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HomeMy WebLinkAbout12993 (13) _�\ CITY OF DIAMOND BAR _ DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � - w . ai6w E.copieyvr;�e s,�te i90 PRESS (909)860-3195 Fax,(909)861-31 t7, 9�•..•, BUII.DING P�RMIT APPLICATION ._ _ FIRMLY _- o DDRESS I��� ���j��1� L��� APPLICATION�-�,..�!��, PERMIT V ���� P/C °° APN OT, �' TRACT � �� DATE .�� _ , �. ONSER � G OCC p OWNER . y�Lt 'C, , Y ROUP � ADDRE3S a � 'ia ZONING SETBACKS Z CITY �. ZIP �j�TEL.�iaf)�����/`s EART RW �❑ � PLICANT R TEL. SIDE/SIQE STREET 'RW' ❑ CONTRACTO � SIDE ❑ � AP � �.IRI' ��'Yt� . 11.� .. pC ADDRES$ , PROPOSED USE o CI7Y�5 ior'i �4�.:�, ZIP� TEL aL' fJ , � ARCH/ENG! , `z, DESIGNER `NO.DWEL. NO.' NQ a ADDftESS I� UNITS STORIES BEDR6dMS � CITY ' ZIP TEL. � " DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION ', ¢ 4 — WNER-BUILDEFI DEC64RATION� � � SFR/ADD/REM � � ' �� O p, I HEREBY AFFlfiM 11N�ER PENALTV OF PERJURY THAT I AM IXEMPT FROM THE CONTRACTORS LI- G8ffl98/CflfpOft � W. CENSEL4WFORTHEf-0LLOWiNGREASON(SEC.7031.SBUSMESSANDPROFESSIONSCADE:ANYCINOR (J� . , ��U'� -COUh'iYWHiCHFEWrRESAPERM�rTOCIXVS7RUCT,ILLTER,IMPpOVE,DEMOLISH,ORREPAIRANYSTHUC- LLI- PflIIONBCk '� �'w'.. ','TURE;PRIOR TO fTS ISSUANCE,WI.SD REQUIRES THE APPLICANT FOR SUCH PEFMIT TO FILE A SIGNED w ' ' � STATEMENT THAT HE OR SHE I�^LICENSE�PURSUANT TO THE PftOVI310fi3 OF THE CONTfiACTOfl3 ll- � , .,.,c��, ,CENSEIAW(CHAPTERe(COMM6NCINaWfTHSECTION70oo)OF�IVISION30FTHEBUSINESSANDPRO- � POOVSPB V FESSlONSCOOE109THATH'cOF{SHEISEXEMPT7HEREFqOMANDTHE0A515FORiHEALLERE�EXEMP- (� U, TION.ANYVIOUTIONOFSECTIOY7031.5BYANYAPPLICANi.FQRAPERMITSU&IECiSTHEAPPLICANTTO z Re-Roof 'ACMLPENAL7VOFNOTMORETHANFIVEHIJN�REODDLLAAS(5500)J: . �� .�'. ❑I,ASOVJNEROF7HEPR0 ERTV,ORMVEMPLOVEESWITHWAGE$ASTHEIFSOLECAUPENSATION, 0 COf11f118fCIdI � '� ' ..� ; i � CTURE�5 NOT INTEN�Eb'OR OFFERED FOR SALE(SEC.7044,BUSI- � J �, �WILLOOTHEWOFlK,MID-HESRU .'NESS ANU PpOFE5310NS CODE:THE CONCRACTOfiS LICENSE LAW DOES.NOT APPLY TO AN OWNEP OF . � - � 'VROPERTYWIiOBUILD50RIMPHOVE5IHEREON,ANDWHO�DOE55UCHWORKHIMSELFORHERSELFOR � � � '[[ ��THROUGHHISORHEROWNEMALOYEES,PflOVIUEO7HAT5UGHIMPROVEMENTSARENOTINTENDEDOR' m� ' • QI �OFFEREDPoRSALEIFHOLVEVER,THEBUILOINGOHIMPROVEMENTISSOLDWRHINONEYEAftOFCAMPLE- . �� � � ��y � � '" � ��� ��, ��.!TKKJ,THE OWNER-BIIILDER WILL NAVE TFiE BURDEN 6F PROVING Ti-1AT HE OR SHE�ID NOT BUIt�0�9 � 'IMPROVEFOR7HEPUHPOSEOFSALE} . � � . ,yy� �, �I,AS ONMER OF THE Pfl PERTY,AOd EXCLUSIVELV CONTRACTINC WITH LICENSED CANTRqCTORS . , '.70 CONSTRUCT THE PROJECT(�EC.7014,DUSINESS AND PflOFESSIONS CODE:THE CONTRACiORS LI- Vdllldtl�fl ' ADJ.AREA �Li.l �CENSEI.�WDOESNOTAPPLYTQANOWNEROFAPPOPERTVWNOBUILDSORIMPAOVE3THEREON,AND � ' � � ".WHOCONTRqCT5FOR5UCMPRO.lEGTSWITI{ACONTRFCTOfl(S)LICENSEOPUFSUANTTOYHECONTRAF �� QUANTITY DESCRIPTION � FEE � Q TORSOI�AMEXEMPTUNDEFiSE� . .. , . . . .,�.� � . ,J ! � " . 8.8 P.C_FORTHI5 REASON Q il U LLI . ',, .,. . � �. ,DATE OWNER � U � ..�i . �: , J . � �i LICE SED CONTRACTORS DECLARATION W � �� I HEREBY AFFIRM UNDER PENA OF PERIURV THAT IAM LICENSE�11NqER PPOVISIONS OF CHAPTER �� g�y^p, �s' ' � � � ��.�8(COMNENCINGWITHSECTION OW)OFDIVIStON30FTHEBUSlNESSANDPROFESSIONSCODE,AND � '��- 6..Ra° �. l� � MY 61GENSE IS Ild FULI FOftCE D EFFECY. �i�'," m o '� LICENSE C1A55 LIC.NO. , �!J�.'��.�� � .. � . ... '� . ' . ' �. ��V, �DA1E CONTRACTOR 0- � W ��; WORP�ERS'COMPENSATION DECLARATION Q �, � � ������ IMEREBYAFFBiNUNOEHPENAL��fYOPPERJllRYONEOFTHEWLLOWINGUECLARATIONS: Z ��. _171AVEANDWILLMIVNT�JjINACEATIFICATEOF.CONSEMTOSELF-INSUREFORWORKERS' - _ �+�����'� COMPENSFTION,ASPROViDEDBYSECTION37000FTHELABORCODE,FORTHEPERFORMANCE U �" OFTHEWORKFDRWHI�HTF715PEflMIT15lSSUED. � „ 41S ' '�IHAVEANDWILLAAAINTIINW�RKERS'COMPENSATIONINSURANCE,ASREOUIREOBYSECTION Q 37000FTHELA90RCJ E,FORTHEPERFORMANCEOFTHEWORKFOflVdHICHTHISPERMITIS . ISSU�.MYWORKERS' PENSRT�IIN,JeINSUR r/�ECAHRIERFNDPOLICYNUMBERARE; CONSTRUCTION j caaaiea ��16�"� / PLAN REVIEVV �. _ POLIcvNUMB6A '� ELEC7RIC � (THISSECfIONNEH7NOTtlEO7A�LEfEDOFhIEPERMJTISFORONEHUWRED00LLARa�S100�ORLE35). PLUMBING t � I CER7lFYTHAT INTHE PERFORMANCE OFTHE WORK FOR WHICH THlS PERMIT IS ISSUE�,I MECHANICAL �j��,� (� SHAIItdOT EMPLOV�GER$ON IN PN`/MANNER SOAS TO BECOME SUOJECT TOTHE � WORNERS'COMPENSAlONLhWSOFCALIFORNIA,ANDAGREETHATIFISHOULDBECOME INSPECTIONFEE � �� SU&IECTTOTHEWbp RS'COMPENSATIONPRWISIONSOFSECTION37o00FTHELA00R f_ = COUE,ISHALLFORT THCOMPLYWIT�H'yTHOSEPROVISIO�NJS�.7 6 ISSUANCE �g g��y yti( �p�ryp���eyq� ✓ � ¢��' �ATE:���� PPLECANT: /`.�,�' : //1�A��FY SMIP �_�� Ord�aJa/ . �! ENERGY P/C . WAHNINO:FALURETO SECURE WORKERS'COMPENSATION COVERAGE IS UNIAWFUL,AN�SHALLBE '�y SU&IECTANEMPLOYERTOCRI INALPEPoALTIESANOCIVILFINESUPTOONEHUNDREDTHOUSAND ENEFGYPERMI��T.. � � DOLLAflS(5700,000),INAUDITIO TOTHECOSTOFCOMPENSATION,DAMAGESASPFOVIOE�FORIN ' �� SECTION 3708 OFTHE LA80R DE,INTEREST,ANDATTOHNEI"S FEES, FlETENTION FEE: �' ��� - pc, C�NSTRUCTIIJN LENDING AGENCY PRE-ALT FEE: �'�,.- IHEREBVAFFIRMUNDERPENANOFPERJURYTHATTHEREISACONSTRUCTIONLENDMGAGENCY ' � FOR TFE PERFORMANCE OFT WORK FOR WHICH THIS PEFIMIT IS ISSUED(SEC.3097,CIV.C.). , �. I �., " . � . . . . . . . . . �� . . � LENDER'S NAME J6�,,,�„ LENDER'SADDflESS � -y `2`' _I ,, " �r R � �"� iCERTIfYTHATiHAVEREADTHISAPPLICATIONANDSTATETIiATTHEABOVEINFORMAiIONISCARRECT. TOTAL FEES . . .. ���� ���.' 1 AGREE TO CAMPLY KITH ALL QITV ANO COUNTY ORDINANCES AND STATE LAWS flEUTINCa TO BUILDMCa .. ', . , � � � CONSTRUCTION,AND I�REBV iUTHORIZE REPRESENTATIVES OFTHIS COUNTV TO ENTEFUPON THE -� � ���,' ABOVE-MEM'ANEO PqOPERT'FOR INSPECTION PURPOSES. COMMENTS � � �—��I,m�. l�n � �i PEHM AME(Pfll I . � � '� CJ . , , ��.: SIGN EOFPERMITTEE '� UATE ), �' � � � RECPT.NO. 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