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HomeMy WebLinkAbout16662 (35) !i 9� � � CITY oF DIAMOND BAR ------1�''-- DEPARTMENT OF COIvIlbiUNITY&DEVELOPMENT SERVICES '� rz � � 21825 E.Copley Drive (909)860-3195 Faac(909)861-3117 PRES.S ``'-����,' BU[LDING PERAZIT APPLICATION FIRMLY o� JOBSITE ����� ������ ]1��� APPLICATION�,�g+ �� � � PERMIT � ' P/C ADDRESS_ �� �ATE "'`� a NUMBER . W ISSUE � 9� � " TYPE OCC APN LOT YRACT �ATE �' CONST. GROUP p OWNER � ADDR 5 `� ` W ZONING SET6ACKS z CITY ZIP TEL. a � REART RW ❑❑ a APPLICANT TEL._� SIDE/SIDE STREET RW ❑ ¢ CONTRACTOR '�� ` •-�"CD P'� SIDE ❑ � ADqRE $, PROPOSED�S� ��'� . b �� � T/°���C � � CITY Z1P TEL. iZ ` '� �w ARCFi/ENG! ��,�� � � � �� wDESIGNER NO.DWEL. NQ. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� ' OINNER-BUILDEft DECLARATION SFR/ADDlREM O ��, 1 HEREBY AFFIRM UNDEFI P�NALTV OF PERIURY THAY 1 AM EXEMPT FROM THE CAN7RACTORS LI- � Garage/Carport "W� CENSE LAW FORTH6 FOLLOWING REASON�SEC.7037.5 BiJSMESSAN�PPOFESSIONS CODE:ANY CITYDR , '�U COUNiYWHICHqEQUIflESAPEfl,ITTOGONSTRUCT,ALTER,ISIPROVE,DEMOLiSH,ORREPAIRANYS7RUC- W �P0110/DBCK '� .w TURE,PRIOR TO IYS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SI1CH PcRMIT TO FILE A SICNED W STATEMEM"THAT HE OR SHE IS LICEN$E�PURSUANT TO THE PROYISIONS OF iHE CONTftACTORS LI- � '�,� CEN$E LAW(CHAPTER s(COMMENCING WITH SECT;ON 7oD0)OF�IVISION 3 OF iHE BUSINESS AND PRO- V" POOVS(lfl � � 'FESSIONS CO�E�OR iHAT HE OR SHE IS EXEMPT THEREFPOM AND THE BA515 FOfl iHE ALLEGED EXEMP- ,V, T�ON.ANYVIOLATIONOP9ECTION7o31.5BYANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICP.NTTO Z pe-Roof �� � ACIVILPENALTY OF NOT MORE TI'�IAN FIVE HUNDRED�OLLARS($500�.): ,',Q .[]I.A50WNEROFTHEPROP,ERTY.OflMYER1PLOYEESWITHY✓AGESASTHEIRSOIECOMPENSATION, Q ,- WILL DO THE WORK,AN�hiE STqUGTURE IS NOT IMeNDED Oq OFFERED FOR SALE(SEC.7a44,BU51- J C011'If110fCldl � �Z'. �NE55 AN�PROFESSIOMS COOE:7'HE CONTRACTOflS LICENSE LAW DOES NOT APPLY TO AN OWNEFi DF � 'PflOPERTYWHOBUILDSORIMPROYESTHEREON,ANOWHO00ESSUCHVlOflKHIMSELFORHEflSELFOR � ' �.�'� THROUGHHISORHEROWNEMPOYEES,PROVIDED-HATSUCHIMPROVEMENTSARENOTINTENDE�OR CD �� '',� OFFERE�FORSALE.IFHOVJEVER,hIEBUILDINGORIMPROVEMENTI550LDWITHINONEYEAROFCOMPLE- ;�Z TION�T�'�E OWNER-BUILDER WILL�HAVE'.THE BURDEN OF PROVI�G THAi HE OR SHE DID NOT BUILD OR � .� �IMPROVEFORTHE�PURPOSEOFSALE).' '. W. � pI,A50WNEROFiHEPROPERiW.AMEXCLUSlVELYCONTRACTINCWITHLICENSEDCONTRACTORS ,�,`. ' '�,(r� TO�CANSTFl1CTTHE PFOJECT(SEC.7044,9USINE55 AN�PROFESSIONS CODE:THE CONiRACTORS LI- "'��uation ADJ.AREA .W CENSEU+W�OESNOTAPPLYTOANOWNEROFAPROPERNWHOBUILDSORIMPFlOVESTHEREON,AND ' '�' WHOCONTRACTSFOqSUCHPROJECTS.WITHACONT�ACTOR(5)LICENSEDPURSUAN7TOTNECONTRAP QUANTI DESCRIPTION FEE ,� TORSUGENSE,�A'N). ', � , �OIAMEXEMPTUN�ERSEC.��� B.SP.C.FORTHISREASON Q � U W � DATE � OWNER U W �,'��—,' LICEN�ED CONTRACTORS DECLARA770N W ��". I HEREBV AFFIflM UNQER PENAIT�OF PERJURV THAT I AM LICENSED UNGER PROVISIONS OF CHAPTER � ' '�.d 9(COMMENCINGWRHSECTION7d00)OF�IVISION30FiHEBU5WE55ANDPROFE5510NSCO�E,AND Z ',,4X MY LICENSE IS IN FULI FORCEANb EFFECT. �-�------ ��� m ��I LICENSE SS�,� LIC.NO. � � ,.W: DATE �����r i,�___ CONTRACTOR p C .0 � � d �J � WOAK�RS'COMPENSATION DECLARATION �" � a = U "�;' IHEREBV0.FFIfiMUN�ERPENALNOFPERJLIRYONEOFTHEFOLLOWING�ECLAFiATIONS: z '��"�� �IHAVERN��WILLMAINTAI ACERTIFICATEOFCONSEMTJSELF-INSl1REFORWORKERS' _ � ''Z" CAMPENSATION�,AS PROV OED 6Y SECTION 370o OF THE LABOF CODE,FOA THE PERFORMANCE U ¢� ! OF THE WOflK FOR WHl THIS PERMIT IS IS5UE0. � �' �IHAVEANDWILIMAIN'fAI WORKERS'COMPENSATiONINSURANCE,ASREQUIREDBYSECTION ��� � Q,'�. 3700 OFTHE I.AAOFS CODE F�R THE PERFOqMANCE OF THE WORK FOR WHICH THIS PERMIT IS 0"i ISSUED.MYNVORKE�15'C P ATIONIN RANCECARFIEFANDPOLIGYNUMBERARE: CONSTRUCTION V ¢', , ,>. cnqRreR���� PLAN REVIEW ,������ POLICY NUM9EH � � � � ELECTRIC ¢��� (hIISSEC�I,ONNEmN0T9EpJMPCETEDOFiHEPERMiTISWROh�Ht1NDRE�00LUR5($10qORLESS� PLUMBINC� W I .� �, ICERT�FYTFIATI,N�THEPEqFORMANCEOFTHLWO�KFOflWHICHTHISPERM�TISISSUED,I MECHANICAL (,�il'i SHALLNQT��PLOVANV�Eq50NINANVMANNER50ASTOBEfbME5L18JECTTOTHE (n; WORKER$'COMPEN5ATI0 LAWSOFCALIFORNIA,ANDAGREETMATIFISHOUIOBECOME INSPECTIONFEE { � 'y �I, SUBJECT'�O�WORKE 5'COAAPENSATIONPROVISIDNSOFSECT���ooOFTH LABOR ISSUANCE ��`fJ_a\ �v �i f �1� . t S.Jf,��+ �i C E,15 ALG FORTHWIi COMPLY IT T �E P S�IgNS. 3 �$d �� Oi, � i ' ���� SMIP - 4 ' n %�J �I,, DATE: A PLICANE � , — J WARNING FAIL�RE TO SECUpE W�,KERS'GOMPENSATION GOVEflAGE IS UNLAWFUL,AND SHALL 6E ENERGY P/C ��__ _�.� �y SUBJECTANEMPLONERTOCRIMI ALPENALTIESANDCIVILFMESUPTOONEHUN�REDTHDUSAND ENERGYPERMIT � �JOLLARS(f700.otlp),IN AO�ITION T iHE COST OF COMPENSATION,DAMHGES AS PROVIDED FOR IN JI SECTION9lo80F7HE'i,4�OpCOO,INTEREST,ANDATiORNEV'SFEES. FETENTIONFEE: {{ � .�' ��GO STRUCTION LENDING AGENCY PRE-ALT FEE: E��r�_ --.._--�'_�---` O',; ��'� IHEflEBVAFFIRMA�';UNDERPLNALTYOFPERJUFVTHAiTHERE'SACONSTRUCiIONLENDINGAGENCY ��i FORTHEPERF-0HMANCEOFYHEWOFKFORWHIGHTNISPEHMITISISSUED(SEG.3o9],CIV.G.). , � � w, I �;li. LEN�ER'S.NAME , ____ _ � ��� LENDER'SADORESS; I �� TOTAL FEES � ��_ � � �I'''' I CERTIFV THAT I HAVE�,REA�TNIS APPLICATION AND SiATE THAT THE ABOVE INFORMATION IS GOqflECT. 0.�,I:�'�, I AC.REE TO COMPI:Y',��"l1TH ALL CITYAND COUMV ORDINANCESAND SiATE LAWS RELATING TO BUILDING !� � WIJSTftUCTION,bND�IEREBVAUT� RIZF.REPRESFNTATNESOFTHISCOUNTYTOENTERUPONiHE + �,�- ABOVE�v1ENTIOFIED WAOP'cRTY FO� SP CTI N PURPOSE Q I COMMENTS - J ���'.. � ' PERMITTEENhkY�(P�IN� � I I � i� �II, �i .. � ' n� — '� SIGNATUREOFhER' E � DATE �,,,. RECPTNO. 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