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HomeMy WebLinkAbout17546 (10) —__ __ _ --- -- _ l _ __ � � CIT�'QF DIAMOND BAR ` - -1``'��'°`-- DEPARTMENT OF COMNiUNi'd'Y&DEVELOPMENT SERVICES I I �� 21825 E.Copley Drive � ' '�'" (909)860-3195 Fax(909}861-3117 PRESS '"`%.�riy"" BUILDING FERMIT APPLICATION FI RM LY � JOBSITE > � rp,,��� , � APPLICATION PERMIT P/C � a ADDRESS `e�� ��,����. DATE ` NUMBER # �o ISSUE TYPE OCC `�° APN LOT TRACT DATE CONST. GROUP °C OWNER �,e,� %c^�c.f-Z.`'a o ADDRESS l��� ����v°�.�'0 �� ZONING SETBACKS Z CITY� C��"� �c3�ZIP TEL. y — � FRONT RW ❑ o APPLICANT s" >�-i' d � ' ��xa � TEL�1Y° �3 REAR ❑ SIDE/SIDE STREET RW ❑ m CONTRACTOR �t � �, SIDE ❑ ¢ ADDRESS "` ' 6 '� PROPOSED USE ' o CITY 4� ' '�, ZIP , `� TE .�� ti'� � w ARCH/ENG/ -�-° z DESIGNER • NO.DWEL. N . j �"�- a ADDRESS UNITS S ORIES �����"�bR S � CITY ZIP TEL. C° DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION u� � OWNER-BUILDER DECLARATION SFR/ADD/REM O p�, 1 HERE6Y AFFIRM L1N�ER PENALTY OF PER,lIRY THAT i AM EXEMPT FPOM THE CONTRACTOFiS LI- G2fH9B/C8fp0�I W.'� CENSELAWFORTHEFOLLOWINGREASON{SEC.7o37.50USINESSAN�PfiOFES5lON5CaDE:PNYCITYOR [n �, G.�'�. COUNTYWHICHRE�WFESAPERMITTOCONS'fRUCT.AITER,IMPROVE,DEMOLiSH,ORREPAIRANYSTRUC- . W pgtlo/DEdc '�. w�� TUFE,PRIOR 70 I75 ISSUANCE.ALSO RE�UIRES TNE APPLICANT FOR SUCH PERMITTO FILEASIGNED W � SiATEMENT THAT HE OR SHE IS LICENSED PUftSUANT TO THE PROVISIINJS OF THE CONTRACTORS�I� �, CENSE LAW(CHAPTER 9(COMMENqNG WITH SECTION 7o00)OF�IVISION 3 OF THE 6VSINESSAND PRO- V' PooVSpa �, �FESSIONSGODE)DRTHATHEORSHEISIXEMPTTHEREFROMAN�THEBASISFORTHEALLEGEOE%EMP- � (� :V, TION.ANYVIOLATIONOFSECTION7037,5BYANYAPPLICpNTFORAPERMIT5U8JECT5TFiEAPPLICANT'O Z Re-Rooi ��., �ACIVIL PENFLTY OF NOT MORE THAN FIVE HUNDRED�OLLl�RS(55oo),J: 0 ❑I,ASOWNEROFTHEPROPERTY,ORMYEMPLOYEESWITH.WAGESASTHEIRSOLECOMPENSA710N, � Comfn2fCial ,Z�, 'WILL DO'THE WORK,AN�THE STRUCTURE IS NOT IMENDED OR OFFERED FOR SALE(SEC.7�44,BUSI� .J ��NESS AND PROFESSIONS CODE:THE CONTRACTOfiS LICENSE LAW DOES NOT AGPLY TO AN OWNER OF � PROPERTYWHOBUILOSORIMPROVESTHEREON,AN�WHOOOESSUCHWORKHIMSELFORHERSELFOR �' m p["��.THROUGHHISORHEROWNEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTeNDEDOR W'� OFFEREDFORSALE.IF,HOWEVER;THEBUILDINGORIMPflOVEMENTISSOLOWITHINONEYEAROFCOMPLE� '��i i ',TION,THE OWNER-9UIL�ER WIIL HAVE THE BUR�EN OF PROV!NG TMAT HE OR SHE�ID NOT BUILD OR Z�' � IMPROVEFORTHEPURPOSEOFSAIE). _ ❑I,ASOWNEROFTHEPROPERTY.AMEXCLUSIVELYCONTRACTMGWGHLICENSEDCONTRACTORS ��,' TOCONSTRUCTTHEPPOJECT(SEC.7o64,Bl1SWE5SANDPROFESSIONSCODE:THECONTRACTORSLI- V8I1J8110f1 ADJ.AREA � '�W�' ".�CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERiYWHOBNLDSORIMPROVESTHEREON,AND �' WHOCONTRACTSFOflSUCHPROJECTSWITHACONTRACTOR[S�LICENSEDPURSUANTTOTHECONTRAC� QUANTITY DESCRIPTION FEE Y TORS LICENSE LAW.). , , O J ❑I AM EXEMPT UNDER SEC. B.8 P.C.FOR 7HI5 REASON �� �S � � DATE OWNER V ' Z', W � LICENSED CONTRACTOAS DECLARATION �j ' � IHEPEBYAFFIRMUN�ERPENALiYOFPERJURYTHATIAMIICEN5E0UN�ERPROVISION50FGHAPTER �' d,� 9(COMMENCINGWITHSECTION7000�OF�NI510N30FTHEBU5WES5ANDPROFE5510N5CODE,AN� Z 'X MY LICENSE IS IN FULL FOPCE AN�EFFECT. '��� qj¢�� , m , � LICENSE C SS �L �L�(.�+�� LIC.NO. � ~ DATE � r p '"�� CONTRACTOR � a � '�i�c��RKERS'COMPENSRTIONDECLARATION a � � U � IHE 1�j�FMRMUN�ERPENALTVOFPERJURYONEOFTHEFOLIOWINGDECLARATIONS: Z Q O IHAVEANDWILLMAINTAtJACERTIFICATEOFCONSENTTOSELFINSUREFORWORKERS' _ . CAMPENSA71oN,ASPFOVIDEOBvSECTION37ooOFTHELABORCODE,FORTHEPERFORMANCE U a , AP1°HE WORK FOR WHlqi THIS PERMIT IS ISSUED. � � �/ l� IHFVEANDWILLMAINTAINWOPKERS'COMPENSAiIONINSUHANCE,ASFEQU:REDBYSECTiON � O 370o OF THE LABOR CODE.FOR 7HE PEFFORMANCE OF THE WORK FOR WHICH THIS PEfiM1T IS ISSUED.MY WORICEAS'COMPENSATION IN ANCE CA IER AND POI_ICY Nl1MBER ARE: CONSTRUCTION �J ,�C�!�, -, CARflIER /g � y�� �_ P�.N pEV�EW c 0 POLICY NUMBER_��Y'��e ^^ ��%"9�� �� ' �.�. ELEC7flIC z a � (IHISSECTIONNEmMJTeE�A�L.�EDOFTHEPERMITISFORONEHUNDREDDOLUIRS(5700)ORLESSI. PLUMBING W MECHANICAL Z I CERTIFY iHAT ly THE PERFORMANCE OF THE WOFK FOR WHICH TH:S PERMIT IS ISSUE�,I '(}' SHALL NOT EMPLOYFNY PERSON INANY MANNER 50 AS TO BECOME SUBJECTTO THE � WORKERS'COMPENSATION LAWS OF CAUFORNIP,AN�AGREETHAT!F I SHO LD BECAME INSPECTION FEE � Sl18JECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION.37oo F THE LABOR _('�'� = COOE,I SHALL FDRTHWITH COMPLV WITH THOSE PROVISIONS. --ISSUANCE �`+��� � � SMIP - � p DATE:_��~V�—C��APPLICANT. + ' , . W ENERGY P/C J WA NWG�U SECURE WORKERS'COMPENSATION COVERAGE IS UNLANlFUL,AND SHALL BE J SUB ECTAN EMPLOYER TO CRIMINAL PENALTIES ANO CIVIL FINES UP TOONE HUNDRED THOUSAN� W ENERGY PERMIT DOLLARS�$ioo,000),INADDITIONTOTHECOSTOFCOMPENSATION,DAMAGESASPROVIDEDFORIN � , J SECTIDN3�OBOFTHELABORCODE,INTEREST,ANDATTORNEY'SFEES. RETENTIONFEE: � � CONSTRUCTION LENOING AGENCY PRE-ALT FEE: . O � I HEREBV AFkIRM UNDER PENALTY OF PERJURV THATTHERE IS ACONSTFUCTION LQJOWG AGENCY � FOR TIiE PERFORMANCE OFTHE WORK fOR WHICH THIS PERMiT IS ISSUED(SEC.309],CIV.C.). � Z W 2 LENDER'S NAME � F= LENDER'SA�ORE55 � TOTALFEES � � � � I CERTIFY THAT I HAVE READ TNIS APPLICATION AND STATE hiATTHE ABOVE INFORMATION IS CORRECT. � IAGREETOCOMPLYWITHALLdTYANDCOUNTYORDINANCESANDSTATELAWSRELATiNGTOBUILDING � � GONSTFiUCTION,ANDHEREBYAUT ORIZEREPRESENTATIVESOFiHISCOUNTYTOENTERUPONTHE � A80VE-MENiIDNEOPROPERTYFO INSPECTIONPURPO5�5. 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