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HomeMy WebLinkAbout16908 (40) � CIT'Y OF DIAMOND BAR I�� DE�ART'P�NT OF COMMUNITY 8i DEVELOPMENT SERVICES 21825 E.Copiey Drive (909)860-3195 Fax(909)861-3117 PR ESS - \%v�v'' B�JILDING PERMIT APPLICATION FIRMLY � JOBSITE �g �s ,s� APPLICATION / / PERMIT P/C � a ADDRESS 17�"__/ �]I�� �A°�L1� DATE .X'�L�Z3 "�! NUMBER��� # o ISSUE / TYPE OCC °T APN LOT TRACT DATE ��` t�O ' �� CONST. GROUP p OWNER o ADDRESS ������y� �F�1� � ZONING SETBACKS Z CITY � � ��t'1-ZIP TEL. FRONT RW ❑ A APPLICANT TEL. SIDE/SIQE STREET RW ❑ m CONTRACTOR �� � �� SIDE ❑ � ADDRESS '� m � CITY ii,IIL°S�LJ1)'u-`T ZIP TEL��9�� PROPOSED USE�il�^ ����f'�� ��.�i'• w ARCH/ENG%� z DESIGNER NO.DWEL. NO. N0. a ADDRESS UNII'S STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER-BUIL�ER DECLAFiATION SFR/ADD/REM O � I HEREBY AFFIRM UNDER PENALTY OF DERJURY TH4T I AM'=XEMPT FROM TNE CONTRACTORS'�_I- � �,arage/Ca�port � W CENSEIAWFORTH'eFOLLOWMGfIEASON�SEC.7031.6BUSINESSANDPftOFE5510N5CODE:ANYCITYOR U COUNTVWHICHREQUIRESAPEFMITTOCON6TRUCT,ALTER,IMPflOVE,DEMOLISH,OftREPAIRANYSTRUG W Patio/Deck tURE,PRIOR TO ITS ISSUANCE,dL50 REOUlRES THE APPLICANT FOR SUCH PERMIi TO�IIE A SIGNEO W I, � STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO TME PROVISIONS Of THE CONTRACTORS LI- ' � CENSE LAW(CHAPiER 9�COMMENCING WITH SEC7:ON 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- LL PooUSpa 0 FESSIONSCODEjORTHATNEDS�HEiSEXENPTTHEREFRCMA4DTHE6A545FaRTHEALLE3EDEXEMP- V TIDN.ANYVIOLATIONOFSECTION'�`7a31.5BVANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO Z Re-Rwf � �ACIVIL PENALTY OF NOT MOPE Tr7AN FNE HUNDRED DOLLAHS(E5oo).): . 0 ❑I,F50'J1t1EROFTHEPROPERN,ORMVEMPLOYECSWiTHiYapESA'sTHEIR50LECOMPENSATiON, 0 COfi1RIEfC12I Z WILL DO THE WORK,AN�THE STRUCTURE IS NOT INTENDEO OR OFFCRED FOR SALE(SEC.7044,6U51- J NESS AND PHOFESSIONS CO�E:THE CONTRACTORS LICENSE lAW DOES NO7 APPLY TO AN ON'NER OF � PROPERTYWHOBUILDSORIMPRO�,VESTNEFEON,ANDWHODOESSUCHWORKHIMSELFORHERSELFOR m [[ 7HROUGHHISORHEROWNEMPLbYEES,PROVIDEGTHATSUCHIMPfloVEMENTSARENOTINTENOE�OR QOFFER�FORSALE,If,h'OWEVE9.h"HEB'JILOMGORIMPP.OVEMENTISSn(DWITHINONEYEAROFCOMPLE� 2 � TION,THE OWNER-BUILDEF WILL�IAVE THE 6Up0EN OF PROVING THAT HE OR SHE�ID NOT BUILD OR = IA�PROVE FORTHE PURPOSE OF SALE). ❑I,AS OWNER OF THE PROP�EflTV,AM EXCLUSNELY CONTRACTING WI1H LICENSED GONTRACTORS '�. � TO CONSTRUCT 71IE PROJECi(SEC.7044,@USINE55 AND PflOFE5510N5 COOE:THE WNTRACTORS LI- V2IU8llOf1 � ADJ.AREA '� W �CENSELAWDOE3NOTAPPLYTOANOWNEROFAPROPEHTY6NNa9UILD50RIA1PROVESTHEREON.AND � WHOGONTiiACT5FOR5UCMPRO.IECiSWITHACONTRACTOR(S)LICENSEDPUHSUANTTOTHECONiRAt- QUANTIN DESCRIPTION FEE . Y TOflS LICENSE LAW.�. J � O ❑I AM EXEMPT UNDER SEC.', B.8 P.C.fORTH15 REASON U � — S � � �ATE " OWNER.� U � LICENSED CONTRACTORS DECLARATiON w � � I HEREBY AfFIRM IINDER PENALTY OF PEAJUPY THA71 AM LICENSED UNDER PROVISIONS OF CHAPTER � d 9�COMMENCING WITH SECTION 7dao)OF DIVISION 30F THE BUSINESS AND PROFESSIONS CODE,AN� z '' `X 6/�UCENSEISINFULLF09CEAN�EFFECT. � �G � � � LICENSE SS UC.NO.� � J � V DATE�� ' ¢ CONTfiACTOR�"bt— .Q!` � n- W � � WORKEqS'COMPENSATION DECLARATION a � IHEHEBYAPFIRMUNDEHPENALNOFPERJURYONEOFTHEFOLLOWING�EGLARATIONS: � � Z Q � _IHAVEANDWILLMAIN7AlIJ,ACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKEFS' 2 COMPENSATION.A3 PROVIDE�BYSEC710N 3�0o OF THE LABOR COOE,FOR THE PERFOFMANCE W OF THE WORK FOR WHICH'�THIS pERMIT IS ISSUED. � � W _IHAVEANOWILLMAINTAIN�,WORKEFS'COMPENSATIONINSURANCE,ASRcQl11RED8YSECTION Q 37000FTHELABOFCODE'�FORTHEPERFOflMANGeOFTHEWORKFORWHICHTHIS?EFMITIS p�� ISSUEP.MYWORKEAS'CCqAPEN5ATl0 NSURANCE FRIERAN�POLICYNUMBERARE: GONSTRUCT�ON r�� j caaaiEa� 1_�*-�� PLANREVIEW Z POLICY NUMBER � � ELEGTRIC Q � Q (tHISSECT}JNNEmNDTBEF.UMPLETEDOF7HEPERMTISFORqJEHUNOREDDOLA95(510D)ORLESS). PLUMBING � � ICERTIFV iHAT INTHE PE�FORMANCEOFTHE WORN FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL �J' SHALL NOT EMPLaY ANY P RSON�N ANY MA4NER S�AS T�9ECDME SUO,IECTTO THE � ' � WORKERS'COMPENSATIO�I LAWS OF CALIFORNIn,ANDAGREETHAT IF I SHDULD BECOME INSPECTION FEE � � SUBIECTTOTHEWORKEF�S'COMPENSATIONPROVISIONSOFSEC710N3]ooOFTHELABOR ISSUANCE . � CO�E,1 SNALLFOflTHW1Tl�GOMPLY WI7H iFIOSE FFOVI'IONyl,�� _-- d' SMIP -�� p DATE:���. AbPLICANT: '',■ � J ' ENERGY P/C J WARNING GAILURE TO S[CURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE �y SUBJECTANEMPLOYcRTOCPoMIh�ALP�NALTIESANDCNILFINESUPTOONEfiUNURE�THDUSAND ENERGYPERMIT ._ DOLLARS(5����'+).IN ADDITION Tb THF�COST OF COMPENSATION,OAMAGES AS PROVIDED FOR W r v � SECI ION 3148 OF THE LABOR CO�E,INTEREST,AND ATTORNEV'S FEES. RETENTION FEE: ,._ / � - � CONSTRUCTION LENDING AGENCY PRE•ALT FEE: �ryj � I HEPEBYAFFIRM UNDER PENALiYIOF PERJURY THA�THERE IS A CONSTRUCTION LENDING AGENCY r'P/ �� FOR TNE PEFiFOHMANCE OFTHE N�OflK fOR WHICH THIS PERMIT IS ISSUED(SEC.3097.CIV C.). Z '.�..d ' � _ 3 LENDER'S NAME ,� I I-= LENOER'SA��RE55 �_I��',/�'� __.��- �fa..v'�y�` �+''�`� . � ICEPTIFY?HATIHAVEREADTHISAPPLIGATIONANDSTATETHATTHEABOVEINFORMATIONISCORRECT. TOTALFEES ��� � � IAGREETOCOMPLVWITHALLCIN�ANDCOUNTYOfl01NANCESAN�STATELAWSRELATING708UILDING � CGNS7RUCTION,ANDHEflEBYAl1T��iOFI2EREPriESE13TA71VE5OFTHISCOUNTYTOEN7ERUPOIJTHE / � p , Z ABDVE-MENTIONEO PROPERTY FO(i INS{?ECTION PURPOSES. CDMMENTS - �' ��S � o ��- t �L�.� y e� °4� L�� "�� J � � O..d�� �y{y t �J ' � . aPERMIT'fEENAME PRI T) ' �NL�i-)� ^�+'��' � '� " - � � ,� � �- -� p�--- ���' , � SIGNA R ITT � �ATE ' . _ , RECPT.NO. 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