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HomeMy WebLinkAbout13489 (25) __ 1�_ CITY OF DIAMOND BAR C./ DEPARTMENT OF COMMUNIT'Y Qc DEVELOPMENT SERVICES � , 21660 E.Copley Drive Suitc 190 (909)860-3195 Fax(909)861-3117 PRESS ����� BUII,DING PERMIT APPLICATION FIRMLY } JOBSITE fs'� � S'a ny�A;re LA n� APPLICATION PERMtT �� �Q �1C o ADDRESS � �_r DATE NUMBER / 15SUE � / �/_�� TYPE OCC � APN LOT TRACT a� DATE `�` CONST. GROUP g OWNER a�" �� �� � ADDRESS . a ZONING SETBACKS �� CITY Q � 21P L �- TEL I - I REART RW p❑ APPLICANT , TEL. SIDE/SIQE STAEET RW ❑ CONTRACTOR IA� . C . SIDE ❑ g ADDRESS PROPOSED USE CITY ZIP TE . -0 D � ARCHJENG/ DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION H Q OWNER•BUIIDER DECLARATION SFRlADD/REM O I HEREBY AFFlRM UNDER PENN.TY OF PERRIIRY TVIAT 1 AM EXEMPT FROM THE CONTMCTOqS LI- G8/BQB/CBIpOfI CEMSEUWWRTNEFOILOWINOREASON(SEC.70.97.6BUSMVESSANOPROFESSIONSCODE:ANVCITYOH (n �OUNi1'WHIGIREOURESAPFi1MRlOODNS7RUCT.ALTE0.IMPFOVE,DEMdJSH,ONNEPAHiANYSTAUC. W PfitIO/DBCk 7URE,lRpN TD R9185UANCE,AL90 REOUIRE9 7HE MPLCNYT FOR 9UCH PERMIT TO FILE A SIONED 87ATEMENf TIAT IIE Oii BHE IS LIGENSED PUHSUMIT TO TlIE PHOVISIONS DF TME CONTRACTORS LI• CENBE U1W(CHAP7ER Y�COAIMENCINO N77H 6ECTION 7000)OF DINSION 7 OF TNE BUSINE55 M1D PR6 LL POOVSp3 FESS�ONS COOE)OR i14�7 ME Ofi 6HE IS IXENPT TIEREFHOM AND TME BASIS FOR TF1E ALlEOED EXEMP• TpN.M1YVql.ATqNOFBECT10N7W7.6BYANYAVPLIGNTFORAOERMRSU&IEGTSTHEAPPLIGN7T0 Z 1�B-qpOF � A G11NL PENAL7Y OF NOi NORE iHAN FIVE HUNDHED OOLLAHS(i600�.): � O OI.ASOMMEROFiMEiROPERT',ONMYEMPLOYEESIM�7HWAOESRSTHEIRSOIECOMPENSATqN, COmmBfClBI � Z YN1 DO THE NfORIC,ANP iME 6TRUCTURE IS NOT INfENDED OR OFFEPEO FOR 6ALE(SEC.704.BUSI- � NESS AND PAOfE5S10NS OOOE:TNE CONTMCTOR9 LICEN9E LAw DOE&NOi ACPLY TO AN OWNER OF ? PPDPERIY MM1iO BUILOS di YPRDVES 7HEREON.AND WIiO DOES 6UCH YYORK MMASELF OR MERSELi 011 � iHIiOUGHtN50RMEROWIIENPLOYEES,PROVIDEOiHATBUCHIMPROVEMENTSARENOTINfENDEDOR m OfFEFIED FORSALE IF,MDMIEYERTME BUlDINO ORMIPROVEMB�fT19 SOID WITMIN ONE YEAR OF QONPLE- TION.TME OWNERBVIIDER WILL NAVE TFIE BURDEN OF PIIOVINd TXAT ME OR BHE�ID NOT&1M OR EIPIpYE FORiHE PURPOSE OF 8ALE). W OI,ASOVYNEROFTMEPNOPEPIY.AMEXCLUSIVELYNH7PACTl1CiNfiHLICENSEDOJNTRACTOR3 � TO CONSiRUCT THE PRpJECT�SE0.7a1.BUSINE93lWD PRDFESSIDN5 OO�E:TME CONfRACTORS L4 VBI118tiaR ADJ.AREA CENSE UW DOE8/pTAPPLY TO MI OWNER OGA PROPERiY NTIO BUILDS OR W vIqVE3 iNEPEON.AND MfIqCOMRACTHFORBUdIPRO.IECTSW:THACONiRACTOti(S)LICENSEDPURSUANT70TF1EC�NTMG QUANTITY DESCRIPTION FEE � 70RSUCENSELAW.�. J ❑I AN EKEYPT lA1[IER SEC. B.l P.G FOR TIIS REASON Q U �= pATE OYMER � Z W �q LICENSED CONTRACTORS DECIARATION W LC INEFIEBYAFF�AYUNDERPENILLTVOFPERIURVTIUTIAMIICENSEDUNDENPROY1510N50FGHAP7ER V. � �(COMMENCING N7TH 88CTION 7000)OF DNI610N 70F iME BUSINESSAND Pf10FE5SIONS COCE,A!D Z �./ LV MY UCENSE Ai MI FULL WNCE AND EFFECL /�. � �L�L/t'l � LICENSE CLASS LIC.NO. [/ � � �' � pA7E � CONiRACTOR a SI � 4VORKERS'COMPENSATION�ECLARATION Q y I NEREBY AFFlRM UNDER VENALT'OF VERR1flY ONE OFTHE FOLLAWING DECLAMTpNS; U y Z 4 � �_IWNEMlDWILLMAMTNNACERTIFICATEOFCONSEMM6ELFINSUREFOFWORKER6' Z OdIVENSIITION,A4GROVIDEDBYSECTION37000FTNElF80FiOWE.FOH7YEPERFORMANCE W Q OFTHE WORK FOR WHICHTMIS VERMIT 18195UE0. � O �1 HAVE MID WILL MA7ITNN WORKER3'OOMPENSATION INSUFIANCE,AS REOU�REO BY BECTpN ]700 OF iNE LABOR CODE,FOR TFIE PERFORMMICE OF THE WORK FOR WHIp1 TMIS VERMIT IS � ISSVEO.MY WORNEfl'COAP�f''�SATqN INSURANCE CMRjER AND POUCV NVMBFA ME: CONSTRUCTION � upqiEq �,,OJ4GN ��j/Q PLAN REVIEW � voucrM»aeER �LtI LL I� . .. ...� EIECTRIC � �gEenpN�rqiBeoor,w�i�CFn#vew.u'r�swrtwetAro�ooaluas��aa�oA�ss} PLUMBING � I GERTIFY THAT IN TtE PERFORMANCE OF iHE WORK FOR WHICH TNIS VERMIT IS IS511ED,1 MECHANICAL 6HALL NOT EMPLOY MIV FERSON N ANY MANNER 50115 TO BECAME SU&lECT TO THE A 4;S.� � � 1M�RKERS'COIAPENSATIONLAWSOFCAIIFORNIA,MIDA6REE7HATIFISYKKIL�BECOME INSPECTIONFEE �, C'�� BU&IEGT TO THE WORKERS'C01.9PEN511TqN 7qOY�510N5 0F SEGTqN 97D0�THE IABOR �A OCODE.ISHALLFORi}IWITHCOMPLVWITH7MDSEPROVISIONS. ISSUANCE �,�.` ' .;_' � i�'� � �F� I�-'-��I � p �are:�� APPLICANT: Cl GM SMIP C:E��,;:s;:: � ENERGY P/C � WARNINO:FAILURE i0 SBCURE WOPKERS'COMPENSATqN COVERAOE IS UNUWFUL.IWD BHALL BE � BU&IECTANENPLOYERTOCRIMINALPENALTESMApVILFlNE3UPTOONEHUNOPEDTHOUBAND ENERGYPERMIT OOLLARS(lt00.00Dj.N�D�ITION TOIHE COSTOF COMPENS�TION,OM�M3ES AS PROVIDEO fOR�N � 8ECTIONJ70lOFTMElA00RCODE,MITEREST,ANDATTORNEM8FEE5. RE7ENT�QNFEE: d CONSTRUCTION LENDING AGENCV PRE-ALT FEE: O � 1 HEREBYAFFNVA UNUER PENALTV OF PE0.1VIiY TIIATTHERE l5 ACONSTHUCTION LENDNO AL7ENCY FqR THE PERFORMMICE aF TIE WORN FOp WHIp7TH13 PEi1MITIS ISSUED(SEC.70Y�,CIV.C.]. � � LENDEi75 NPAIE ' CS LENDERSACDRE53 W ICERTIFYTH�TINAVEREADTMISFPPLMATIONNIDBTATE7WlTT1EABOVEINFORM�TqNISCORRECT. TOTAL FEES . d 1/WREETOCOMPLYWI7H�LlCRYANDCOUNTYOROINANGE5MIUSTA7EUW5REUTINOT09u1LDIN0 � CONSTRUCTIW�LANDHEREeVl�U7HORI2EREPRESENfATIVE50FTW5COUNTYTOEARERUPONTME ABOVH.IENTIONE�CROPERTY FOR INSPECTqN PURPO6ES. �pMMENTS � ��c.�tr�rd � � YYl e[(�N m PERMI7TE�(IHINT)_ i/ - /�� Q � r_ � �-� � � y 81G�F E 1 EE OA7E � RECPT.NO. PAID BV VALIDATI wHITE-0epanmem Capy,YELLOW—Financa Capy.PINK—Asaessor Copy,601DE ROD—File Copy.GREEN--Applicant'e Copy CtTY �� UTAMOND BAR It'�SPEGT'iOC'�t F�ECG�t� �. .„ . ..�,. �� �; ,�=e.�� � _.� .: � �� � _ �� °��si►'� C�-�,� �6���� ����.: . �,�`�. .=� ,� :. I�rF= �;,�����► pry t�` �� +� •,� � , �.ro�;, �..*:� ,..,. 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