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HomeMy WebLinkAbout17303 (23) _ _ _ �� CITY�F DIAMOND BAR 9�� � -�� — DEPARTMENT OF COMMtJNTfY&D�VELOPMENT SERVICES � ,�� .�� 21825 E.Copley Drive � � �` (909}860-3195 Fax(909)$61-3 i 17 �� PRESS "''-�;' $ui�.��GP�x�rn��L�cArioN FIRMLY � JOBSITE r� PPLICATION �} y � PERMIT �'Y� P/C o ADDRESS_ L��`I�,� �� ��s°'��dB wt�>�:r��='" DATE � ✓� � NUMBER ��___�"�'� #� � ISSUE TYPE CC APN LOT TRACT DATE � �� CONST. GRDUP p OWNER d"'u�' 'Y�r�a 4� " ADDRESS ..r' �- ZONING SETBACKS oCITY �€2�E'�1�*�"�f� i���'�ZIP :�TEL,��/'bs'a��"� FRONT RW ❑ APPLICANT _ TEl.. REAR ❑ � SIDE/SIDE STREET RW G I ¢ CONTR.4CTOR ~ i°�a.``�s,� SiDE C � ADDRESS �' �`." dO�'� a"3 m.� r- ,-.n PROPOSED USE ���""��'°'�'� �` CITY L"t'r, �'�t»�... ZIP t' ��TEL.�� �. �°"' n :�- -_•"�-�"'_" ' �.- ��� 'e� �'�.f ��a..�+ w ARCH/ENG/ z DESIGNEft NO.DWEL. N0. NO. = CDDRESS ZIP TEL. J UNITS STORIES � BEDRDOMS c�n DESCRiPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION �� OWNER-BUfL�ER DECLARATION SFRIADD/AEM O p, 1 HEREBY AFFIRM'UNDER PENALTV OF PERJURV THAT I AM EXEMPT FROM THE COMAACiORS LI- G8f29B/CBfPOrt W'� CENSELAWFOR7HEFOLLOWING.REASON(SEC.7031.66USINESSANDPROFES510NSCODE:ANVCITYOR (n 'U COUNTYWHICHAEQUIRESAPERMITTOCONSTRIICT,ALTER.IMPROVE,GEMOLISH,ORREPAIRANYSTpUC- W pgt10ID8CK Z�� TURE,PRlofi To ITS ISSUANCE,ALSO REQIlIRES THE APPLICANT FOR SUCH PERMIT TO FIL'c A SIGNED w STATEMENT THAT HE OR SHE IS�ICENSE�PURSUANT TO THE PROVISIONS Of THE CONTqACiORS LI- W �, 'CENSE LAW(CHAPTEfl 9(COMMENCING WITH SECTION 700a)OF DIVISION 3 OF THE BUSWESSAND Pp0- � POOUSPd ' FESSIONSCA�EjORTHATHEORSHEISEXEMPTiWEflEFpOlAANDTHEBASISFORTHEALLEGE�EXEMP- (� �. TION.AN�VIOLATIONOFSECTlON7a31.5BVANVAPPLICANTFORAPEPMIT5l1BJECTSTHEAPP�ICANiTO z R6ROOf �� A CIVIL PENALTY OF NOT MOHETHAN FNE HUN�RED DOLlARS(ESDo)J: ' �, � ❑I,ASONMEROFTHEPROPERTY,ORMYEMPLDYEESWITH3M1'AQESAS?HEIRSOLECOMPENSATION, ❑ COf7lrtiBfCl21 - Z.'.',WILL�O THE WORK,AN�THE STRUCTUPE IS NOT INiENDE�Ofl OFFERED fOP SALE(SEC.7044,8US1- J �' NESS AN�pROFESSIONS CODE:THE CONiRACTORS LICENSE LAW DOES NOTPPPLV i0 AN OWNER OF ? �,pROPER7V VNiO BUIL�S OR IMGROVES THEREON,AND WHO�OES St1CH WOflK NIMSELF OR HERSELF OR �.;', 'TXROUGHHISORHEROWNEMiPLOVEES.PROVIDE�THATSUCHIMPROVEMENTSARENOTINTENDEDOR m Q,'�,�;OFFEREDFORSALE.IF,HOWEVER,iHEBUIL�INGOflIMPROVEMENTISSOLDWiTHiNONEYEAROFCOMPLE Z,�.,�.TION,iHE'OWNER-BUIL�ER WIL!HAVE THE BURDEN OF PROVMG iHAi HE OR SHE DiD NOi OUILD OF ��IMPROVEFORTHEPURPOSEOFSALE). ❑I,AS ONMER OF iHE PROPERTY.AM EXCLUSIVELY GONTRqCTING WITH LICENSED CONTRACTOPS �.','.TO GONSTRUCT THE PROJECT(SEC.7044,BUSWESS AND PROFESSIONS CODB THE CONTRACTORS LI- � df10l1 - �� ADJ.AREA W',�'�';CENSELAWDOESNOTAPPLVTOANOWNEROFAPROPERTVWHOBUILDSOflIMPROVESTHEflEON,AND °' l.','WHOCANTRACTSFOASUCHGROJECTSWI7HACONTRACTOR(5)LICENSE�FURSUANTTOTHECONTFAG QUANTITY DESCRIPTION FEE - k— TORS LIGENSE LAYJ.). �. J Q ❑I AM EX�MPT UND'cR SEC. B.3 P.C.FOP iHiS REASON Q � U W � DATE OWNER U Z, w ��I LICENSED CONTRACTORS DECLARATION w 'GC�'�, IHEREBVAFFIRMUN�ERPENALTYOFPEPJURYTHpTIAMLICENSEDUhDERPflOVISiONS�FCHAPTER � . ' (,L '�,, 9(COMMENCINGWIiHSECilON7a00�OFDl'✓ISION30�THE9VS�NESSANDPaOFc&SpNSCODE,AND Z 7G '� MV IJCENSE IS IN FULL FORCEAND EFFECi. ¢ Q � LICENSE CLASS �� �,n IIC.NO.�4�'���� � V � DATE - ��`a ,� ���. CONTRACTOR.._ ��._�.�_ ✓ d � W � WORKERS'COMPENSATION DECLARATION � � U � IHEREBVAFFlRMUNDERPENAI.TYOFPERJl1RYONEOFTHEFOLLOWINGDECLARAT10N5: Z Q . 2 _IHAVEANDWILLMAiNTAINACERTIFICA7EDFCONSENTTOSELF-INSUREFORWORKERS' _ COMPENSATION',AS PROVI�ED BY SECTION 3�0o OFTHE LA60R CODE,FOR THE PEPFORMANCE C.� �� ¢ OFTHE WORK FOq WHICH THIS PERMIT IS ISSUED. � � w ' _I NAVE AND WILL�MAINTAM WORKEFS'COMPENSATION INSl1qANCE,AS flEQVIRF�BY SECTION �,py�a�� Q 370�OF THE LABOR CO�E,FOR THE PERFORMANCE OF iHE WORK FOR WHICH THIS PEflMIT IS �� ISSIJE�.MYWORKEAS'C MPENSATIONINS NCECAR EflAN�POLICYNUM6ERAflE: CONSTRUCTION � j CARRIER �•��'�"��' � . p y,� FLAN REVIEVJ � POLICYNUMBER ��� �� t,,,e+.���" ��q��°'�' ELECTRIC Q . � (fHI55ECTKKJNEmNOTBECOMPLEfEDOFhiEPERMffISFOftONc'HUNDREDDOLLAFiS(E70�)ORLE55} PLUMBING W . Z '�i ICEflTIFYTHATINTHEPERFORMANCEOFTHEWORKPoRWHICHTHi5P6RMITISIS5l1E0,1 MECHANICA� (,� � SHAIL NOT EMPIOYANY PERSON IN ANY MANNER SOAS TO BECOME SUBJECT TO iHE �(j WORKERS'C�MPENSAiIONLAW50FCALIFORNIA,AND GREEi ATIFISHOUL�BEGOME INSPECTIONFEE . , � � SU9JEGTTOTHEWO:�KERS'COMPENSATIONPROVIS NSOFS TION37oaOFT CODE,ISHALLFORTHWITHCOMPLI'WITHTHO P VISION � ���ISSUAI�CE���- �" � � ✓���".�PS.s�'j 'e SMIP " � {5� � �ATE: APPLICANT, � � ENERGY P/C � , WARNING FAIWRETO SECURE WORKEflS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE � �, SUBJECTANEMPLOYERTOCRIM!NALPENALTIESAN�CIVILFWESUPTOONEIIUNDFEDTHOUSAN� ENERGYPERMIT � �OLIARS(51a0,aa0),INADDITIONTOTNECOSiOFCOMPENSATION,DAMAGESASPROVIDEDFORIN � J, SECTION3]080FTHELABOF7CO�E,INTEREST,AN�ATTORN[Y'SFEES. AETENTIONFEE: � ' a CONS7RUCTION LEN�ING AGENCY pRE-ALT FEE: Q . CG 1 HEFEBYAFFIRM UI�EP PENAL7Y OF PERJUPV iHAiTHc'RE IS ACONSTflUCT10N LENDING AGENCY � FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITISISSUE!]�SEC.309],CIV.G.). � Z W. _. LENOER'S NAME � . f=-, �LEN�ER'SADDRESS ' �'' � ICERTIFY7HA71HAVEREADTHISAPPLICATIONAN�STATETHATTHEABOVEINFORMATIONISCORftECT. TOTAL FEES � �I_ e � � b �� IAGREETOCOMPLVWI7HALLqTYANDCOUNTYORDINANCESAN�STATELAWSRELATINGTOBUILDING lC �Y � CONSTRUCTION,AND HEREBV AUTHOflIZE REPRESENTATNES OF THIS COIINTV TO ENiER UPON THE Z, "A80VE-MENiI NED RO TYFOflINSPE URPOS^c5. . COMMENTS ', a �� � : ��.�� m, _�.�a.._____.w__.���. �, _---��.�_.� �' SIGNA7UREOF� 1 EE �ATE ' � RECPi NO. PAID BY VALI�ATION � WHITE—Department Copy,YELLOW—Finance Copy,PINK—AssessorCopy,60LDENROD—File Copy,GREEN—ApplicanPs Copy . .. z 3 � � . .,.< r s .. .. �.°.��k .,.. �: �., x A � . .. , f t e.. . 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