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HomeMy WebLinkAbout17240 (23) CITY OF DIAMOND BAR ��-r._,.., --`�' -- DEPARTMENT OF COIvA�tUNITY&DEVELOPMENT SERVICES �r' / I �� 21825 E.Copley Drive / pRESS (909)860-3195 Fax(909)861-3117 ��"�•�� BUILDING PERMIT APPLICATION FIRMLY � JOBSITE j -�'� p APPLICATION i PERMIT �y�P!C o ADDRESS!� Z� ��-ds4.�i �i�_��_ DATE r� �r G�NUMBER �� v# °� APN LOT TRACT D TEE �IJ J I (J �'PE OCC p OWNER Y CONST. GROUP o ADDRESS 1-- �� ZONING SETBACKS z CITY �) �t ZIP�'��1'EL.^ .� C �� FRONT Ryy � � APPLICANT �- � TEL. ` REAR z SIDE/SIOE STREET RW ❑ ¢ CONTRACTOR f.sY�. .; Cs :+� SIDE ❑ � ADDRESS_�� �� , '? Z� 1 - � CITY +� ZIP�,�TEL.��:,,� P O�OSED USE . f ..� ' ,.:�,p_ �, oARCH/EN� �e• � S�� f" ' , 1�,"�'" ' ' t w DESIGNER `�� N0.DWE�� NO. � � NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION p SFR/ADD/REM � p I HERE6V AFFlRM UNDER PENALTV OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI� � Garage/Carport W CENSELAWFORTHEFOLLOWIN6PEASON(SEC.]C31.SBUSINESSANDPROFESSIONSCODE:ANYCITYOfl U COUNTYWHICHRE�UIRESAPERMITTOCONSTRUCT,ALTcR,IMPROVE,DEMOLISH,ORREPAIqANYSTRUC� w TURE.PRIOR TO Ii5 ISSUANCE,AL50 REQUIRES THE APPLICAN7 FOR Sl1CH PERMiT TO FILE A SIGNED W PatiO/OBCk � STATEMENT TIiA7 HE Ofi SHE i5 LICENSED PURSUAN7 TO THE PROV�SIONS OP THE CON7RACTORS L4 � � CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS ANO PRD� POOUSpB � FESSIONSCO�E)ORTHATHEORSHEISEXEMPTTHEREFROMAN�THEBASISFOR7HEALLEGE�E%EMP� (� U TION.ANYVIOLATIONOFSECTION7031.5BYANYAPPLICANTFORAPERMITSUBJECTSTHEAPPUCAMTO Z Re-Root ACIVIL PENALTV OF NOT MORE THAN FNE HUNDREO DOLL4FS�55oaJ.): ❑I,AS OWN ER OFTHE PROP ERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSFTION, Z WILL DO THE WORK,AN�THE 5?RUCTUaE IS NO7 IN7ENDED OH OFfERED FOfi SALE(SEC.7oa4,BU51� � COR11118PCidl � NE55 ANO PROFESSIONS CODE:THE CONTRAC70fiS LICENSE LAW DOES N07 APPLY TO qN OWNER OF = PROPERTY WHO BUILDS OR IMPROVES THEREON,AND W110 D�ES SUCH WOflK HIMSELF OR HERSEL�OR � TMRIXIGHMISORNEf10WNEMPLOVEES,PRDVIOEDTHATSUCHIMPROVEMENTSARENOTMTEN�E00R m 0 OFFEREDFORSALE.IF,HOWEVER,THEBUILDINGORIMPROVEMENTISSOtAWITHINONEYEAROFCOMPLE- Z 710N,7HE OWNER-BUILDER WILL HAVE?HE BUPDEN OF PROVING THAT HE OR SHE 01�NOT BUILD OR = IMPROVEfORTHEPURPOSEOFSALE). w ❑I.ASOWNEflOFTHEPROPERTY,AMEXClUSIVELVCONTRACTINGWITHLICENSEDCONTRACTORS � TO CANSTRUCT THE PROJECT(SEC.7044,BUSINESS AND PROFES£IONS CO�E:THE CONTRAC70RS U� V8IU8I10(1 �'�" ADJ.AREA W CENSELAWDOESNOTAPPIYTOANOWNEROFAPROPERTYWHOBUILDSORIMPROVESTHEREON,AND � WHOCONTRACTSFORSUCHPROJECTSWITHACONTRACTOR(S)LICENSEOPUqSUANTTOTHECONTRAC� QUANTITY DESCRIPTION FEE Y TOHS LICENSE LAW.). � ❑I AM E%EMPT UN�ER SEC. B.6 P.G FOR THIS REASON Q � U � � DATE OWNER F— � W � LICENSED CONTRACTORS DECLARATION W � I HEREBYAFFIRM UNOER PENALTV OF PERJURV THAT 1AM LICENSEO UNDER PROVISIONS OFCHAPTER � � 9(COMMENCINGWITHSECTION7oov)OFDIVISION30FTHEBUSINESSANDPPO%ESSIONSCODE,AND z X MY LICENSE IS IN FULL FORCE AN�EFFECT. ` � UCENSE CLAS/$_�� /y� LIC.NO. � "-'� � V �ATE�,��_ CONTPACTOR ' _�,�...t + 6J. W T t 1�"�-r. � WORKERS'COMPENSATION DECLARATION ¢ � IHEREBYAFFIRMUNDERPENPLTYOFPEFiJURYDNEOFTHEFOLLOWMGDECLARATIONS: Z Z _IHAVEANDWILLMAWTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' a 2 ¢ CAMPENSATION,AS PPOVIDED BY SECTION 3�Do OF THE LABOR CODE,FOR THE PERFORMANCE U Q OFTHEWORKFOFWHICHTHISPERMIiISISSUEO. � QW _I HAVE AND WILL MAINTAIN WOFNERS'COMPENSATION INSURANCE,AS REOl1iRED BY SECTIOM1' 3700 OF THE LABOR CADE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEO.MV WORKERS'COMPENSATION INSURANC CkflRIER AND POLICY NUMBER ARE: CONSTRUCTION � ?�q �� J j CARRIER �'i'1e. � PLAN REVIEW _ Z POLIGYNUMBER y h`_.IL��..- C? F ��--�—�� ELECTRIC 4 � (fHISSECTKYJNEmNOTBECOMPLEfEDOFTIiEPERMRISFORONEHUNDqEDCOIlAFiS(5700)ORLESS) PLUMBING Z I CEflTIFYTHAT IN THE PERFORMANCE OF THE WORK FOfl WHICH THIS PERMIT IS ISSUED,I MECHANICAL C} SHALLNOTEMPLOVANYPERSONINANYMANNERSOASTOB OMESUBJECTTOTHE Vj WORKERS'COMPENSATIONLAWSOFCALIFORNIA,AN�AGPEE HATIFISHOUL�OECOME INSPECT�ONFEE � SUBJECTTOTHEWORKERS'CAMPENSATIONPROVISIONSOF CTION37000FTHELABOR � � CO�E,i SHALL FORTHWITH COMPLY WITH THOSE PFOVISIONS ISSUANCE � ��`��,,,,��-��r��' ,,, w SMIP `� p DATE:� APPLICANT. J WARNING:FAILURETOSECUFEWORKERS'COMPENSATIONCOVERAGEISUNLAWFUL,ANDSHALLBE ENERGYP/C � SUBJECTANEMPLOYERTOCRIMINALPENALTIESANOCIVI�FINESUPTOONEHUN�REDTHOUSAND ENERGYPERMIT OOLLAFS(5100,000�,!N ADDITION TO THE COST OF COMPENSATION,DAMAGES AS FROVIDED FOR IN � SECTION 3708 OF THE LABOR CODE.WTEREST,AND ATTORNEY'S FEES. RETENTION FEE: � d � CONSTRUCTION LENDING AGENCY PRE-AlT FEE: O � 1 NEftEBYAFFIRM UNDER PENAINOF PER1l1RV THAT THERE IS ACONSTRUCTION LENDINC�AGENCV FOfl THE PERFORMANCE OFTHE WORK FOF WHICH THIS PERMIT IS ISSUE��SEC.3087,CIV.C.�. Z w � LENDEfl'S NAME H LENDEP'SADDRESS � TOTAL FEES ,�'1 'o!1,,� � I GERTIFY THHT I HAVE READ THIS APPLIGATION AND STATE THATTME ABOVE INFORMAT�ON IS COqRECT. w I pGREE TO CAMPLY WITH ALL CITY AN�COUNTV OHDINANGES ANO SiATE LAWS RELATING i0 BUIL�ING � CONSTRUCTION,ANDHEREBYAUTHORIZERePRESENTATIVE50FTHISCOl1NTYTOENTERUPONTHE � ABOVE�MENTIONED PROP TY FOR INSPECTION PURPOSES. COMMENTS Z ��� 0 _ � �`7*�� _ m PERMITTEE NAME�PRINTj Q � f v�- - v � SIGNATV47EOFPERMITT� L�! OATE � = RECPT.NO. 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