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HomeMy WebLinkAbout17239 CITY OF DIAMOND BAR � - - ��`` -- DEPARTMENT OF COMMLTNIT}'&DEVELOPMENT SERVICES 21825 E.Copley Drive J "� (909)860-3195 Fax(909)861-3117 ` PRE$$ ��'%.tiK�� BUILDYNG PERMTT APPLIG`ATION FIRMLY a q�ppR'ESS (�� S, � �' , � APPLICATION ��i �� � r PERMIT ��1�� P/C o DATE o NUMBER � # � ISSUE / d TYPE OCC APN---��- LOT—�--- T�T DATE ��/{r� � I CONST. GROUP p OWNER C/!a;Q� C:a�.��f Lir:�F. o ADDRESS 7� ''� '� ✓�cr °' F ZpNING SETBACKS OCITY I7�, � ZIP�!�TEL. o .- � FRONT RW ❑ APPLICANT TEL. REAR ❑ � SIDE/SIDE STREET flW ❑ � CONTRACTOR f � aC" ' SIDE ❑ ADDRESS �'"' PROPOSED US � �C �. , � CITY �7� � ZIP TEl_. � � � ARCHlENG/ �^ "`/�I' '�'- `F``'��"�'� - � _ ~ ' � z DESIGNER �e3'�1 V��''{`� � w NO.DWEL. NO. O. a. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATIGN � SFR/AD�lREM �!a I HEREBY AFFIRM UNDER PENALTY OF PERJURV THAT I AM E%EMPT FROM THE CONTRACTORS LI- G2f890/CdfpOfi W CENSELAWFORTHEFOILOWINGREASON�SEC.7031.5BU51NESSANDPROFE5510NSCODE:ANYCITYOR (/) U COUNTYNMICHREdJIFESAPERMI7TOCONSTRUCT,ALTER,IMPROVE.�EMOLISN,OqqEPAIRANVS7RUC- W P8t10/DBCk w TUflE,PRIOR TO ITS ISSUANCE,ALSO REdUIflES THE APPLICANT FOR SUCH PERMIT TO FILE A SIONED W � STATEMENT THAT HE OR SHE IS LICENSED PURSUA4T TO THE PROVISIONS CF THE CONTRACTORS LI� � � CENSE LAW(CHAPTEF 9(COMMENCING WITH SECTION 7000)OF OIVISION 3 OF THE BUSINESS AND PFO- POOUSPB FESSIONSCADE)ORTHAiHEORSHEISEXEMPTTHEREFROMAND7HEBASISFCRTHEALLEGEDEXEMP- (� � 710N.ANYVIOLA710NOFSEC710N7IX11.SBVANVAPPLICANTFORAGERMITSUBIECTSTHEAPPLICANTTO Z RB-Roof A CIVII PENALTY OF NOT MORE THAN FIVE HUNDRE�DOLLARS(5600).): � ❑I,ASOWNEROFTHEPROPERTV,ORMYEMPLOYEESWITNWAGESASTHEIRSOLECOMPENSATION, � COR1f110IC12I Z WIIL DO THE WORK,AN�THE STFiUCTURE�S NOT INTENDE�OR OFFERE�GOR SALE(SEC.704a,AUSI� J � NESS AND PPOFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOTAPPLY TO AN OWNER OF � PflOPERTY WM0 BUILDS OR IMPRDVES?HEREON,AND WHO DOES SUCH N'ORK HIMSELF OR HERSELF OR � THROUGHHISORHEROWNEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTMTENDEDOR m w OFFERE�FORSALEIF,HOWEVER,THEBUIL�INaORIMPROVEMENTI550L�WIiHINONEYEAROFCOMPLE- � TION.THE OWNER-BUILDER WILL HAVE 1}1E 9URDEN OF PROVING THAT HE OR SHE OID NOT Btlf��OR Z IMPROVE FOR THE PURPOSE OF SAL�. �_ ❑I,ASON7JEROFTHEPROPERTY,AMEXCLUSIVEIYCONTRAC7INOWITHLICENSEDCONTRACTORS TO CANSTRUCT THE PROJECT(SEC.7044.BUSINE55 AND PROFESSIONS CODE:7HE CANTRAC70R5 LI- VaIl/3ti0n ADJ.AREA W CENSELAW�OESNOTAPPLYTOANOWNEROFAPROPEPTYWH06UILDSOpIMPROVESTHEREON,AN� = WMOCONTPAGTSFORSVCHPROJECTSWITMACONTRACTOR(S)LICENSEDPURSUANT?OTHECONTRAP QUANTITY DESCRIPTION FEE ~ 70RS LICENSE LAW.). Y � ❑I RM EXEMPT UN�ER SEC. B.&P.C.FOFi THIS flEA50N Q � U W � DATE OWNER � Z W � LICENSED CONTRACTOfiS DECLARATION �j � I HEREBYAfFIRM UNDER PENALTY OF PERJURY 7HAT I AM LICENSED UND'eR PROVISIDNS OF CHAPTER ��, � 9(COMMENCWG WITH SECTION 7000)OF�IVISiON 3 OF THE BUSINESSAND PROFESSIO�'S CODE,AND Z �X IAV UCENSE IS IN FULL FORCE AN�EFFECT. m � UCENSE CLASS ___�� UQ NO. ��.S !'"'"GD j ~ DATE I I'7^�� CONTRACTOR �L. d w -�"'P�^�`4 �`�" � WOAKERS'COMPENSATION DECLARATION w Q = U � 1 NEREBY AFFIRM UNDER PENALTY OF PERJURV ONE OF THE FOLLOWING�ECLARATIONS: � Z Q � IHAVEANDWILLMAINTqINACERiIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' '_ ^COMPENSATION,ASPROVIDEDBVSECTION37o00FTHELA60RCODE,FORTHEPERFORMANCE U ¢ OF THE WOPK FOR WHICH TFi15 PEfiM1T IS ISSUEO. � � W __I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BV SECTION p ///'''��� �`� Q a70o OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WOPK FOR WHICH THIS PERMIT IS I;���r L.�V ISSUED.MYWORKERS'COMP NSATIONINSURANCF.CARRIERANDPOLIC�NUMBEi1ARE�, CONSTRUCTION 1 J '�� � J � CARAIEFl J �/���'�- PLAN REVIEW Z POUCY NUMBER i (a '3-�.,�+' d � ELECTRIC ¢ � � (THI55ECTKKJNEmNOTBECOtdf'LErE00FhiEPERMfTISFORCN=HUNDREDDOLW2S(51oo)ORLESS7. PLUMBING Z I CERTiFYTHAT INTHE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL C7 SHALLNOTEMPLOYANYPERSONINANYMANNERSOASTOBECOMESUBJECT'O'HE � WORKERS'COMPENSATIONLAWSOFCAUFORNIA,ANDAGREETVIATIFISHOUL�BECOME WSPECT�ONFEE = Sl/BJECTTOTMEWORKERS'COMPENSATIONPftOVISIONSOFSECT10N3�ooOFTHEL4BOR CO�E.I SHALL FORTHWITH COMPLV WITH THOSE P OVISIONS. ISSUANCE � �� p DATE��� "`Q APPLICANT: SMIP � w ENERGY P/C J WARNMGFAILUFETOSECUFEWORKERS'COMPENSATIONCOVERAGEISUNLAWFUL,ANDSHALLBE � S�BJEC7ANEM?LOVERTOCRIMINALPENALTIESANOCIVI'�:MESUPTOONEHUNOREDTND�SANO ENERGYPERMIT DOLLARS(St oo.oaDJ,IN ADDITION TO THE COSi GF COMPENSATION,DAMAGFS AS PROVI�ED FOR IN J 5'cCT10N3]aeOFTHELA80RCO0E.INTEREST.ANDATTORNEY'SFEES. RETENTIONFEE: � d CONSTRIJCTION LENDING AGENCY PRE-ALT FEE � IHEREBVAFFIRMUNDEflPENAITVOFPERJUFYTHATTHEREISACONSTRUCT10NLENDINGAGENCY � FOR THE PEAFORMANCE OFTHE WORK FOR WHICHTHIS PERMIT IS ISSUED(SEC.3097.CIV.C.�. - Z W � LENOER'S NAME H LENDER'SADORE55 � C . y � ICERTIFVTHA7IHAVEREA�THISAPPLICATIONANOSTqTETHATTHEA80VEWFOPMATIONISCORREGT. TOTAL FEGS � '� �,�v w IAGREETOCOMPLVWITHALLdTYAN�COUNTVORDINANCESAN�STATELAWSRELATINGTDBUILDING � CONSTRUCTION,AND HEHEBY AUTHORIZE REPRESENTATIVES OF TH�S COVNTV TO ENTcR UPON THE � ABWE-MENTIONED PROPERTY FOP INSPECTION PURPOSES. z COMMENTS � J � 3 � �.4(��� _ ¢ PERMITTEE NAME IPRINTJ� /� � � � � � G�,p�.` '� / ,—c � SIGNATURE OF PERMI E '�^' DAT'e = RECPT.NO. 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