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HomeMy WebLinkAbout16853 (44) _�.� CITY OF DIAMOND BAR - DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES _ a 22660E.CopleyDriveSuite190 C��SS1 C�.� �,}��� PRESS �°���� BUiLDING PERMIT APPLICATION FIRMLY } JOBBITE i q�,y APPLICATION a" PERMIT �� ,,d�� P n ADDR85S r � � V DATE � � NUMBER_� #� 'r�' $ - 8� ISSUE �. � �p -y'TYPE dCC -- APN LOT TRACT�� Ul( DATE °8'��CONST. GROUP d OWt3ER , , :" ZONING, SETBACKS ` ADDRESS � Q CITY "8 ZIP TEL. REORT RW ❑ �� APPLfCANT � TEL. ` SIDE/SIQE STREET RW ❑ � CONTRACTOFi / SIDE ❑- � ADDRESS ' , PROPO.SED USE '; Y ., O C,I'IY IP L. �a ARCH/ENG! DESIGPlER � � I � �� _ I '� ADDRE NO.DYtiEL. NO. NO. `� C!?`l . IP TEL. '' � �` ��� � UNITS STORIES BEpROOMS � DESCRIPTION SQ.FT. ACTOR PSF ADJ.AREANALUATION ' � � ,o ��� ��� OWN6R-BUILDERpECLARATfON SFR/ADDIREM � � , ,, �,� ' ;I HEREBV AFFIRM UNDER 7ENPLTY OF PEIL'l1RV THAT�AM EXEMPT FR6M THE CONTRACiOHS LI� GdfBgE/CeR?Oh .;� LLf CENSELAWFY7RTWEFOLLOWMGREASON(SEG.70�t,58U31NE33ANDPqOFESSIONSCAOE;ANYCITYOR (n , C.] COUNTYkhiICH.REWIRBSNPERMITTOWN37flUCT,�h'7EB,IMPROVE,DE�lOLISH,OPREPAIRANYSTRUG �W ,Pg110/DBCk � TURE.PRlOR TO ITS ISSUANCE,ALSO REQUIfiES THE APPLICANT FOR SUCH PERMIT TO FI�,EA SIGNED W � , . ," STATEMENS THAT H5 OR SHE IS LICENSE�PURSUAMTTO THE PRtlVISIONS OF THE CAN?RACTORS LI- ' � ''i,� AEN9E LAW(CHAPTER 9�COMM19ENCINa WITH SECTION 70a01 OF DIVISION 3 OF 7HE BUSINESS AND PRP �,V"'- 'PQOUSPB �� . � - � ' ' ' FES$qN$CODE)tlRTHATHEOASHEI&EXEMPT'THEREFHOMANDTHEBASISFORTHEALLEGEDEXEMP- (� . � � �TIDN.ANVVIOI.qTKFlOFSECTIOh7091.5BYANY�APPLYCANi FOflA?ERMITSU&lECrSTHEAPPLICANTTO Z� RE-RO04 � � � � � - � ';r A CIYI'a PENALTY OF NOT MOAE THAN F1vE HUNOR�p pOLlAR5(Ssoa).): , ��.i�� ❑I,ASOWNEROFTHEPFOPERTY,OftFqVEMPLDYEESiNPTHiKAGESASTHEIPSOLECDMPENSATION, ��C� COfY1f118(Clei � ' . �(g iHs� THE WORK,APID THE 3T'RUC1'URE V5 NCT'lNTENDE�OR OFFERE�FOp SALE(SEC.7044,BU51- '�..�4 � '� VALL '� ANO VHOFESS�ONS CODS THE CCNTRACTONS'�LICE#ISE UW DOES NOT APPLY 70 AN OWNEF OF ;� , _, _.. - _ � ' , ' '. PROPEflM4VhiOBUliD50RIMPR6YESTHEREOM1f,ANDMMOU0E5SllCHWORKHIMS'cLFORNERSELfOR "' GHHISORH6RONMER9PLOYEES,PROVIOE�THATSUCHIMPROVEMENTS.GRENOiINTENDE�OR m � 'j�i� ',OFFEREOFORSALE:IF,HOWEVEFi,THEBUILDINGORIMPHOYEMENTIS50LDWITHINONEVEAROFCOMPLE ' ' .� �TEDN,THE OWNER-BUILDEFl WILL HAVE THE�URDEN Of PROVING YHAT HE oR SHE OID NOT BUILD OR . ,� IMBFIDVEFORTHEPWRPOSEOPSlaCEf� ' ' dI,ASOWNEHO(TNEPROPERTY,AMEXCLUSNEIYCOMRAC7INGWITNLICENSE�CAN'WIC70R5 , � I� ,TO COfdSTRIICT'[H&PFOJEGT(SEC.7W4,9ll5!NE55 AND PROFLSS�ONS CODE:THE CONTpACTORS LI• . V81UflP1011 DJ.AREIA ,;IJ-I �,CEN¢EtAWDOESNOTAPPLYTOAIdDWNEROFAPHOPEfiTYWHUBUILDS�FIMpROVESTHERE04,AP1D ' - � �' �'�;� 'NAiOCOMTRACTSFORSUCHPAOJEi;TSWITMAC�NTR,SCTOR(S�LICENSE�PURSUAftlT70TNECONTRAG QUANTITY DESCRIPTION FEE ��,i� ��TORSLICEkBELAW.).. . , . ,y.�., - . i0 ❑IAMEXEMPTUNDEfdSEG B.BP.C.FDRT=IISREASON ��,<Q � 8,.. 1�� i, '' ,� . . .. , . U, �A '' � '�� � �' .iY 1 lf++ G✓ "` q '.OATE OWNER_. iU I � � �. �•!L�'�-. W� I���Q .. � . � LICENSED CONTRACFORS DECU1FiAT!ON ,� �` . .�. � � � �,¢ '�iIHERE9YAFFIpMUNOERPENALTYOFPERIURYTHATIAtALICENSE�UNDERYROV151oN50FCHkPTER � �„��, ' '��a "e{COMMENCINGWITH9ECTION70o9)OFDIV!SlON30FTNEBUSMESSAN�PROFESSlONSCODE,APID �� ' IX. .IAY LICENSE IS W FULL FORCE AND EFFECT. � � LLl g, �p uceNss c ua No:- - — 'J � �,,�,, � � 'omre_ _ coraTY�acroR a . � g. ' � � ��� � � WORKERS'COPAF'ENSAT30N OECl.ARATION �� � `�.. . �� �' I HEREBYAFFIRM UN6ER PENfl9.7Y OF�ERJUFV ONE OFTHE FOLIAWING DECLARATIONS: � s �� 'u��' ¢A Z P�'�� _,�,IHAVE�IiDWILLMAINTAP7ACERTIFICA7EOFCANSENTTOSELFdNSUPEFORWOqKEAS' _ j� �� COk'FEN6ATK7N,A6PRDYIDE�BySEC710N370oOFTHELA80RC06E,FORTHEPERFOftMAA10E tS � ��`"'� W '�' � . Z OF THE WORK FOR WHICH THIS PERMIT IS ISSUE�. � . �.' . W �lHANEANDWILLMAIRTAWWORKERS'�COMPENSATIONINSURANCE,ASREBLIlREDBYSECTION r'� (�`p�,, ��� 37000F3'FIELABORCOOE,F6RTHEPER:-0RMANCEOFTNEWORKFOPWHiCHTHISPEAMITIS _.) "+�` y� � ISS�E0.MY. RKER5' P,ENSA71 IhSURAN E CARRIER AN�PO,CY NUMBEfiA E: CONST�h.UCTION i,�, d ��r ,���� cARrtiEa �� � � ��� � " ! �' ge ,,.�, PLAN REVIEW � _ . i � Poi.ICVNUMFiER , r � � . � ,. '� . . ELECTRIC � Q �� � �4�N���C�N_EfEDOFTVfc-7ERh7fA5i-0HIX�EHUPIDREGCClIPA5l81W}ORLE55). PLUMBING __�.�,. i,� � �.6 y t'�^"�, ' � �� ICEPYIFYY!iATiNTHEPERFOr^.M�ANC�OFTHEWORiCFOFWHiCHTHISPERMITI5ISSUE�,1 MECHAMCAL � �� fb/� '(3' '�: SNAL1-NdTEPRPLOYAA'YpER50NiNAIdYMANNER50A5T00ECOMESUBJECTTOTHE ' ' ��'�' WORKEAS'COMPENSATIONIAWSqFCA!iFOftNfA�AN�AGREETHAYIFISHOUl�BECOMe lNSPECTfONFEE SUBJECT TO THE NH)flKEliS'COMPENSATION PR�VISI6NS OF SEC?ION 37000F THe W3Qfl q�, ' _ (:ODE,I S LL FORTHIKiTH COMPLY WITH TN05� ROYISION. ISSUANCE �e;�i I,' � ,�7���d ��� �}�.i SMIP p �:'OATE: APPLlCANT: � I ('" � ��� � ENERGY P!C ,.% – ';WAflNING;FAILURE T6 SECURE WOPKERS'COMPENSATlpN COVSRAGE IS UNL4WFUL,AND SNALL BE �'"� ���'�;SU&IECTANEMPLOYERTOCWMINALPENAL'itESANOCiYILFINES�P700NEHUN�REDTHOUSAND ENERGYPERMIT -""��� � �DOLUflS ISi oD.oOo),IN AD�ITQN TC THE COST OF COMPENSATION,�ANAGES AS PROYIDED FOfl W ��� � .SECTION3�oaOKTHELABORCOfIE,INTEREST,ANOhTTORNEVSFE6. RETENTIONFEE:� - � Q . CONSI'AUC710N LENDING AGENCY pRE-AlT FEE: �� i ���.�,�HEflEeYAFFIRMUNDEAPENALT'VbFPERJUCiYTHATTHEREiSAGONSTflUC710NLENDINGAGENCY �'��',FOR THE P6RFORIAANCE OFTHE WORK FOR WHiCH THIS P,ER�MIeT IS ISSl1ED(SEC.3�5],CIV C.). --v -� � . '� ;���LENQER'SNAME� . �.�.1�.� t @ y,� . ��_ � ���I F�-il LENDERSAD�RE59 � III � '�,.IAGREETOCOMPYVWITHALLC'IttANDCCOUfJTYORDINAN�CE5AND5TATElAWSREIATWOTOO�J�ILDING TOTAL FEES - �� �� � t � ',' ''�I . �'�'i CANSTRUC710N,ANDHEREBYAUTNOR�ZEREpRESENTA71yE50FTHISCAUNTYTOENTERUPONTHE �'�'�.I�qgpyE-MENTIONEO PROPERTI'FQq INSPEGTION PUflPOSES. . �' ' I� � .:'. . . COMMENTS - .'�;, �,'„PERMITfEE NAME(?� T} ,"{S' . . ��I'. �i . ��'SIGNATUqE OF PEFMITfEE �� DATE - � , I ' ��� RECBT.NO. i PAID BY VALIpATION_ ~ WFrITE—Depertment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOL7EN O ile Copy,GREEN—ApplicanYs Copy � � � a�^' ��� '''��,r� ri�.�:� '�'.�„�;�:�'$� `�����.�'��"ai . . 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