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HomeMy WebLinkAbout17309 (23) CTI'Y OF DIAMOND BAR f��} ^- J�"`� —� DEPARTI�NT OF COMMUNITY&DEVELOPMENT SERVICES �/ � I �_ '.w 2(825E.CopleyDrive (909)860-3195 Fa�c(909)861-3117 PRESS ` �'-���� BUILDING PERMIT APPLICATION FIR Y o� JOBSITE � PPLICATION �j PERMIT P/C ADDRESS , � DATE_�/� �� NUMBER���# � APN L�T 'rRACT_ ISSUE TYPE OCC p OWNER L I✓y�,����'/LJS'C1 rll DATE � � CONST. GROUP p ADDRESS ZONING SETBACKS W CITY /� J�.ova_ ZIP ��TEL. 5 S� FRONT RW ❑ � APPLICANT TEL REAR ❑ ¢ ' ��`G SIDE SIDE STREET ' RW O � CONTRACT R ADDRE S C T�k � CITY � ZI /� TEL. y�6,2�� PRpPOSED USE •- � oARCH/ENG/ � �� z DESIGNER w � �,�- NO.DWEL. NO. NO. o.. ADDAESS cn UNITS STORIES BEDROQMS � CITY ZIP TEL. "__`�� cn pESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION a OWNER-BUILDER DECLRRATION SFRJADD/REM O I HEREBY AFFIRM UNDER PENALTV OF PERJURV THAT I AM EXEMPT FROM THE CONTMCTORS LI� G2f0gB/CdlF70rI W CENSELAWFOflTHEFOLLOWINGREASOM(SEC.�o31.5BU51NESSANOPROFE5S10N5CODE:ANVCITYOR (n U COUNTVWHICHRE�UIRESAPERMITTOCONSTRUCT,AL7ER.IMPROVE,DEMOLISH,ORREPAIRANVSTRUG W TURE,PRIOR TO ITS ISSUANCE,ALSO REOUIRES THE APPLICANT FOR SUCFi PEFMIT TO FI�E A SIGNE� W PatiolDeck STATEMENT THAT HE OR SHE IS LICENSED PI:RSL/ANT 70 THE PROVISIONS OF THE CONTRACTORS L'�- � CENSE UW(CHAPTER 9(COMMENCINO WITH SECTION TD00)OF DIVISION 30F THE BU3INESS AND PRO• � PooUSpa � FESSIONSCODE�ORTHATHEORSHEISEXEMPThIEREFROMANOTHEBA515FORTHEALLEGEDEXEMP• (� V TION.ANVVIOLATIONOFSECTION703i.58YANYAPPLICANTFORAPERMITSUBJECiSTHEAPPLICANTTO Z Re-Roof ACIYIL PENALTV OF NOTMORETHAN FIYE HUN�flED DOLLAFS�SSaO).): ❑I.AS OWNER OFTHE PROPERTV,OF AAY EIAPLOVEES WITH WAGES AS 7H EIR SOLG COMPENSATION, Z WILL DO THE WORK,AND THE STRUCTtiRE IS:NOT INTENOED OR OFFERED FOR SALE(5EC.7044,BUS'�.- � COfI1mBfCiel � NESSAND PROFESSIONS CO�E:THE CONTRACTORS LICENSE LAW OOES NOT APPLY 70 AN OWNER�F � PROPERN WHO BUIlDS OR IMCROVES THEREON,AND NMO DOES SUCN WORK HIMSELF OR HERSELF OR � THROUGH HIS OR HER�WN EMPLOVEES,PROVIDED THAT�UCH IMPROVEMENTSAqE NOT WTEN�ED OR m OOFFEREDFORSALEIF,HOWEVEP,THEBU0.�INGORIMPROVEMENTISSOIAWITHINONEVEAROFCOMPLE- Z TION,THE OWNER-BUILDER WIIL HAVE THE BURDEN OF PROVING THAT HE OR SHE DI�NOT BUILD Ofl = IMPROVEFORTHEPUqPOSEOFSALE�_ w ❑I,ASOWNEROFTHEPROPEflTV,AME%CLUSIyE�YCONTflACTINOWITHLICENSE�CONTRACTORS d TO CONSTRUCT THE PROJECT(SEC.7044,BUSINE55 AND PfiOFE5510N5 COOE:THE CONTRACTORS LI� V81U2LI0� ADJ.AREA W CENSELAWDOESNOTAPPLVTOANOWNEROFAPROPEPTYWHOBUIL�SORIMPROVESTHEREON,AND � � WHOCON7RqCT5FOR5UCHPROJECTSWITHACON7RACTOR(5)LICENSFOPURSUANTTOTHECONTRAC- (,�UANTITY DESCRIPTION FEE Y TOFS LICENSE LAW). � ❑1 AM EXEMPT UNOER SEC. 6.S P C.FOR THIS REASON J O V � � u" DATE OWNER U Z W QLICENSED CONTRACTORS DECLARATION W [C IHEREBVAFFIRMUNDERPENALTYOFPEflJURVTHATIAM'_ICENSEDUNOEPFPOV�SIONSOFCHAPTER � p. 9(COMMENCING WITM SECTION 700aJ OF DIVISION 30FTHE 9USINESSAND PROFESSIONS COCE,AND Z X MY UCENSE IS IN FULL FORCE AND EFFECT � LICENSE C�LASS �` UC.NO. �j a �� /� j V �ATE ���C� ` � CONTRACTOR����Z d . W � WORKERS'COMPENSATION DECLARATIO a � �HE0.EBYAFFIRIAUNDERGENA�TVOFPERJURYONEOFTHEFOLLOWINGDECL0.RATION5' Z Z _IHAVEANDWILLMAINTAINACERTIFICA7EOFCONSENTTOSELF-INSUREFOFWORKERS' �' _ ¢ COMPENSATION,AS PROVIDED BY SECTION 370o OFTHE LABOR CODE,FOR iHE PERFORMANCE W OF THE WORK FOR WHICH THIS PERMIT IS ISSUE�. � � � w _I HAVE AND WILL MAWTAIN WORKERS'COMPENSPTION INSURANCE,AS REOUIRED BV SECTION r Q 37000FTHELA90flCODE,FORTHEPEflFORMANCEOFTH WORKFORWHICHTHISPERMI7IS ��p 5� ISSUED.MVWO ' ENSATIONINSURANCECAR RANDPOL'�.CVNUMBERARE: CONSTRUCTION ¢ w� /+� > cqaaiEa PLAN REVIEW �V" Z POLICYNIJMBER t ELECTRIC ¢ (iHIS5ECT70NNEmNOTBEmMPLETEDOFl1$PERMfTIS�ORONEHLNDRED001.1AA5(510DjORL�S�_ PLUMBING � W Z ICERTIfVTHA7INTHEPERFORMANCEOFTHEWORKFORWHICHTHISPEflMITISI5SL1ED,l MECHANICAL _ ._. C:J SHALL NOT EMPLOY ANY PEftSON IN ANY MANNER SOAS TO BECONE SI/BJECT TO THE (n WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOUI.D BEGOME INSPECTION FEE = SUBJECTTOTHE WORKERS'CONPENSATION PFOVISIONS OF SECT'.ON 37aoOFTHE L4BOR CODE,I SHALL FOftTHWITH COMP4Y WITHTHOSE PROVISIONS. ISSUANCE P � SMIP p DA7E:_ APPLICANP. � WARNING:FAl1.UFETOSECUFEWORHERS'COMPENSATIONCOYERAGEISUNLAWFUL,AN�SHALLBE ENERGYP/C �—y SUBJECTANEMPLOVERTOCRIMINA�PENALTIESANDCIVI'.FINESUPTOONEHUN�REDTHO'JSAND ENERGYPERMIT DOLLARS(51oo,oao�,IN ADDITION TOTHE COST OF COMPENSATION,DAMAGES AS PROVIOED FOR IN J SECTION37oeOFTHELAeORCODE,INTEREST,ANDATfORNEV'SFEES RETENTIONFEE: ♦ � nw, CONSTRUCTION LENDING AGENCV pRE-ALT FEE: O � I HEREBV AFFIRM UNDER 7ENALTV OF PER.IURV THAT THERE IS ACONS7PUCilON LENDING AGENCY FOR THE PERf-0RMANGE OFTHE WORK FOR WHIGH THIS PERMITIS ISSUED(SEC.3a9],CIV.C.). . Z W � LENOER'S NAME F LENOER'SADDRESS � TOTAL FEES ��`��m 4?J � � I CERTIFV THAT I HAVE REAO THIS APPL'CATION AND STATE THAT TNE A80VE INFORMATIDN IS CORR'cCT. w I AGREE TO COMPLY WITH ALl CITY AND COUNTV OqDINANCES ANO STATE LAWS RELATING TO BUILOING � � CONSTRUG�ION,AND HEFEBV AUTFORIZE REPRESENTATIVES OF THIS COUNTY'O ENTEfl UPON THE � ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. Z COMMENTS � J � m P ITT NAME(PRINT)C� Q N .�� ..��� � S�t`�NAW�OF� �"�{I TE�E DATE = RECPT.NO. AID BY VALIDATION ~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy.GOLDENROD--File Copy,GREEN—ApplicanYs Copy -- -_ � ��3. 1��- _ . _ _. _ � ....� .euf�:.:-... aAi.,,{'�r",J:, ,�,t��..--..�c4.V . , ..�.. .P.'....�.�-.. .. . " . . .t'x fS " ' .. ; . ., .c.lip.;.. ,II.,.. �rtr'N: .��.t3 . .. .., .. ... . ,. 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