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HomeMy WebLinkAbout16297 ��!���� _�.,,� CITY OF DIAMOND BAR G���o�/ � ° "' DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICSS �%(:/ a 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS ����'�f BLIILDINGPERM APPLICATIUN FIRMLY o� JOBSITE � ���,'A,�j�- � APPLICATION � y..t Gy� PERMIT r„ � P/C ADDRESS E�'"� ��� DATE Y� NUMBER IV # � APN OT TRACT ISSUE v TYPE OCC �..L ��� DATE CONST. GROUP p OWNER ��I�?R'�. o ADDRESS S��� — ZONING SETBACKS W CITY�.1�/Aq,Q/tC/f1� ZIP��L...f� G... 61� FRONT RW ❑ � APPtICANT TEL. REAR ❑ � SIDFJSI�E STREET RW O � CONTRACTOR �G . SIDE CI � AD�RESS - PROPOSED USE L�" ��-1� CITY • ZIP���TEL. o ARCH/ENG/ � DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � v� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADD/REM O I MEREBY AFFlRM UNDER PENALTY OF PERJURY TMAT 1 RM EXEMPT FROM THE CONTRACTORS LI� G2f290/C3fPOfi W CENSELAWFORTHEFOLLOWINOREASqJ(SEC.7031.5BUSINESSANOPROFESSIONSCODE:ANYCITVOR (n C.7 COVNIYWHICHREQUIflESAPERMRTOCONSTRUCT.ALTER,�MPROVE,DEMOUSH,ORREPAIRANVSTRUG u NflE.PRIOR TO ITS ISSUANCE.ALSO RE�UIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w Pdfio/DeCk STATEMENT 1YIA7 HE OR SHE IS UCENSED PURSIIANT TO THE PROVISIONS OF THE CONTqACTORS LF � CENSELAW(CHAPTERB(COMMENCIN�WITHSECTION7000)OFDIVISION30FTHEBUSINESSANOPRQ � Pool/Spa FESSIONSCODE)ORTHA7HEORSHEISEXEMPi7HEREFROMANDTHEBASISFORTHEALLEGEDEREMP- (� TION.ANYVIOLATN>NOFSECTION7o37.5BVANVAPPLICANTFORAPERMITSJ&IECTSTHEAPPLICANTTO Z Re-Roof � ACIVIL PENALTY OF NOT MQRE 7HAN FIYE HUNORED�OLlAii3(5500).): � ❑I,ASOWNEROFTHEPROPERTv,ORMVEM7LOYEE5W17HWAGESASTHEIR50LECOMPENSATION, � CommefCial � WILI DO THE WORK.AND THE STRUC7URE IS NOT INTENpED OF OFFERE�FOR SALE(SEC.7044,BU51- J � NESS AND PROFESSIONS COOE:THE CONTtiACTORS LICENSE LAW DOES NOT APPLY 70 AN OWNER OF � PROPERN Vv}i0 BUROS OR IMPROVFS THEREON,AND WHO�OES SUCH WORK HIMSELF OR HERSELF OR CL THROUGHHISONHEROWNEMPLOYEES,PHOVIDEDTHATSUCHIMPROVEMEMSARENOTINTENOEOOR m �1 OFFEpED FORSALE IF HOWEVER TME BUILDING OR IMPfiOVEMENT IS SOU7 WITNIN ONE VEAR OF CAMPIE ' �710N,hfE AWNER$UIIAER WILL HAVE THE BUAOEN OF PROVING THAT HE OR SNE DID NOT BUILD OR W IMPROVEfORTHEPURPOSEOFSALE). _ ❑I,AS OWNER oF THE PROPEHTY,AM E%CIUSIVELV COMRACTINCa WITH LICENSED CONTRAC70R5 � TO CONSTRUCT THE PFiQ1ECT(SEC.)044,9USINESS ANO PROFESSIONS COCE:TNE CONTRACTORS ll- VBIUaSlO[I ADJ.AREA_ W CENSELAWOOESNOTAPPLYTOANOWNEROFAPROPERTYWFIDBUILDSORIMPROVESTHEP.EON,AN� f_ VAIOCONTRACTSFORSUCHPR0.IECTSWITNACONTRAC70R(5)UCENSEDPURSUAN7TOTHECONTRAG QUANTITY DESCRIPTION FEE Y TORS UCENSE LAW.). g ❑IAMEXEMDTUNDERSEC. __ ___e.BP.C.FORTHISREASON a � � __ U W � OATE OWNER ._ V Z W � LICENSED CONTRACTORS AECLARATION W � 1 HEflEBY AFFIRM UNDER VENAI.TY OF PERJURV TNAT I AM LICENSED UMDER PROVISIONS OF CHAPTER U, -I, A�� A � A [L Y(COMMENCINC3 WRH SECTKKJ 70oa�OF OIVISION 30F THE BUSINESS AND PROFESSIONS COOE,AND Z W�� �t� �" MYLICENSEIS�NFULLFORCEAND FEC7. 0 IICENSE CLASS�'��� LIC.N0. ` �� `��� � ~ DATE___ CONTRACTOR �� � W �- -�,C__ — � WaRKEftS'COMS'ENSATION DECLARATION � ¢ � I HEREBY AFFIRM UNDER PENALTY OF PEi{JURY ONE OF THE FOLLOWING DECLARATIONS: Z � �IH�VEAN MAMTNNACERTIf!CATEOFCONSENTTOSEIF-INSUREFORWORNERS' _ ATION,AS PROVIDED BY SECTION 370o OP'f}1E LABOR CODE,FGR THE PERFORMANCE U a E WORK FON WHICH TNIS PEAMIT IS ISSUEL7. W � � _IMAVEPNOWILL TRINWORKERS'COMPENSATIONINSUflANC SREWIREDBV5ECTION Q 37aopFTHE OR DE,FORTHEPERFORM FT O FORWHICH7HISPERMI715 ISSUED.MY ORK 'COMPENSATIONINSU C CA LICYNUMBERARE: CONSTRUCTION � CRRRIEA ° PLAN REVIEW � POL�YNUMBER__i���� — ELECTRIC � n� (fF1155ECR�NNEc'�NOTBEOOM!'IETEDOFTHEPERNYTISF�Fi EHlhWfiE� AiiS 1W)OFiLESS�. PLUMBING ' TT—^_ z I CEpTIFY THAT IN THE PERFORMANCE OF TH H HICH THIS ERMI ISSUE�,I MECHANICAL �J� SFiALL NOT EMPLOV ANV PERSON iN ANY IA NCF. AS JBJECT O THE � WORKERS'COM�ENSATIOMLAWSOFCAL ORNI P ETH ISHOU BECOME INSPECTIONFEE S SUB.IECTTOTHEWOFKERS'COMPENSA ON SE I 137W ELA80F ' CODE,I SHALL FOfl7H ITH COMPLY WI7t TH 5 ON. �SSUANCE p DATE:L-�a%0.PPLICANT: y� SMIP � ENERGY P/C J WARNING:FAILURE?G SECURE WORKERS'CAMPENSATI AGF IS UNLAWFUL,ANO SHALL BE �y SU&IECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFWESUPTOONEHUNOREDTHOUSAND ENERGYPERMIT DOLLARS(it00.000),IN APDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVI�ED FOR IN ---- � SECTION3�OBOFTHELABOFCA�E,INTEREST,ANDATTOflNEY'SFEES. RETENTIONFEE: � CONSTRUCTION LENDING AGENCY PRE-A�T FEE: O � I NEREBV AFFIRM UNDEH PENALTV OF PERJURY THAT7HERE IS A CONSTRUCTION LEN�ING AGENCY FOR THE PEpFORMANCE OF'fHE WORK FOR WHICN hIIS PEHIAIT IS ISSUEO(SEC.3oe],CIV.C.). Z W = LENOER'SNAME '�i F— LEN�ER'SADDRE55 _ � I CERTIFV THAT I HAVE READ THISAPPLICATI ANO STATE THAT?HE ABOVE INFORMATION IS CARRECT. TOTAL FE ES I � I AGREETO COMPLY WITH A..�C�T'AND Y ORDINANCES ANO STATE LAWS RELATING TO BUILDING � CONSTRUCTION,ANDHEREBYAUTHOR R ESENTATIVESOFTHISCOUNTYTOENTERUPONTHE ZAeOVE�ME PE a i � PuarosEs. COMMENTS � u.2.�(!. � _ _ m PEPMITT E RI ¢ Z�„-O � � SIGNATUR PERMI OA7E = RECPT.N0. PAID BY VALIOATION ~ WHITE—Deparlment Copy,YELLOW—Finance Copy,PINK—Assassor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy , . . „�. ..,. .,, , , , ,, , � , . ., ,, . �.: � : , . .. . ���'�� �'��. ������ �� _ ���� ������`���� ������� � _ . . � s, � v x.�� q�� .�g� . .� a -� ..�.,'�.^* � .:�� �' .�i�.a'�" r a�`,� � x�. �� ,��� ��� � � ,� � � � ��, .� � '� ��' � � ,� ���„ � � �, �,. �� ° � ; �� �� � � � .� +:�.�.�ro��-� ,.. 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