B115i- J NES9 AND PiqFESSIONS CODE:TiIE CONTMCTON9 LICENSE LAW OOES NO7 APPLv TO Ml OWNER OF � � �pOPERTYMM1lOSULDSORIMPROVESTNEREON,ANDW410DOE49UCHWORI(HIMSFLFORIIENSELFOR � TNAOUGH NIS OR MER OWN EMPIAYEES.PIpVIOED T1Y1T BUCH MIPROVEMENTSME NOT INTEN�ED OR m OfFEF1ED FORSN.E IF,HOWEVER7HE BU0.DINOOR MPAOYEMEM q SOLD WffMN ONE YEAROFOOMP�E TION,iHE OVYNER-0UILDER YVILL FUVE 7F1[BURDEN OF PROVNC+TFUR NE OR SHE DIO NOT BUIID pl MPROVE FOR THE PUHPOSF OF BAIE} W Ot�30MMEHOFTHEPROPERTY,MIEXCLU&VELY MCTNOYYRNLICENSEDCONTRACTORS � TO CONSTRUCi7HE PHOJECT(SEC.70µBUSINESS AN �ss�or+s 000e:rHe cartiucTOAs u� Valuatlon �� AQJ.AREA CBISEtAWDOESNDTMPLYTOANOYYHEHOFAPROPE 9UXDSOHIMPRONESTNEREON,MD W1qfriYTpACTSPoR3UdIPND.IECTSWIh1A00HT R �LICENSEDPU0.5UANTTOTHECONTMG QUANT DESCRIPTION TORS\LI_CENSE LAW.} FEE � QI AM IXEMPT UNDEF BEC. B.i P.4 FOR iHiS RE�SON � ''� �� U ZDA7E OWNER U �` LICENSED CONTRA TORS DECLARATIQN W � 1 MEREBY A{'FIRM UN�ER PENALTY OF PE0.N1pV THAT I AM LICEN6ED UNDER PFqVISpNS OF CHAPiER � ��OOMMENCYiON7TH8ECT10N7oo0)OFDMSIONaOFTHFBU51NE55 OPROFESSIONSCOOE,AND Z MY LICENSE t6 Ml R1LL WHCE MID EFFECT. m � ue�se �—3� uc.No. y Z � � wrs I coHnuc� a WORKERS'COMPENSATION DE RA ION a � I NEREHY AFFlRM Id10ER PENKn OF PERIURY ONE OF ME FOLaWING DECLARATpNS Z � �IMAVEANDWN.LMAINTAINACERTIFICATEOFCONSENTTOSFLF-INSUREFOAY/ORKERS' a � COMPENSIRpN,AS PROVIDED BY SECTION 7T00 OF iHE V80R CODE,FVN TME►ERFORMANCE W OF 7ME WORK FOR MlHICN THIS PERMIT IS ISSUED. � , � _I HIV/E AND Wl1 MANTAIN NfORKERS'CdAPENSATION INSl1FUNCE,AS REOUIqED Bv SECTION a70o OF TME UBOR ODDE,FOR TME PERFORMANCE OF THE WOPoC FOH WHICH 7HIS PERMR 13 �S• O � 159UED.M'WOflNER3'COMPENSATpN INSURANCE CARRIER�lID POLIGY NUMBER ME: CONSTAUCTION > C+�RRIER PLAN F[YIEW � ra.wrr�uMSER — ELECTRIC � (n�saEcnor+r+��aem.s�erIDocnf srnaa+e�moouar�s�+aoloa�essF PLUMBING �q�, ICERTIFYTHIITINTHEPERfOHMANCEOF7H RKFORWNIdIMI5PENMITI5155UE0.1 MECHANICAL P ��' �� (� SNALL NOT EYPIAY ANY PERSON I Y MAN 50 q5 i0 BECOME 9U&IEGT TO THE ��5,� (n riOR1�R'COMPENSA710NUW50 IFO AHD116PEETHATIFIS/10UlOBECOME INSPECTIONFEE S E 7HE M/ORKEN9'COMPE TIDN P 1 S OF SECTION 9700 OF THE 1A80H _ E.I Ny1FOA7MWITMCdJPLY Ti0 � SIONS. ISSU/wCE p OATE: I �l� APPLIC/WT. SMIP �O� "t � � , „ WARNINO. URET06ECUREWORKERS'COM NSATIONCDVEFIVOEISUNLA4VFVI.ANDBHAL�BE ENERGYP/C �y SUBJECTNI P�OYERTOCRIMINALVENALTIE9ANOCIYILFINE3UPTOONEMINDREOTlIOUSAND ENERGYPERMIT OOLLARS(f 700.000).W ADORION TO 1NE COST OF CDYiENSATION,DAMApES AS PqOVIpEO FOR IN � 9ECTIDH77MOFTHELABOHCODE,WTEREST,ANOAiTOHNEV'BFEEB. RETENTIONFEE: � CONSTRUCTION LENDING AGENCY PRE•ALT FEE: � INEREBYAFFIRIAUNOERVEN�LTYOFPER.R/RViHATTNEREI5ACON5TRUC'fqNkENDINGA(iENCV Z FORTXE PERFORMANCE OF 7HE WORK FOR YVHIp/TFIIS 7ERMIT IS ISSUEO(SEG 9oW.pV.G). W � LENDERS WIME F— LENDER'SMORE99 � I CERTIFY TNAT I HAVE READ TMIS APPLICATION�NO STATE 7MAT THE ABOVE INFOWIATION IS CORRECL TOTAL FG ES O�O I A(iPEE TO COIAPLY N7TH ALICRY 1WD COUNTY Oii�NANCESIWO iTATE LAWS REUQING TO BURD�NO 'R OONSTRUCiION,►NDHEREBYl1U7FIORREREPflESEMATIVESOFTW6COUNTYTOENTEflUPONTNE � ABOVE-MEMqN�PHOOEflTY FOR WSPECTION PURPOSES. 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