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HomeMy WebLinkAbout12852 ^ _1� CITY OF DIAMOND BAR � � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES _ Zi66o E.c��ey�i�e s�c�i90 PRESS .w . ,,, (909)860-3195 Fax(909)861-3117 : ' ��»° . BUILDING PERMIT APPLICATION ' __ ;' FIRMLY _, � , ,__ p � � DATE ���� ����� JOBSITE APPLICATION l ERMIT /C Q ADDRESS ��� �j�-�� � /' ��UMBE � , ISSUE TYPE OCC � APN - LOT TR�F T �- DATE CONST. ' GROUP p OWNER� f" o ADDRESS • a ZONING SETBACKS , W CITY ZI� TEL'C FRONT ' RW ❑ � .APPLICANT TEL. REAR .,. .., : ❑ Z SIDFJSIDE STREE7 RW ❑ � � CONTRACTO'R �;� �� SIDE ❑ p� ADDRESS PRqPOSED USE � � o , , , P . ,;'r. CITY Zlp TEL. � 7� z DESIGNERI,��S���N ��'��JI'o °'. �': , �. a ADD SS NO.DWEL. �` NO. ' " NO. IES �_BEDROOMS � CITY ,°.- ZIP TEL . UNi � `� ' DESCRIPTION SQ.�STOR,FACTOR'PSF ADJ.AREANALUATION , .,,,�0 .. . . .. -.. �WNER-BUILDER DwGLARATION , �.� .�.� � SFR/ADD/REM `�, �.. ... ,.....� . . .. . � U, CE�NS�EY��N�f-0LSAPIENb'fl�TM OF PERJURV THAT I AM EXEMPT FROM THE CONTRACTOHS LI- �� Gdf298(C8f(lofl � � �� 1 HEREBY AFFIRM UNDER pE EASON(SEC.7037.5 BUSINESSAND PROFES610N5 CODE:ANV,CITVOR '' � F�1ITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,Ofi9EPA1RANY5TRUG ��:W Pa110/DBCIC ' ����� � '���W "NRE,PRIOR TO ITS ISSUANCE,AL50�RE�UIFES THE APPLICANT FOR SUCH PERMiP TO FILE A SIGNED "'' .� � STATEMENT THAT HE OR SHE I LICENSEO PURSUANT TO�THE PHOVISIONS OF TXE CONTRACTORS U• � , � ��,,� �FCESSIO SwCODE)REiHAT�HEMO�SHEISEX MP77HIE EF OMANDITH BASISFORTHEAL EGE�E%EMP• � Z� POOVSpe ����h ,V TION ANYVIOLATIONOFSECTI 7031.SBYANVAPPUCANTFOPAPERMITSU&IECTSTHEAPPLiCANTTO �'�. RB-ROOf �� .ACIVICPENAL7YOFNOT�MORETHANFIV6HUNOREDDOCLARS(SSoo�.). :�- 'OI,ASOWNEROFTHEPPOpER4Y,ORMYEMPLOYEESWITHYlAGESASTHEIRSOLECOMPENSATIDN, �-���. CORIII18fC131 WILL DO THE WORK,AND.THE.STRUGTURE IS NOT.MTENDED OR OFFERED FOR SALE(SEC.7044,BU51- � J. U '. � � ^., ` � NE55 AND PROFESSION5 Cb[1EL�THE CANTRACTOHS LICENSE L4W DOES NOTAPPLY TO pN OWNER OF �p j_j �� � — ,�� PHOPERTYWHOBULDSORIMPnOVESTHEREON,ANDWHODOESSUCHWORKHIMSELFORHER5ELFOR � � V1'Vi.o��7 . '� ;,�� I'��." �THipUGHHISORHERONMEMpLOYEES;PiiOVIDEOTHATSUCHIMPROVEMENTSARENOTINTENDEDOR � ��W �DFFEREDWRSlLLEIF,HOWEVEp,lHE8UIL01NGOHIMPROVEMENTISSOlDWI7HINONEYEAROFCOMPLE- '� '>��� :��� ^. ��-�0����-TKKi,THE OWNER-BUILDER WILh.HAVE 7HE BUHDEN OF PROVING THAT HE OR SHE DIDNOT BUIIA OR � - �� ���Q'� TO CONS R00T THE PROJECR(SEC 7041,BUSINESS ANOPROFESSIONS CO�EICTHE CO(N�TRACTORSLI- I� (�UANTITY DESCRIPTION ',. ADJ.AREA S IMPROVEFOHTFIEPURPOSEO 3ALE). i � CENSEUWDOESNOTAPPLYTOANOWNEROFAPHOPERTYWHOBIIILDSORIMPROVES7HEREON.ANO � �, . , Y�� ,, , ,..,. . � . �NAIOCONTMCTSFORSUCH PR�.IECTSNATHACONTRACTOR(S)IICEN5E0 PURSUANTTOTHE CONTRAG F� TORS UCENSE LAW.�. �, . , . , .�0��. C .. . . . � B.8P.0.fORTHISREASON ;. Q� . :, � . . ..��� ❑I AM EXEMPT UPDER SE .:�i,: � . . , �'� � .. . u' DATE � OWNER �����,�V ' '��I . LICE� W � I�SED CONTRACTORS DECLARATION " W ��'� IHEREBYAFFIflMUNDERPENA4RV�,OFPER.IUflVTHATiAMLICENSEDUNDeRPROVISIONSOFCHAPTER ���� � '''� �-� 8(COMMENCINOWITHSECTION'�7000)OF�DIVISION30FTHEBUSINE3SANDPROfE3510NSCO0E,AND .. Z ��, MY IICENSE IS N FULL FOP.CE qN�EFFECT. _ m � � ��I.. IICHNSE CLA S � �., . LIC.NO.' � �� �-' - .�.. J .. V, OATE.. �i�� . CONTRACTOFt C a' ITY�� ., . W I ' �� WORlKERS'COMPENSATION DECV+RATION U � E � , .. , _ I �� IHEREBYAFFIRMUND6iPENALNOFPER.IURYONEOFTHEFOLI.OWWGDECLARP.TIONS: � � � �� � �, Z Q �' _IHAVEANDWiLLMAINT INACEFi�'IFIGATEOFCONSENTTOSELF-INSUqEFORWORKERS' _ ' ���'' COMPENSATION,ASPR�VI�ED9V'SECilON370oOPTHELABOACODE,FORTHEPERFDRMANCE � 'U `' OF THE WORK FOR WFl�CH THIS PERMIT IS ISSUED. � � W.' y " IHAVEAN�WILLMAI INWORKERS'GOMPENSATIONINSURANCE,ASREQUIHEDBYSECTION /+�+++��� Qg d� 37WDFTHELA90R E,WRTHEPEFlWRMANCEOFTHEWORKFORWHICHTHISPEHMI715 ��]yi[q ��� �' ISSUEO.MY WORKEAS'COMPENSAT INSURANCE CARRIEAAND POLICY NUMB�R ARE: CONSTRUCTION 9� � u i .�'� cnnRiER - ��� PLAN REVIEW 1�r S 1 . � > y��` py��q Z POLICV NUMBER - ELECTRIC , l s7��ey E���a�✓ a (ffiISSECiIONNE�NOT�BECOM1�IEfEDOFI}�PEFUMISWRONEHUNDRWDOLL4RS(5100�OflLESS). PLUMBING �y1 �6 Y\dC,d __ ___ _ W b MECHANICAL '���"'��L� z � I CERTIFY THAT IN THE ERFOFMANCE OF THE WORK FOR WHICH THIS PEFIMIT IS ISSUED,1 (�"'. SHPLL NOT EMPLOY�PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE � �y', WORKERS'COMPENSAIONLAWSOFCFLIFOFNIA,ANDAGREETHpTIFISHOUL�BECOME INSPECTIONFEE ' SUBJECTTOTHE'WO�ERS'COMPEIISRTION PROVISIONs oF SECTION 3']oa oFTHE LABOR - - ' � '� '= COOE SHALLFORTH ITHCOMPLYWITHTHOSEPflOVISI IS. ISSUANCE o r SMIP � �:;' OATE: � � Ii APPIICANE � . � . J'�; I ENERGY P/C WARNING:FAILURETO SECURE WORKERS'COMPENSATION CAVERAGE IS UNLAWFUL,AND SHALL9E -�y��� SUBJEGTANEMPLOYERTOCRYMINALPENAI.TIESANDCIVILFINESUPTOONEHUNORE�THOUSAND ENERGYPERMIT DOLLARS(5100.0�0).IN ADDITIC�NTO THE COST OF COMPENSATION,OAMAGES AS PROVIDEO FOR IN �; SECTION970BOFTHEtA90R60�E,MSEflEST,AN�ATTORNEV'SFEES. ' RETENTIONFEE: ��I�� � dONSTRUCTIDN LENDING AGENCY PRE-ALT FEE: ��� I HER�Y AFFIflM UNDER PENqLTV OF PEP�URYTHAT THERE IS ACONSTRUCTION LENOINGAGENCY � � � FORTHE�PERFORMANCEOFTWEWORK ORWHICHTHISPERMITISISSUED(SEC.3oB],CIV.CJ. w � / ���� LENDER'S�NAME���1� � � I� LENDER'S�ADDRESS ` ' y p e�-� m �) �� ICERTIFYTHATIHAYEREADTIISAPPLICATIONANDSTATETHATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES -- Z.�1� � l� "����� 4� / ����, IAGflEETOCAMPLVN7THALL IYY.PNDCOUNNORDINANCESANOSTATEL4WSRElATINOTOBUILDING . �� � ' � �. CONSTRUCTION,ANDHEREBY U7HORIZEREPRESENTATIVESQFTNISCOUNTYTOENTERUPONTHE 'Z�, A60VEMENTION PROPEFir FOR INSPEC N PURaosEs. . COMMENTS - � �� � �-����,� �,�� PERMfTTEE NAM R y^ )� s 6 /�dB . f!j' r i�� �� �'� SIONATUFiEOFPERMITfEE ,, DAT � � RECPT.NO. 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