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HomeMy WebLinkAbout17217 (23) /'�� _ CITY OF DIAMOND BAR �� DEPART'MENT OF COMMUNITY&DEVELOPMENT SERVICES 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 PRESS "'-Hrt�'�� BUILDING PERMIT APPLICATION FIR Y o DDR'ESS� ' � I � `�' �'���r "�V�d �� DATECATION ��/�, � �� NU BER�� �`C � � ISSUE TYPE OCC APN LOT TRACT DATE � � CONST. GROUP p OWNER _Sf)1GF ��� p ADDRESS S% ✓�/" --- ZONING SETBACKS � CITY K- ZIP TE .,��/r�lS".�//� FRONT RW ❑ g APPLICANT A�7=-ti T�6zbl� 3'Si�""- REAR ❑ Z SIDE(SIDE STREET RW ❑ Q CONTRACTOR �-^ac SIDE ❑ ADDR SS � PROPOSED USE 1'e0.r'-O OR. �a.St 0.r'a, t. 7c,� � CITY ZIP TEL. -b�� �� , , �� �v o ARCH/ENG/ Z DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS STORIES _�__BEDROOMS � CITY ZIP TEL. � � pESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION $FR/ADD/REM � O p 1 HEREBV AFFIRM UNDER PEN0.LTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTfiACTORS LI� � Garege/Carport W CENSEUWFORTHEFOILOWINGREASON�SEC.7031.58USINESSANDPROFESSIONSCODE:ANVpNOR U COUNTVWHICHRE�l11RE5APERMITTOCON5TRt1CT,ALTER,IMPROVE.OEMOLISH.ORREPAIRANY5TRl1G W palio/Dack W TURE,PRIOR TO ITS ISSUANCE,ALSO flEQUIRES THE APPLICANT FOR SUCH PERMIT TO FlLE A SIGNE� W � STATEMENT THAT HE OF SHE I5 LICENSE�PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- .� CENSE LAW(CHAPTER 9(COMMENGING WITH SECTION]ODO)OF�IVISION 3 OF THE 6USINESS AND PRO- � POOVSPB FESSIDNSCODE)ORTHATHEORSHEISEXEMPTTHEREFP,OMANDTHEBASISFORTHE0.LLEGEDEXEMP� (� � 7ION.ANYVIOLATIONOFSECTION703t.5BYANYAPPLICAMFORAPERAAITSUBJECTSTHEAOPLICANTTO Z Re-Root a � A CIVIL PENALTV OF NOT MOiiE THAN FIYE HUN�RED DOLLARS�E5o0).): O ❑I,ASOWNEROFTHEPFOPERTY,ORMYEFAPLOY'eESWITHWAGESASTHEIRSOLECOMPENSATION, � COrt1R18fC101 Z WILL 00 THE WORK,AND THE STRUCTURE IS ND7INTEN�ED OR OFFERED FOR SALE(SEC.701a,BUS�� J � NESS AND PflOFES510N5 CO�E:THE CONTflACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF � PROPERIY WH0 9UIlDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIAISEIF OR HERSELF ON � THROUGMHISORHEHOWNEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMENTSAFENOTINTENDEDOR m QOFFEREDFORSALE.IF,HOWEVER,THEBUILDINGORIMPROVEMENTISSO'�DWITHINONEYEqqOFCOMPLE� Z TION,TME OWNER-BNLDER Wf�.L HAVE THE eURDEN OF PROVING THAT HE OR SHE DID NOT BUIIA OR � IMPROVEFORTHEPl1RPOSEDFSALE). ❑I,AS ONTlER OF THE PROPEflTV.AM E%CLUSNELY CONTRACTING WITH LICENS ED CONTRACiORS � TO CANSTRUCT THE PROJECT(SEG.7a44,BUSMESS AND PFOFESSIONS CODE'.THE CONTflACTORS LI� V81113110f1 � ADJ.AREA W CENSEIAWOOESNOTAPPLVTOANOWNEROFAPROPERTVWHOBUILDSORIMPROVESTHEREON,ANO � WHOGONTRACTSFORSUCHPROJEGTSWITHACONTFAGTOR(5)LICENSEDPURSUANTIOTHECONTRAG QUANTI7Y ��ESCRIPT70N FEE Y TORS IIGENSE LAW.j. � ❑I dM EXEMPT UNDER SEC. B.8 P.C.FOR THIS REASON Q � U � � �ATE 4WNER V � W � LICENSED CONTRACTORS DECLARATION W Q � I HEREBV AFFIRM UNDER PENALTV OF PERJURV 7HAT IAM LICENSE�UNDER PROVISIONS OF CHAPTER � d 9(COMMENCINGWITHSECTION7000)OFDIVISION30FTHEBUSWESSANDPROFESSIONSCODE,AND Z w MV LICENSE IS IN FULL FORCE ANO EFFECT. / m � LICENSE CLASS G-�� LIC.NO.b����� j � DATE ���I ��'- CONTRACTOR��r�� a W � WOFKERS'COMPENSATION DECLARATION � N I HEREBY AFFlqM UNDER PENALTV OF PERJURV ONE OFTHE FOLLOWING DEC�-ARATIONS: U UJ Q � IHIWEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' _ CAMPENSATION,ASPROVIOEDBYSECT�ON37000FTHELABORCO�EFORTHEPERFORMqNCE U ¢ OF TME WORK FOR WHICH THIS PERMiT IS ISSUED. � � �� w " I HAVE AN�WILL MAINTAIN WORKERS'COMPEN5A71ON INSURANCE,AS PEOUIRED BY SEC710N Q 37oC OF THE LABOii CO�E,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ��� `� � ISSUE�.MY WORKEflS'COMPENSATION IN_SUfR�ANCE CAFRIEF AND POLIGY NUMBERARE: CONSTRUCTION j cnRRieA ►I ZL�-� N�v� pLAN REVIEW Z POLICVNUMBER �r�l.�f�0� ___._ ELECTRIC Q � ((HISSECTKKJN[mN0T6EO�MPlETE00FTHEPERf�ISFORONEHUnDREDDIX1AFi5(S100)ORLESSJ. PLUMBING W Z I CERTIFY THAT INTHE PERFORMANCE OF THE WORK FOR WHICH TF'IS PERMIT IS ISSUE�,I MECHANICAL (,�J SHALL NOT EMPLOY ANY PERSON IN ANY MANNEF 50 AS TO BECOME S�BJEGT TO TNE � WORKERS'COMPENSATIONLAWSOFCALIFOPNIA,ANOAGREETHATIFISHOULDBECOME INSPECTIONFEE = SU&IECTTOTHEWORKERS'COMPENSATIONPROVISIONSOFSECTION37ooOFTHELABOR COOE,I SHALL FORTHWITH COMPLV WIT QSE PROVISIONS. ISSUANCE � O ,�.�j..�� � Q DATE: �a� �� APPLICANT: � ' �^`��"—� SMIP !� J ENERGY P/C J WARNING FAIIUflE TO SECURE WORKERS'CAMPENSATION COVERAGE IS UNUIWFUL,AN�SHALL BE � SUBJECTANEMPLOYEFTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDflEDTNOUSAND ENERGYPERMIT DOlLARS(S100.000),IN AD�ITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN � SECTION37oBOFTHEL480RCODE,INTEREST,AVDATTORNEY'SFEES. RETENTIONFEE: � d CONSTRl1CTION LENDING AGENCY pRE-ALT FEE: � I HEREBV AFFIRM UN�ER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR iHE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUEO(SEC.3091,CIV.C_�. Z W � lENOER'SNAME ____._.._ F- LENDER'SADDRESS („� W ICERTIFYTNA7IHAVEREADTHISAPPLICATIONANDSTATETHATTHEABOYEWFORMATIONISCORRECT. TOTAL FEES ��Z� 4�� d I AGREE TO COMPLV W17H AI.L CITY AND COUNTV ORDINANCES AND STATE LAWS RELAT�NG TO BUIL�ING � CANSTRUCTI�N,ANDHEREOVAUTHORIZEREPRESENTATNESOFTHISCOUNTVTOENTERUPONTHE Z ABOVE-MENTIONEJ PROPERTY FOR INSPECTION PURPOSES. COMMENTS � ��,� m NPEf�AITTEENqME�PRINT)y-� ���� _D r f� M c.�� � � 51 A E OF PEF TfEE DATE _ . RECPT.NO. 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