HomeMy WebLinkAbout15147 (20)CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909) 860.3195 Fax (909) 861-3117 PRESS
BUILDING PERMIT APPLICATION FIRMLY
JOBSITE c
ADDRESS?3S2L - 235-38
APN LOT TRACT
OWNER CICA9- CrtL'r C!3FJ 4401 -
ADDRESS f-17 as r0C rI LzIL tz 10, LI
CITY ZIP4:t4If TELC)atY379-
APPLICANT TEL. 3 F S
CONTRACTQR C0 AoGFzac.
ADDRESS '1124 5 -
CITY
CITY Pos.00n- ZIFr(21,L'-),- TEL(E.:1)g"- 1412
ARCRTNG1
DESIGNER
ADDRESS
CITY ZIP TEL.
01NNER•BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY Or PERL:RY THAT 1 AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOW'NG REASON (SEC 7031 s 9JsNE55 AND PROFESSIONS CODE. ANY CITY OR
COUNTYMIICH REOUTRESAPERMTTO CONSTRUCT, ALTER IMPROVE. CCMOLISIL OR RCPA.R ANY STRUC-
TURE. PRIOR TO RS ISSUANCE. ALSO REOL21RES TNC APPLICANT FOR SUCH PERM T TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS UCENSED PURSUANT TO THF, PROYSCfIS OF TIC CONTRAC70RS LI-
CENSE LAW IC IAPTER 0 (OoMMENCNO WITH 5ECT10N 70M) Or D'VISION S OF THE BJS'NESS AND PRO-
FESSIONS ECCE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VILxAT1ON OF SECTION 701.6 BY ANY APPLICANT FOR A PERM'T SUIL:EC75 THE APPLICA!ST TO
A C.'Y!LPENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS 1(50¢)1'
OI.A; DWNCRO(THC PROPERTY.OR MY EMPL DYCCS WITH WAGES AS TICm SOLE COMPENSATION.
WILL DO TIE WON, AND THE STRUCTURE IS NOT INTENDED OR OFFERrO FOR SALE (SEC. 7064. BUSI.
NESS AND PROFESSIONS CODE THE CONTRACTORS LICENSE UW DOES NOT APPLY TO AN DWNCR OF
HO BUILDS On IMPROVES THEREON, AND WHO DOCS SUCH WORK HIMSE'J
PROPERTY WOR HE ASCLF OR
TIIOLFGH HIS OR HER OWN E MPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED DR
OrFEREO FOR SALE 6. HCMLYCR THE BULGING OR MI'ROYEMEN' IS SCID WI THIN ONE YEAR OF COMPLE
TION, 114E OWNER BUILDER WILL HAVE THE
BLAZON OF PROVNR THAT HE OR SHE DO NOT B'J:LD On
IMPROVE FORTHE PURPOSE OF SALE).
O LAS OWNER OF THE PTOPERTY.AM EXCLUS VCLY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT TIE PROJECT (SEG 70u, BUSINCSS AND PROFESSIONS CODE. THE CONTRACTORS I.I.
CENSC LAW DOES NOT APPLY TO AN CWNCR Or A PROPERTY M.40 BJLCS OR IMF TIOVES THEREON. AND
WIOCONIRACTS FOR SUCH PROJECTS W:TIACONTRACTOPISI LICENSED PURSUANT TOTE CONTRAC-
TORS LICENSE LAN)
O IAM EXEMPT UNDER SEG 9 A PC. FDR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFrFM UNDER PENALTY OF FE RJURY THAT 1 AM LICENSED UNDER PROOSIONS OF CHAPTER
6 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUs%Ess ANU r RoriSSIONS COLE, AND
MY LICENSE IS N FULL FORCEANDA`N'D EFFECT.
3
LICENSE CLASS C- LIC. NO y> L
DATE �•- Z t- -0 aA CONTrIACTOn C Sft
VIORKERS' CO,V.PENSATION DEC RATI
1 HEREBY AFFIRM LNDER PENALTY OF PER.R•'RY GNC OF CLLOW'NG
_I HAVE AND W LL MANTAN A CEnT:r'CATE OF 'SENT TCI SELF-R4SL'R' OR WORKEi�
COMPENSATION,ASPIgvDL'DBYSECT 370oorTIELA(H7Ronoc.ro(TTHE%EINrcRV4Nt�
Or TIE WORK Fon WHK)1 THIS PERMIT H SSUED.
I HAVE AND IN LL MAINTAIN WOPKCRi'CCM'ENSATION R.SJRANCC, AS REOL7 BY SECT
57o0 OF THE LABCn Coon, FOR TIE PLRrORMANCE Or THE WORK FOR WN ,:I TH'S PCnMIT IS
ISSUED MYWOI:KEns,COMPENSATK)NINSLRiA\CCCARRIERMDPOLCYN_UDERME
CARPER
-Ug[_L_AW^J•t illi.
POLICY NIIL4OF.R It -J, �-C , I
(neSSECnCN%'Lr.DN)TBECM91 TEDOrTCPEMC. Sren CNEILfgPlOCa FAR:,11WICucss;
1 CERTIFY THAT LN TIC PCRrORMA';CE OF THE WCPK FOR WILCII TI1.TT PCRMR T.' ISSOCO,1
SHALL NOT E14PLOY ANY PERSON IN ANY MANNER SEAS TO Bi L''J�II::E CT TO T•r
WORKSPI COMPENSATION LAWS OF CF!IJFORMALANOAGR.-E THAT IF 1 S•Cly=mLCOMC
SUG:ECT TO THC WORKERS' OCAJPENSATKON PROY:SION!1 CF SCCIK)N 3700 Or THE LABOR
CODE. 1 SHALL FCR: HWITH COMPLY W1711 THOSE PNJYSICNS
DATE. APPL?CANT.
WARN:NG rAILURE TO SECURE WORKERYCOMPENSATIDN COVERAGE IS CNLA'ATL"-AND SHALL BE
SL43JECT AN EMPLOYER TO CR:M'NAL PENALTIES AND CTRL FINES UP 70 ME H'JNDRrD THOUSANo
DOLLARS (r 100.0M). IN ADDITION TO THE COST OF COMPENSATION, DAMAC..ES AS PRCV!CED FOR IN
SECTION 3708 OF THC LABOR CODE, INTEREST. AND ATTOME YS FEES
CONSTRUCTION LENDING AGENCY
I FIE RT.BY AFFIRM UNDER PENALTY Or PErUURY THAT THERE IS A CONSTFUCTION LENDING AGENCY
FOil THE PCnroAMANCE OF THL WORE FOR Ve1ICH THIS PERMIT 15 ISSUE 0 (SCC. 3W7, CN C).
LENDERS NAME
LENDERS ADDRESS
1 1 CERTIFY THAT 1 HR.'E READ THIS APPLICATION AND STATE THAT THF, ABOVE IhrORMATIOH 15 OonnCCT.
I
AGREE TO COMPLY W',TH ALL CI Y AND COUNTY CRZ�!NANCES AND STATE LAWS RELATN3 TO BULDING
CONSTRUCTOR. AND HEREBY AUTHORIZE RCPRESCNTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE MENTIONED PROPERTY FOR INSPECTION PURPOSES
IC1;� /A3C0(IL.X h
I PERN:TTE N (PRINT)
i _ Q Cr -21 -21-
SIGNATURE OF PL• M;TTEC GAIL
APPLICATION /- a PERMIT �- l�� P/C
DATE (� NUMBER M
ISSUETYPE occ
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DATE CONST. GROUP
ZONING SETBACKS
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PROPRSLEDUSE �t.^OCF GCLZgLbd�
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NO. DWEL, NO. NO.
UNITS STORIES ( BEDROOMS
DESCRIPTION SO. FT FACTOR PSF ADJ. AREAIVALUATION
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QUANTITY DESCRIPTION FEE
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ENERGY PERMIT ('•7' _
RETENTION FCC: - �L11?1 L •
PRE -ALT FEE:
TOTAL FEES.
COMMENTS
RCCPT. NO. PAID BY
I VALIDATION
WHITE-Oeparlmer1 Copy. YELLOW-FK:BrKw Copy, PINK -Assessor Copy. GOLDENROD-FIk/ Copy, GREEN-Applicanl's Copy
CITY OF DIAMOND BAR -
INSPECTION RECORD
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