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HomeMy WebLinkAbout12951 _��� CITY OF DIAMOND BAR � _� � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES w 216b0 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS •�°��� BUILDIlVG PERMIT APPLICATION _—_ FIRMLY � JOBSITE „ ' APPLICATION _ ,.- q PERMIT P/C o ADDRESS �+��� ��C.��Z��' L�NC DATE � �� � 1 NUMBER �� � # $ APN LOT TRACT �/' �-�{�j ISSUE TYPE OCC 7� " DATE CONST. GROUP p OWNE�`l L`� t+�.7t; E�c�,� p ADDRESS_ I�I�-� ��<� .Y� ZONING SETBACKS Z CITY U���4r�r7 ZIP�� TEL.��}f�yJ��-- REART RW ❑ g APPUCANT TEI. SIDE/SIDE STREET RW ❑ � CONTRACTOR � SIDE ❑ g ADDRESS PROPOSED USE M�f��t,fc?rL t/ ��r'�. t�--�' CITY ZIP TEL. o ARCWENG! z DESIGNER W NO.DWEL. NO. NO. � ADDRESS � CITY ZIP TEL. UNITS STORIES BEDROOMS � u� DESCRIPTIQN SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADD/FlEM O I HEREBV AFFlRM UNDER PENALTY OF PERIURV THAT I RM E%EMPT FROM THE CONTRACTORS L4 Garage/Carport W CENSEUWFORTHEFOLLOWINGREASON(SEC.7o3t.6BUSINE55ANDPROFESSIONSCODE:ANVCI7VOR (n zCOUNT`/NMICHREWIRESAPERMITTOCONSTflUCT,AL7ER,IMPROVE,DEMOLISH,ORREPAIRANVSTRUG �,f pdti0lD8Ck W TURE,PRIOR TO ITS ISSUANCE,AL50 REWIRES THE APPLICMIT FOR 9UCH PERMIT TO FIIE A SIGNED W STATEMENT THAT HE OH SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LF � CENSELAW�CHAPTERe(COMMENCINOWIiHSECTION7Wo)OFDIVISION30FTMEBUSINESSAN�PRO- � POOUSpd � FESSIONSCOOE�ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXEMP- V TION.ANYVplATIONOFSECTiON7IXi1.58VANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO Z R8-Roo1 � A qNL PENALN OFlbT MORE THM!FNE HUNORED DOLURS(S5oo).�: � ❑I,ASOWNEROFTHEPROPERTY.ORMVEMPLOVEESWITHWAGESASTHEIRSOLECAMPENSATION, � CommefC181 - WILL 00 THE WOAK,AND THE STRUCTURE IS NOT INTENOED OR OFFERED FDP SALE(SEC.704�,BUSF J � NESS AND PROFESSIONS OODE:THE CONTFACTORS LICENSE UW DOES NOT APPLY TO AN OWNER OF � PROPEFYfY VRi�BUILDS OR#flPROYES 7HEREON,AND NHO DOES SUCH WOFiK HIMSELF OR HERSELF OR � THtWUGHMISOHHERONMEMPLOYEES,PFOVIDEDTHATSUCHIMPROVEMENTSAFENOTINT�NOE�OR m Q ,OFFEREDFORSALEIF,HOWEVERTMEBUILqNGORIMPitOVEMENTI550LDWITHINONEYEAROFCAMPLE Z �TION,THE OWNER�NUILDEfi WILL HAVE THE BURDEN OF PROVWG THAT HE OR SHE DI�NOT BUILD OR � IMPROVF FOR THE PUFPOSE OF SI�LEI. W ❑I,ASOWNEROFTHEPpOPERfY,AMEXCLUSNELYCAMRACI"INGWfiHIICENSEDCANTRACTORS � TO CONSTHUCT THE PR0.IECT(SE4 1ou,BUSINESS ANO PROFESSIONS CO�B 7HE CON7RACTORS LI- VeWet100 ADJ.AREA W CENSELAWDOESNOTAPPLVTOPNOWNEPOFAP0.0PERTVWHOBUILDSORIMPqOVESTHEREON,AN� F WFIOCOMHhCTSFORSUCHPROJEC7SWI7HACONiMCTOR�S�UCENSEDPUHSUANTTOTHECON7RA4 QUANTITY D SCRIPTION FEE Y TORSLICENSELAW.). � ❑I MI EXEMPTUNDER SEC. .8 P.C.FOR THIS REASON Q 3 � � � DATE _ OWNER C U � , W LICENSED CONTRACTOPS DECLARATION -� � W 1 MEREBY AfFlRN UNUER PENAITY OF PERJURV TMAT 1 AM LICENSED UNDER PROVISIONS Of CHAPTER � � B(COMMENCiNO WITH SECTION 7000)OF DIYISION 30F TME BUSINESS AND PROFESSIONS CODE,0.ND Z X MY LICENSE IS IN NLL FORCE AND EFFECi. m LLJ � LICENSE CLA55 LIC.NO. j ' � J V DATE CONiRACTOfl O. W � WORKERS'CQMPENSATION DECLARATiON Q � IHEREBYAFFIRMUNDEHPENALTVOFPERJURYONEOFTHEFOILOWINGDECIAFATIONS: Z � _IHAVEANDWILLMAINTAINACEfRIFlCATEOFCONSENTTOSELF-MSUqEFORWORKERS' _ COMPENSATION,ASPROVIDEDBYSECTION37000FTHELABOFCODE,FORTHEPERFORMANCE U � OF THE WORK FOR WHICH THIS PERMIT IS ISSUEO. � O W _IHAVEANDWILLMAIMAINWORKERS'COMPENSATIONINSURANCE,ASREOVIREDBYSECTION � Q 370oOFTHELABORCODE,FOFiTHEPERWRMANCEOFTHEWORKFORWHICHTHISPERMITIS ISSUED.MY WORKERS'COMPENSATION INSURPNCE CARRIER AND POLICY NUMBER ARE: CONSTflUCTION � �_r_(�O � CARRIER PLAN REVIEW 2 POLICY NUMBER ELECTRIC Q 0 (fHISSECTptJNE�NOiBEOOA�PLEfEDOFTHEPEPI.tlTISFORONE�iUMRmDOLW75(S1ao)ORLESS} PLUMBING Z I CEflTIFV THAT IN TFIE PERFORMANCE OF THE WORK FOft WHICM h115 PEPMIT IS ISSUED,1 MECHANICAL (} SHAILNOTEMPLOYANYPERSONINANYMANNERSOA5T08ECOMESU&IEC7707FiE � WORKERS COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF 1 SHOULD BECOME INSPECTION FEE _ S SUBJECT TO THE WORKERS'COMPENSA710N PROVISIONS OF SECTION 370o OF THE LABOR / � COOE.1 SHALL FORTHWITH COMPLV WIlH THOSE PROVISIONS. �SSUANCE � � SMIP �wnpg �t OATE: APPLICANT. ���� WWARNING FAILURE TO SECURE WORKERS'CAMPENSATION WVERAGE IS UNLAWFUL,AND SHALL BE ENERGY P/C �gZ 11��(`�7 � �y SU&IECTANEMPLOYERTOCRIMINALPENALTIESANOCIVILFMESl1P700NEHl1N�iiEDTHOUSAN� ENERGYPERMIT DOLURS(f!o0.000),IN ADDITION TO THE COST OF COMCENSATION,DAMAGES AS PROVIDED FOR IN J SECTION3'1O80FTHELABORCOOE,INTEREST,ANDATTORNEY'SFEES. RETENTIONFEE: ,����(��pY��r7+y r W � f ➢ i�'L. �i xr^`.3!'F.` '°-'l F n. CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � I HEREBY AFFIRM UNDER PENRLTV OF PERJUHY THATTHERE IS ACONSTRUCTION LENDING AGENCY FOR THE PERWRA�ANCE OF THE WORK FOR WHICH 7HIS PERMIT IS ISSUEO(SEC.3aW,CIV.G). . Z w � LENOER'SNAME F- LENDER'SAD�RE55 _ � TOTAL FEES � � � 1 CERTIFV THAT I HAVE READ THIS APPUCATION ANO STATE THA7THE A90VE INFORMATION IS CORflECT. � IAGREETOCOMCLVWIiHALICIiYANDCOUNTVOR0INANCESANDSTATELAWSREUTINGTOBUILDING � CONSTRUCTION,AND HEFEBV AUTHORIZE REPRESENTATNES OFTHIS COUNTY TO ENTER UPON THE PBOVE-MENTIONED PROPERTY FOR INSPECT�ON PURPOSES. COMMENTS _ �Zc�° G9� �4e���r- k ¢ PERMITTEE NAME(PRlhff� - x ' -' ' ' � C/� ��ra �'`�� � l�,"!�� �_ � SIONANREOFPERMITTP DATE � � RECPT NO. PAID BV VALIDATION y. WHITE—Depertment Copy.YELLOW—Finance Copy,PINK—Assassor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy ;,,, .: ,,. . . . ,. , . , ,, _:. :: y ���`^` t a.,,:,.: .ta. r. . re". n:. . . 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