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HomeMy WebLinkAbout16607 (22) CITY OF DIAMOND BAR � -� DEPARTMENT OF COMMUNTI'Y&DEVELOPMENT SERVICES �� I 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 PRESS BUILDING PERMIT APPLICATION FIRMLY � JOBSITE � APPLICATION �,,,.��O � NUMB R �.d�v p/C o AD�RESS DATE � ISSUE TYPE OCC � APN LOT P��___ TRACT �- DATE CONST. GROUP p OWNER � � AODRESS ZONING SETBACKS 0 z CITY ' . s ZIP sTEL � FRONT Ryy ❑ � APPLI ANT TEL. REAR ❑ Q SIDE/SIDE STREET RW ❑ m CONTRACTOR SIDE ❑ ADDRESS � CITY ZIP TEL. PROPOSED USE .�'�! G .� oARCH/ENG/ z DESIGNER w NO.DWEL. NO. NO. � ADDRESS UNITS � STDRIES �' BEDROOMS� � CITY ZIP TEL. � cn DESCRIPTION SQ.FL FACTOR PSF ADJ.AREANALUATION � OWNER-BUIIDER DECLARATION SFR/ADD/REM O p I HEREBY AFFIRM UNDER PENALT/OF PERJUPY THAT I AM EXEMPT FROM THE CONTRACTORS U- G8I0(J2/C2tPOR W CENSE LAW FORTHE FOILOWING REASON(SEC.]031.5 BUSMESSANO PROFESSIONS CODE:ANV CITV OR (n V COUNTYWHICHREQUIRESAPEFMITTOCONSTaUCT,ALTEF,IMPROVE,DEMOUSM,ORREPAiRANYSTRUG W TURE,PRIOR TO ITS ISSUANCE,FLSO REOUIRES THE APPLICANT FOF SUCH PERMIT TO FILE A SIGNED W Patio/Deck � STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI� CENSE LAW(CHAPTER e�COMMENCING WITH SECTION 7000�OF DIVIS,ON 3 OF THE BUSINESS AND PRO� � P001/Sp8 0 FESSIONSCOD"e)ORTNATHEORSHEISExEMPTTHEREFROMqNOTHEBA515FORTHEALLEGEDEXEMP- (� V TION.ANYVIO�ATIONOFSECTION7031.SBYANYAPPLICANiFORAPERMI7SUBJECTSTHEAPPLICAN7T0 Z Re-FOOf ''2� 1�,� "� ACIVIL PENALTY OF NOT MOpE THAN FlVE Hl1NDRED ODLUIPS(ESDo).)� � ❑I,ASOWNEROFTHEPROPERTY,ORMVEMPLOVEESWITHWAGESASTNEIRSOLECOMPENSATION, O COf11f178fC1aI Z WILL DO THE WORK,ANO THE STRUCTURE IS NOT INTEN�ED OR OFFERED FOft SALE(SEC,7044,BU51- J � NESS AND PROFESSIONS CODE THE CONTRACTORS LICENSE LAW DOES NOT APPLV 70 AN OWNER OF = PROPERTY WHO BUILDS OR IMPROVES THEfiEON,AND WHO OOES SUCFi WORK HIMSELF OR HERSELF OR CC THROUGH HIS OR HER OWN EMPLOYEES,PqOVIDED THAT SUCH IMPaOVEMENTS AFE NOT WTENDED OR m W OFFEREDFORSALE.IFHOWEVER,THE9UILDINGORIMPROVEMENTISSOIDWITHINONEYEAROFCOMPLE- � TION,TNE OWNEH-9UILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR Z IMPROVE FORTHE PUFPOSEOF SALE�. _ ❑I,ASOKRJEROFTHEPROPERTY,AMEKCLUSIVELYCANTRACTINGWITHUGENSEDCONTRAC70R5 W fL TO CONSTRUCT THE PROJECT(SEC.7o46.BUSWESS AN�PROFESSIONS CO�E�.THE CONTRAC70RS L6 VelU9t10� ADJ.AREA W CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPENTVWH09UILOSORIMPROVESTHEREON.AN� � WHOCONTRACi5FOa5UCHPROJECTSWITHACONTRACTOR(S)LICENSEDPURSUANTTO'fHECONTRAC- QUANTITY DESCRIPTIDN FEE Y TORS LICENSE LAW.). � �7 I AM EXEMPT UNOER SEC. B.S P.C.FOR TMIS REASON q � - U � DATE Cs-IG-�C7 I OWNER M.�'� � Q W F LICENSED CONTRACTORS DECLARATION W � I HEREBYAfFIFM UNDER PENAI.TYOF PERJUFV THAT IAM LICENSED UNDEF PROVISIONS OF CHAPTER � � 9(COMMENCINGWITHSECTION70o0�OFDIVISION30FTHEBUSINESSANDPROFESSIONSCADE,AND Z 'X MY LICENSE IS IN FULL fORCE AND EFFECT. m � L�CENSE CLASS LIC.NO. � V DATE CONTRAC70R � W � WORKERS'COMPENSATION DECLARATION Q � IHEREBVAFFIRMUNDERPENALTYOfPEiiJURYONEOFTHEFOLLOWINGDECLARATIONS: z Z I HAVE AN�WILL MAINTAIN A CERTIFICATe OF CONSEN7 TO SEIF-INSl1RE FOR WOPKERS' _ Q CAMPENSATION,ASPflOVIDEDBV5ECT10N37aoOFTHElA80RCODE,FORTHEPERFORMANCE U Q Of THE WORK FOR WHICH THIS PERMIT IS ISSUED. � w _I HAVE AND WILL MAINTAIN WORNEFS'COMPENSATION INSURANCE,AS REOUIHED BY SEC7ION (� /� �\ Q 37000FTHE LABOfl CODE,FOR THE PERFORMANCE OFTHE WORK FOR WHICHTHIS PERMIT IS 0/�' 'y( J ISSUEO.MV WORKERS'COMPENSATION INSURANCE CARRIER AND POUCV NUMBER ARE: CONSTRUCTION 1\ d — J y CARRIER PLAN REVIEW ZPOLICV NUMBER ELECTRIC Q � (IHISSECTIONNEEDNOTBECOMPLEfEDOFhIEPERMfTISWRONEHUrAREDDIX.LARSIE100)ORLESS). PLUM6ING Z I CERTIFY THAT IN THE PERFORMANCE OF TNE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL �J SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SOAS TO BECOME SUBJECT TO THE Uj WORKERS'COMPENSATIONLAWSOFCA_IFOFNI4,AN�AOREETHATIFISHOULOBECOME INSPECTIONFEE = SUBJECTTO THE WORKERS'COMPENSATION AROVISIONSOF SECTION 37oDOF THE LABOR GODE,ISHALLFORTHWITHCOMPLYWITHTHOSEPflOV1510N5, ISSUANCE —�� 1 � •� O . ...\ TT� �,. p DATE: APPLICANT: SMIP J WARNINGFAILURETOSECUREWORICERS'COMPENSATIONCOVERAGcISUNLAWFUL,AN�SHALLBE ENERGYP/C �.I�i� �C�_L���r_ � SUBJECTAN EMPLOYERTO CRIMINAL PENALTIES AND CIYIL FMES UP TOONE HUNDREDTHOUSAND ENERGY PERMIT OOLIARS(3100,000),IN ADDITION TO THE CAST OF COMPENSATION,DAMAGES AS PPOVIDED FOR IN � SEGTION 3708 OF THE LA30R CODE,INTEREST,AND ATTOPNEV'S FEES. RETENTION FEE: OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: ' __ _ — � I HEREBYAFFIRM UNDER PENALTYOF AERJUFV THATTHERE IS ACONSTRUCTION LENDING AGENCV FOR THE PERFORMANCE OF THE WORK fOF V1F�IIC'�1 THIS PEflMIT IS�SSVE�ISEC.308],CIV.C.�. Z W � LENDER'S NAME — 1-- LEN�ER'SA�DRE55 � TOTAL FEES � ��"� � � I CEPTIFV THAT I HAVE READ THIS APPLICATION AN�STATE THATiHE ABOVE INFORMATION IS CORRECT. w I AGFiEE TO COMPLY WITH ALL CITV ANO COUNTV ORJINANCES AND STATE LAWS RElA71NG TO BUILDING � CONSTRUCTION,ANDHEREBYAUTHORIZEREPRESENTATNESOFTHISCOl1NTYTOENTERUPONTHE � ABOVE�MENTIONED PFOPERTY FO INSPECTION PURPOSES. Z COMMENTS � � �. m PERMITTEE ME(PRI a •�- � J: � SIG REOFP I E E = RECPT.NO. PAID BY VALIDATION ~ WHITE—Department Co YELLOW—Finance Co PWK—Assessor Co GOLDENROD—Fi�e Co GREEN—A IicanPs Co PY. PY. PY. PY. 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