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HomeMy WebLinkAbout12858 Pi � �h _�.� CITY OF DIAMOND BAR ;,.. DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � 21660 E.Copley Drive Suite 190 �' B)850-3195 Fae(909)861,3117 -` PRESS 9N"� UII.DING PERMTl'APPLICATION FIRMLY � JOBSITE � ,��,^�� ��L�� "L� APPLICATION��,��y�/ PERMI��� ` P/C o ADDRESS '1 DATE � NUMB # � APN - LOT �{� TRACT ��Of�, ISSUE TYRE ," OCC � DATE CONST. ' ' GROUP LL �R� LF �J o G�E��� L[.�s M�1i�� 2 ZONING SETBACKS - ADDRESS �y � P. - TEL. �. II�L�' FRONT ^ ' RW CJ APPUCANT -P TEL. REAR '.. ❑ SIDEISIQE STREET RW ❑ � CQNTFtACTQR �, �1.4�' SIDE � I � ADDRESS ,: ` C,,. � CITY I � ZIP TEL. PROPOSED USE Sr� � p^ P� 'ARCH/ENG/ � y ,�� ,�, z DESIGNER ��./�.���I� [..�I�tY'tY�`� 'u^ ^ ' ' NO.DWEL. N0. NO. �W ADDRE$$ � UNITS STaF�IES BE�ROOMS CITY . ZIP TEL. . Q , OWNEa-aul�eR oeC�a,RnrioN ��wq 6��EM N' SQ.F`i'. FaCTOR pSF ADJ.AREANALUATIQN ' O � ,Q , EBY AFFlRM UNDEfl F�ENALTY OF PERJURY THAT I AM EXEMPT FHOM THE CANTflAC70RS LI- ,,�'i01d9B/CBfpOfS-- ' IHEfl II�. ldJ CENSE(AWFORTHEFOI,LOWIN6qEA90N(SEC.70.97.5BUSINESSANOPpOFES310N3CODE:ANYCITYOp (/) .0 COUNryWHICNf�OUIpESAPERMI7TOC6NSMUCT,ALTER.IMPROVE,DEMOLISH,OqREPAiRANYSTRUC- �W p21i0/DeCk � � �Z �.TIIRE;PRIOR�TO ITS ISSUANCE,�pL50'REOUIRES THE APPLICANT FOA St1CH�PERMiT TO FILE A SIGNED W �� �. �� �STAT9stENY THAT HE OR SFIE IS LICENS��PURSUANT TO THE PROV�SIONS OF THE CONTMCTORS.LI-� ,� . �,,,CENSE�tAW(CW1PTEqe(COMMBNpINO WI7H$ECTION 70Do)OG qIVISION 3 OFTFE BUSINESS ANO Pq0- POOUSpe 'i�� � � �, ,FESSI�NSIb�E)ORTHATXEO SHEISEXEMPTTWEPEFqOM11NDTHEBASISFORTHEALLEGE�6XEMP• � " ,', ',�', �.TION.ANYVIOLATIONOFSECTI�7037.58YANYAPPLICANTiOflAPEflMITSU&IECTSTHEAPPLICANT70 Z Re-ROof � � �'I'��� , �� 'AdVILPENATYOFNO7MORET�iAN'fYVE�HUNDREDDOLLARS(SSoo).): � � � — ' ' „a.. , ,, �,; � , ❑I,ASOW.NEROFTHEPRORERTY.ORMYEMPLOYEESWITHWAGESASTHEIRSOLECAMPENSAiION, �'� �� CpmmBfCldl - � „ ,�,WILL D0.7FIE WORI(AND.THE STRI/6T.URE IS NOT IN7ENDED OR.OFFERE�FOR 3ALE(SE0.7044,BUSh � _I �NESS AN�PROFESSIONS CODE:�fHE CONTRACTORS�LIpENSE LAW OOES NOT APPI.Y TO AN OyVNER OF '� �PROPERTYYY}i09I111D50RIMPf�DYESTMEREON,ANOWHD�OESSUCHWORKHIMSELFORHERSELFOR �� �,I �'���� ' � '[,'G THf10UQHHISbRHEROV/MEILWLdYEE3,PHOVIDEDTHAT9UCHIMPROVEMENTSARENOi1NTENDE�OA m ' � �. Q �OFFEREDWRSALEIFHOWEVE THEBUL�INGORIMPqOVEA1ENiIS50LUWITHINONEVEAROFCOMPLE ' � ^'�.TON,THE�OWNER�BUIL�ER WI HAVE THE BURUEN GF AflOVING THAT HE Ofl 5HE 01�NOT Bl11LO Ofl � ��IMPROVEfORTFEPURPOSEOF�EJ. . � ' � •��,..` .. � . �W�, ; ❑I,ASQNMEF10F7HEPRO�FifY,AME%CWSIVELYCANTFAC7INGWIYHLICENSEDCONTRACiOqS � � Q�. �TO CONSTAUGT THE Pp0.1EC7(�6C.7a46,BUSWES$./WO PMOFESSIIXJS CODE:TIiE CONiRACTORS L4 V8IU8t1011 ` /A�J./1A�, � � �� CEN9ELAWDOE3NOTAPPLYTO(JIONTIEROFAPRQPFRTYWHOBUILDSORIMPRWES7HERFAN,AND "YVFIOCONTRqCT5FOR5UCHPRbi1ECT5WITHkCONTHACTOR(S�LICENSEDPURSUAN7TOTHECONTRAG � � QUANTITY DESCRIPTION ' FEE' � N . �R1RS IJCE SE IAW.: � `�C. ,,I' ,.. , �.�, i i� .,,Q . - J . �.,,, .. . ... � O I AM DfEMPT UNDER SEC. B.8 P.C.POR THIS qEASON Q .'�.S . � . I �,• .. , '. ., . ' � �ATE .. II'.�.. OWNER � . . U . . . , '..I `z W . .... �'�I'�I O�„ , LICEN�EO CONTRAC70R5 DECLARATION W . � �.IHEREBVIIFFIRMUPIDERPETJALrqQFPERJURYTHATfAMUCENSEDUNDERPROVISIONSOFCHAPTER � . �. LICENSECLA �'�DIVISION30FTHEBUSINSSSANOPROF6SSIONSCODE.AND z ' ''� ' �'� ��', � X D EFFECL �^�' — I � MY LICEN5E IS IIV FULL FOR� .... .LIC.NO. -. v�" '������ �� � d 9 COMMENCINO W17N SECTIOP!7 � DATE � ����� �.. CONTRAC'fOR JJ IJ���. . d .. . ISJ � WORK RS'COMPENSATION DECIARATION -� � a � �o�'��.����fl� � ���'� y �"�I HEREBV AFFIqM UNDER PBJALiV OF PERJl1RV ONE OFTH6 FOLLDWING DECLARATIONS: a� $T T �����s� �� - e� � _IHAYEANDWILL.M111NTAI ACERlIFICATEOFCONSEN7TO5ELF-INSUflEFOqWORKERS' y �� � COMPENSA710N:ASPpOV�DED6Y5ECTION37oo'OFTHELPBORCO�E.FORTHEPERFORMANCE �U Q OfTHEWORKFORWHICHiTH19PEflMI7151SSUE�. - � w "`�.:fHAVEAND WICL MAINTAIN WOHKERS'COIAPENSATION INSURANCE,AS RE-0UIRED BV SEC710N /� Q 37000FTHELABORCQ�E�FORlHEPERf-0R6IANCEOFTNEWORKFORWHICHTHISPERMITIS �Q�� ��p ISSUm:MYWO EFiS'CO PENSATIDNINSURANCECARRIERANDPOLJCYNUM6ERARE CONSTRUCTION ��' _ �A - �.. . . ... . � �^� . . ¢,. p.�..I�d'i� .. CARRIER �l� I PLAN REVIEW �" SJ � > Q ' POLICYNUMBER. � � -�a.� � ELECTR C �p'7�C��}l� 4 � ,(IFiSSECIKXJNE�l�pTBE�Y�CETmOFTF�PERPMISFORONEHU�DFlED00LL71RS(S7W�ORLE55). PLUMBING I�V l O� � 'I�I� w.:.. , p ,/� /��y . �� ICEflTIFVTHATINTHEP FOflMdNCEOF7HEWORKFORWHICHTHISPERMITI51SSUE0,l MECHANICAL �SCd�Clls° ' (�J SHAIL NOT EMPLOV ANV P RSON IN M1V MANNEq SOAS To BECAME SUBJECT TO THE ` � . WOflKEf�S'CpMPENSAT LAWSOFCALIFORN�A,ANDAGREETHATIFISHOULDBECOME INSPECTIONFEE ��� SU9JECT i0 THE'WOHKERS'C00.1PENSATION PAOVISIONS OF SECTION 3700 OF THE LABOR - �,I��il�l �� CA ,I.�gHA�LL�FOqT�HWITFI,COMPLYlSfiTNTH SEpROVISI S. ISSUANCE ~I �� ,',II o �„ ,," ' - _ , ^ �SMIP � i p ��ATE[ . APPLICANT: � � � WARNING.FAILURETO SECURE W�FIKERS'COMPENSATION fAVEflFGE I5l1NLAWFUL,AND SHALL BE ENERaY P!C F "y � I,SU&IEETANEMPLOVERTOCRIMIN LPENAITIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT �� P�J �OOLLARS(5100,OooJ.INAODITIONT THECOSTOFCOMP�NSATION.DAMAGESASPFOVIDEDFOHIN �.+� j� ��II � ��$ECTION37080FTHELABORCOD�,INTEftEST,ANOATiOflNE1"SFEES. ' RETENTIONFEE: Z �7 � �4/ '� � � � � CON�TRUCTION LENDING AGENCY PRE-ALT FEE- � li���ll,l � ,�IHER�YAFFIRMUN�ffiPENpLTY�F.REflJURYTHATTHEREISAGONSTHUCTIONLENOINGAGENCY ' �II '�FORTHEPERWRMANCEOFTHEWp�RWHICHTHiSAERMITISISSUE�(SEC.a09],CIV.CJ. , , , � ��I� � ,LENDER'S NAME. . ..�. . . . ' ' ' III F- LENDERSAUDRE66 �I e,y. III� � I'.CFATIFVTHATIHMEREADTNISAppPLICqTIONqNOSTATEhiATTHEABOVEINFORA1ATbNISCORRECT. TOTAL FEES � � 'Z-�� ��� -���'t�.�C�,�� . i I�II � ,I��AGpEE TO CAMFLV WITH qLL qTY�4ND COl1NTY OROINAryGES AND STATE LAWS qEI.FTING TO BlNl01NG � � ��i60N5TR4CTION.ANDHEREBVAUn{ORIZEHEPflESENTATIVE50FTHI5COUNTYTOEM'ERUPONTHE = ''�PBOVE•MENTIONEOPHOPER7YWqIN5PEC NPURPOSES. 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