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HomeMy WebLinkAbout16682 (39) -----�'�— CITY OF DIAMOND BAR � � DEPART'MENT OF COIe�IIvIUNITY&DEVELOPMENT SERVICES � 2L825 E.Copley Yhive (909)860-3195 Fax(909)861-3117 PRESS �v�� � BUILDING PERMIT APPLICATION FIR LY � JOBSITE � �- � �. . , )I APPLICATION 0,�.,, P� � PERMIT �'� � o ADDRESS_ �!� �-`� �� V��� ��d�i/t%L������'� DATE � ri�� NUMBER ��'# � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER _ �':+9f/`��%-'}�--"16+.tt��dd , o ADDRESS ¢ ZONING SETBACKS z CITY ���'Mf.Jf�7s�t'-��^�-ZIP��TELdC`��.. '„f�� ;f � FRONT RW ❑ o APPLICANT " TEL. SDE/SIDESTREET RW ❑ z ¢ CONTRACTO ' � � " SIDE C, � ADDRESS � .T,. , " _ � CITY�`'���+"�i�r�`AI t�'- ZIP -� TEL � "�`'s � ./�� PROPOSED USE � ARCW/ENG/ z DE$IGNER '' w NO.DWEL. NO. NO. n, ADDRESS � CITY ' ZIP TEL. UNITS STORIES BEDROOMS u� cn DESCRIPTION SQ.FL FACTOR PSF ADJ.AREANALUATION OWNER-BUILDER DECLARATION SFR/ADD/REM O I Q I HEREBY AFFIRM UNOER P NALTY OF PERJURV THAT I AM EXEMPT FflOM THE CONTRACiOFiS�_i- GaragelCarport W CENSELAWFORTHEFOLLOWING EASON�SEC.7037.5BUSINESSqN�PROFESSIONSCO�E:ANYCITYOq (n U COUMYWHICHfiEQUIRESAPER�AITTOCONS'RUCT,ALTER,IM�ROVE,DEMOLISH,ORREPAIRANYSTRUC- - � w,' TURE,PRIOR TO 1TS ISSUANCE, LSO REQUIRES THE APPLICANT FOR SUCH PERMITTO FILEASIGNE� w Pd[io/DeCk STATEMENT hiAT HE OR SHE IS ICENSE�PUqSl1ANT TO THE PROVISIONS OF THE CONTRACTORS LI• �' CENSE LAW(CHAPTER 9(COMME�CING WITH SECTION 7000)OF DIVISION 3 DF THE BUSINESSAND PRO- �'�' POOVSpB ' � , FESSIONSCODE)ORTHATHEOR�HEISEXEMPTTNEREFROMAN�THEBASISFORTHEALLEGEDE%EMP- (� , , v TION.ANVVIOLATIONOFSECTION7o37.5BYANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO Z Re-Rooi ��.ACIVIL PENALN OF NOT MORE T AN FIVE HUNDFED DOLLARS(b50o).): ❑I,ASOWN£ROFTHEPftOP RTY,ORMYEMPLOYEESWITHYJAGESASTHEIRSOLECOMPENSATION, O � Commercial � - Z, WILL DO THE WORK,AND THE ST UC7URE IS NOi IN7ENDED OF OFFERED FOR SALE(SEC.7044.BUSI- _.I �' NESS AN�PROFESSION5 CODE: HE CONTRACTORS LICENSE LAW�OES NOT APPLV TO AN OWNER OF ? .�PROPERTY WHO BUILDS OF IMPR�VES THEFEON,ANO WHO DOES SUCH WOqK HIMSELF OR HERSELf OR ' Q. THqOUGH HIS OR HER OWN EMP YEES,PROVI�EO THAT Sl1CH IMFqOVEMEtvTS APE NOT INTENDE�OR m �. w" OFFEREDFORSAIE.IF,HOWEVER, EBUILDINGORIMPROVEMEN7ISSOIDWITtiINONEYEAFOFCOMPLE- " 0. .TION,TFiE OWNER-BUILDER WILL HAVE 7HE 6UFIDEN OF PROVING TMAT HE OR SHE DID NOT BUILD OR Z��,IMPROVEFORiHEPURPOSEOF ALE). � _ ❑I,ASOWNEROFTHEPRO ERTY,AMEXCLUSIVELYCONTRACTINGWI7HLICENSEOCONTRACTORS W , � �TO CANSTRUCT THE PROJECT(SEC.7044,BUSINE55 ANO PROFESSIONS CODE:THE CONTRACiOflS LI- ValuBtiOn ADJ.AREA ' W ' CENSE LAW DOES NOiAPPLY7OAN OWNER OFAPFOPERTV WHO Bl11LDS OR IMPROVES THEREON,AN� �.� WHOCOMRACTSFORSUCHPROJECTSWITHACONiRACTOF�S)LICENSEDPURSUANTTOTHECONTRAC- QUANTITY DESCRIPT�ON � FEE � ''TORS LICENSE LAW.). � 0 ❑I AM EXEMPT UNDER SEC.�I B.8 P.C.FOR THIS REASON Q � U � �'L' �ATE I OWNER F– O � W � LICEN�ED CONTRACTORS DECLARATION W ¢ � I HEREBYAFFIRM UNDER PENALT OF PERJURY THAT I AM LICENSED UNDER PFiOVI510N5 OF CHHPTEfl � .� ��, 9(COMMENCINGWITFiSECTION700)OFDNISION30FiHEBU51NE55ANDPROFE5510NSCODE,AND z �X ' MY LICENSE IS IN FULL FORCE ANP EFFECT. ,{" ,�e m (� `'� y'.ap � �� LICENSE C��"A�5�,5, `�� LIC.NO. b �� �" . / ` � F � DATE__`✓ E� I� CONTRACTOR �Y � a CJV.I I G� � WORK�RS'COMPENSATION DECLARATION U � �_ - �a�y�C���„r���� � , I HEREOYAFFIRM UNDER PEhAL OF PERJURV ONEOFTHE FOLLOWING DEGLARATIONS: Z � '� � � �. _IHAVEAN�WILLMAINTA�ACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' d 2 ¢ , CAMPENSAiION,ASPROI�EDBYSEC'TION37aoOFTHELAeORCO�E,FORTHEPERFORMANCE U Q . OFTHEWORKFORWHIC THIS.PERMITISISSUE�. � �. � ' _IHAVEAN�WILLMAINTAIf�WORKERS'COMPENSAiIONINSURANCE,ASREQUIREDBYSECTION Q370o OFTHE LABOR CODE.FORTHE PERFORMANCE OFTHE WOFiK FOR WHICH7HIS PERMITIS � ISSUED.MY WOFKFRS'C�MPENSATION INSUflANCE CARPIERAN�POLICV NUMBERAPE�. CONSTRUCTION j �. cnaaiea i PLAN REVIEW Z � aoucvNUMeER � ELECTRIC .___ ¢ I 0 �'�, (iF1155ECilONNEmNOi6EO�MPLEfE00FTHEPERMfTISf-0RONEHUNDREDCOLLIRS(y700)ORLESS). PLUMBING W , ! u , Z I CERTIFYTHAT INTHE PE�tFORMA�E OFTHE WORK FOP WHICH THIS PERMIT I5155UED,1 MECHANICAL d�^ 4 �' �. SHALL NOT EMPlOY ANY DERSON IN ANY MANNER 50 AS TO BECOME SUBJECi TOTHE ' (/� WOFKERS'COMPENSATI N LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOUL�BECOME INSPECTION FEE � ' SUeJECTTOTHEWORKE 5'COMPENSATIONPROVISIONSOFSECTION370oOFTHELABOR �---� � � . CODE,I 'ALL FORTHWIT COtviPLY WITHTHOSE PROVISIONS. �SSUANCE _ /�\ � � • _. . ,. .� . . ' p DATE: � :��� -- A PLICANT. � SMIP � J WARNING ILURETOSECUFE RKERS'COMPENSATIONCOVE SUNLAWFLIL.ANDSHALLBE ENERGYP/C �,i, SUBJEGTANEMPLOYERTOCRIMI ALPENALTIESANDCIVI 11PTOONEHl1NORE0TNOUe^AN� ENERGYPERMIT DOLLARS(Eioo,oaD),INAD�ITION OTHECOSiOFCOMPENSATIDN,DAMAGESASPROVI�EOFORIN J SECTION 3]08 OFTHE LA90ft CO E,INTEflEST,ANDATTOflNEY'S FEES. i � p� � RETENTION FEE:j � CO STRUCTION LENDING AGENCY PRE-ALT FEE: g� � _— � INEREBYAFFIRMUNDEFPENALTpOFFERJURVTHATTHEREISACONSTRUCTIONLENDINGAGGNCV FOfl THE PERFORMANCE OF THE wORK FOR WHICH THIS PERMIT IS ISSUED(SEC.309],CIV.C.j. z w _. � LENDER'S NAME 1— LEN�ER'SADOFE55 ' � I CERi1FY THAT I HAVE flEAD THISIAPPLICATION AND SiATE THATTHE ABOVE INFORMATION I5 COFRECT. TOTAL FEES � � � I AdREE TO COMPLY WITH AlL dM ANO COUNTY ORDINANCES AND STAiE LAWS RELATING TO BUI�DING � CONSTfll1CTION,ANDHEREBYAUi7HORREflEPftESENTATNESOFTHISCOUNfVTOENTERUPONTHE '�� Z ABOVE�MeNTIONE�PROPERTY FOR INSPECTION PUftPO5E5. 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