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HomeMy WebLinkAbout13448 (22) CITY OF DIAMOND BAR e�,�'"'y� � � ----1�' DEPARTMENT OF COMMUNITY Bc DEV.ELOPMENT SERVICSS � 21660 E.Copley Drive Suite 190 �� (909)8603195 Fax(909)861-3117 PRE$$ .... ""BUII.DING PERMIT APPLICAT,ION —_- ' FIF��IALY 9tts . o ES5 � .. SSUE a DDRI ., + ATION PERMIT /��� P/C ' Q TE APPLIC NUMBER # /��/^� a TYPE OCC °D APN LOT' ` T T DATE � P ( CONST. GROUP p OWNER F' " a _ p ADD S :` ZONING SETBACKS Z CI ZI , , TEL. REART RW ❑�. o APPLBCANT I - TE SIDE/SIQE STREET RW O � CONTRAC ,,R ;. � � SIDE. ❑ s C� E i ZI r • a ' TEL. PROPOSED USE w ARCHlE G/ ��i�i�� NO.DWEL. NO ' z ,DE5IGNER NO. w � , i MS TS STORIES BEDROO ' = CQDRESS � ZIP TEL. `� - " ' uNIDESCRiPTION SQ.Ft FACTOR PSF ADJ.AREANAI,UATION' � I ' �, dWNER,-6UILDER DECLARATION ' _ ' . SPR/ADD/REM .. � ��, �� � ' . � � .� � � O , ' 0 I H�REBY AFFIRM UNDER PENALTV OF PEPJURV THAT I AM EXEMPT FROM THE CONTRACTORS LI � � Garage/Carport ' ���W� CENSELAWFORTHEFQCLOWWGPEA90N(9EC.7o97.58USINESSANOPROFESSIONSCACE:ANVCINOR , � �UNTYWHICHHEOUIflESAPERMITTOCONSTRUCT,ALTER;IMPROVE,DEMOlISH,ORREPAIfiANY$IAUG �'W PdUO/DeCK - W NRE�,PRIOR TO ITS ISSUANCE,PLSO'�REQUIRES THE PPPGCANT FOR SUCH PERMIT�70 FIIE A SIGNED �.W � �57ATEMENT THAT HE OR SHE IS�,LICENSED PUFlSUANT TO THE PROVISIONS OF iHE CONTRACTORS.LI- ,� �,CENSE 4AW(�APTER 9(COAAMF,NCINO WRH SECTION�oaU),OF DIYISION 3 OP THE BUSINESS AN�PRO- � u' PooUSPe FESSIONS�E�ORTHAT HE OR SHE IS EXEMPTTHEREFROM AN�THE BAS�S FOR THE ALLEGED EXEMP- V TION.ANYVIOIATIONOF6ECTION7081.68VANVAPPLICANTFORFPERMITSUBJECTSTHEAPPLiCANTTO �'�Z Re-Roof i � � ' � '� ACINL PENALTYOF NOT MORE 7HAN FIVE HUNDRED DOLLARS(5500):): "' "' ' ' . , . � �;, ❑I,ASOWNEROFTHEPROPERTY,ORMYEMPLOYEE9WIhIWA0E5ASTHEIF150LECAMP�NSATION, � �� Commercial . - � .Z... „WILLUDTHE WORK,AND THE.STRUC7URE IS NOT IYTENOED OR OFFEflED FOR SALE(SEC.7044,.BU51- J NESS MD PROFESSIONS CODE:�,THE CANTRACTORS LICENSE LAW�OES NOT APPLY iD AN OWNEROF N� PHOPERTYWIiDBU1LOSORIMPROVES7HEREON,pN�WHOD0E55UCHWORKHIMSELPORHERSEIFOR �� � �,�'��� THROUGHHISORHEROWNEMpLdVEES,PFiDVID�7HAiSUCHIMPROVEMENTSAREN071NTENDEDOR 'm � - � � � '�. '.W IF OWEVEq,7HEBUILAINGORIMPROVEMENTISSOLDWITHINONEVEAROFCAMPLE• � OFFEREDFORSN.E ,H . 0�� ,'�TION,THE OWNER�BUIIDER WILL HAVE THE BURiDEN OF PROVWG 7HA7 HE Ofl SHE�ID NOT BUILD OR � � � ��j�� IMPROYEFORTHEPURPOSEOFSALE} � . ' . � � � W ❑I,ASOWNEROFTHEPRO�PERfY,AME%CLUSIVELYGONTRAGTINGWITHLICEN3EDCONTRACTOi19 �. �(��. TO CONSTRUCTTHE PHQJECT(SEC.70N;BUSINESS AND PROFESSIDNS CODE:THE CANTRAC70H5 LI- ' V21U2f10� ADJ.AREA W CENSELAWDOESNOTAPPLYTQMIOWNEROFAPROPERNWHOBUILDSORIMPROVESTHEREON,AN� � � WHOCONTRACTSFORSl1CHPRdJECTSWITHACONTRACTOR(S)LICENSE�PURSUANTTOTHECONTRAG � �QUANTITY DESCRIPTION FEE �� � TORS LICQJSE LAW.). . .,a... . . , . . . ? ' . .,,: , � . � . Q O ❑I AM EXEMPT INJDER 3�C.�, B.&P.Q FOR THIS REA50N . ' 3 � �s,� � � • •" ---- � , W ' ! � ' „,;,, DA7E OWNER Z., �. I... . . .. . (� �,, .. � LICENSED CONTFACTORS DECLARAl10N W ' IHEREBYAFFIflMUNDEflPENAlTYOFPERJURYTHAYIAMLICENSEDUNOEflPROVI510N50FCHAPiER '�� �I ,�� �e(COMMENCIN(iW17HSE SOaO)OFO�VISION3DFTHEBUSWESSANOPROFESSIONSCODE.AND ..Z � X, MY LICENSE IS IN FULI Ar10 EFFECL � d,� �f , LlJ : ! /, .-�' �� . o �. LICENS S ��' LIC.NO. �-s .J�. , U •� �'�. � CONTRACTOR..� ` '�a � ...DATE' .I � �.'6 -� �. W � WORKERS'COMPENSATION DECLARATlON Q ���� IHEREBYAFFWIAUMDEHPENAL�fVOFPERJURVONEOFTHEFOLLDWINGDECLARATIONS: �� U ' � C�' Z Q ��� _IHAVEPNDWILIMAINT INACERTIFICATEOFCONSEMTOSELF•INSUREFOflWOflKERS' $ ����� CAMPENSATION.ASPRt�VI�EDBYSECTION37000FTHEUBORCODE,FORTHEPERFORMANCE W � OF T1ff WORK FOR WHICH YHIS PFRMITIS ISSUED. g W HRYE ANO WILLMAINT IN WORKEPS'COMPENSATION INEURANCE,AS REOUIRE�BY SECTION Q37oa0FTHELA80RCO�E,FORTHEPERWRMANCEOFTHEWORKFORWHICHTHISPEFM1T15 � ISSUED.MV WORKE�PENSATION INSURANCE[,�ARHP�A�NDy ICV NUM9ERARE: CONSTRUCTION . .,�.. . CARRIER R / '`"��P.i`�� . - P . . .. . _ . .. .�. - � � POucvNUMBER �„��f ELECTRIC . �_.�.. �',� � i, � (iHISSECf10NNE�NGT�EO]Mfl.EiEDOFhiEPERMfl�SFOHONEHUPAREDOqlAR515100)ORLESS). PLUMBING ��i�u �"� Z. 1 CEflTIFYTHAT INTHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUE�,I MECHANICAL - . (,rf, SFIALLNOYEMPLOYAN}'PERSONINpNYMANNERSOASTOBECOMESUBJECTTOTHE e S''�"!��'�' �., WORKERS'COMPENSAYIONLAWSOFCALIFORNIA,ANDAGflEE7HATIFISHOULDBECOME INSPECTIONFEE � -� � ' SU&IECTTO TI$WDRI�ERS'CaMPENSATiON PflOVI51�N5 OF SECTION 37o00F THE LABOR- �SSUA �s Y�� �g � 4����'�� ,�s.� �� CA E.1 SHALL FORTHVJiIiH COMPLY Wl7H PROVISIONS. /// - p . ; � ^ p��. , � ,q� m..�— /�/ .SMIP � r+. � ' �.�l�,.Y,�,�-r— GF. �ATE:_���'iAPPL;CANT: �. . �"�.l�f--��"'�G!` r� r � �L r v � . �,.�, WARNINGPAILURETOSECUREIiWORKERS'COMPENSATIONCOVERAGEISUNIAWPUL,ANDSHALLeE ENERGYP/C S�„3�1� �a =}`-'" ___ 64���, �SU&IEC7ANEAIPLOVERTOCFI,UMALPENAL7�ESANDCMLFINESUPTOONEHUNDREDTHOUSAND -ENERGYPERMI�;�„}��u"��� � '� OOLL4RS(5100,000),INAD�ITIONTOTHECOSTOFCOMPENSATIDN,DAMAGESASPROVI�EDFOHIN � J,� SECTON37080FiHELA90RCbDE,INTEFlEST,AN�ATTORNEI"SFEES. flETENTIONFEE: �'� CPNSTRUCTION LENDINGAGENGY PRE•ALTFEE: . Q�', IHEREBYAFFIRMUNDERPENALTY.DFPERJURYTHATTHEREISACONSTRUCTIONLEN�INGAGENCV - - FORTHEPERWRMANCEOFTFIEWOPKFORWHICHTHISPERMITISISSUED(SEC.30ffl,CIV.C.�. , , W"'.� I ' . ' . ��,�� LENOER'S NAME .i . . . . . . . . . H�. LENOER'SA�DRESS i �� �'� ICEflT&YTHATIHAVEREADTry15APPLICATIONAN�STATETHAT7HEA80VEINFORMATIONiSCORRECT. TOTAL FEES , ' ����- �;'�,. 1 AGREE TO COMPIY W1TH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING V Z.��; CON5iAUCTiDN,AN�MEREBY�,UTHqRIZE HEPRESENTA71VE5 OFTHIS COUNTYTO ENTER UPON THE . . . .. . . ' ABOVEMENTIONED PROPER FOR INSPECTICN PURPOSES. COMMENTS �, ��'��.t r' r'% -�'�",�.�� j,�� m�' PER E N ' . �'` ' . . �f4�. � s/ � 4`�� ' �, �I�NATURC' .� RMITfEE DATE �^ . . . � , RECPT.NO. PAID BY - VALIDATfON � w" - '� '� YVFIITE=Depadment Copy,YELLOW—Finence Copg PINK—Assessor Copy,GOWENROO—File Copy,GREEN—Applicant's Copy � �� _ .. . , ... . ... .:.� . .. ,. :,.�A.,:, y:,..;:'. - i,.�{;.: .....•.,':;�. . . .. . . . . . - . 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