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HomeMy WebLinkAbout16336 (20) ����� _ ���_ CITY OF DIAMOND BAR ���,,-�/ DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �� w 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS ������ BUILDING PERMIT APPLICATION Fl RMLY - y JOBSITE ��/�i�l ������uj�� �� APPLICATION PEHMIT P!C o ADDRESS 7 7 DATE � NUMBER # � APN LOT TRACT �SSUE TYPE OCC �� DATE o _CONST. GROUP p OWNEq �h•°►tt i t/C�e _ WADDRE�SS"�.,5' rL �� ZONING SETBACKS � cirr,.la�p�+`°9'+ IP_ /� 1 TEL. FRONT RW O APPUCANT TEI. REAR p � SI�E/SIDE STREET RW ❑ � CONTRACTOR L-'�I' .4 0� • SIDE ❑ ADDRESS ��'✓� • r � CITY L-u/� ZIP ��LrS TEL. L' - PROPOSEDUSE D !� o ARCWENGI � DESIGNER NO.DWEL. NO. NO. n. ADDRESS � CITY ZIP TEL. - UNITS STORIES BEDROOMS v� �n DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADOlFlEM W� 1 HEREBY AFFIRM UNDER PENALN OF PEHJl1RY THAT 1 AM EXF.MPT PROM THE CONTRACTORS Lb Gdl'agB/COrpOft CENSELAWFORTHEFOLLOWINGREASON(SEC.7o31.58USINESSANDPROFESSiONSCOOE:ANVCINOR (n � COUMVNhiICHRECNIIRESAPERMRTOCCNSTRUCT,ALTER,fMPROVE,DEMOUSH,ORREPAIRANYSTRUC- W Patio/Deck TUHE,PRIOR TO ITS ISSUANCE,AL50 REQUIRES THE APPUCANT FOR SUCH PERMIT TO FlLE A SIGNED W STATEMENT THAT HE Oq SHE IS UCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI� W � CENSE UW�CHAPTER 9(COMMENqNo WITH SECTION'/000)OF�IVISION 3 OF THE BUSINESS AND PRO- U"' PooUSpa � FESSIONSCOOE�ORTHATNEORSHEISE%EMPTTHEREFROMANpTHEBAS15FORTHEALLEGEDEXEMP� (� U TION.ANYYIOUTIONOFSECTION7031.SBYANYAPPIICANTFOHAPERMITSUBJECTSTHEAPPLICANTTO Z Re-Roof F A CIVIL FENALN OF NOT MORE THAN FIVE HUNDRE�DOUARS(SSoo).�: � ❑I.ASONRJEROFTHEPROPERTV.ORMYEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, � COmfnefCiel - Yi1LL 00 THE WORK,AND THE STRUCTIIRE IS NOT MTENDED Op OFPERED FOR SALE(SEC.7044,BUSI� J � NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLV TO AN OWNEF OF = PqOPERiY NM1i�BUIIDS OR MIPROVES THEREON,AND Vh1G DOES SUCH WORK HIAASELF OR HERSELF OR LL THi10UGH HIS OH HERONTI EMPLOYEES,PROVIpEO TFIATSUCH IMPROVEMENTS ARE NOT INTENDED OR m � OFFEREDWRSILEIF,HOWEVERTMEBU14DIN�ORIMPROVEMEMISSOLDWI7HINONEVEAROFCOMPLE- z, TI01J,THE OWNER-BUIIAER N1LL HAVE TFIE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR � IMPRObEFORTHEPURPOFEOFSILL.E). W ❑I,ASOWNEROFTHEPROPERTY,AME%G.USNELYCONTMCTINOWITHLICENSEDCONTRACTORS p[ TO CONSTRUCT TME Pq0.1ECT(SEC.7oN,B1151NE5S AN�PROFESSIONS CODE:7HE CONTRACTOiiS LI- VeW2Si0f1 ADJ.AREA W CENSEUWDUESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUILASORIMPROVESTHEREON,AND � NM1fOCOhTRACTSFQRSUCHPR0.1ECi5WIh1ACONTRACTOR�S)UCENSEDPURSUANTTO7HElX1NTRAC- QUANTITY DESCRIPTION FEE � TORSUCENSEUW.). ❑I MA EX£AIFT UNDER SEC. 8.8 P.C.FOR THIS REASON J Q �- Q 3 _ U � � UATE bWNER U Z W ¢ LIC[NSED CONTRACTORS DECLARATION W dG I NERE6V AFFIRN UNDER PENALTY OF PFRIURV THAT 1 AM LICENSEO UNDER PROVISIONS OF CNAPTER �/♦ ./` (L Y(COMidENCINQ WITH SECTKaY 7000)OF DIVISION 3 OF TH�BUSINESS AND PROFESSIONS CODE,AIJO Z �'.�v F�II� X MV UCENSE IS IN FULL FOHCEAND/F�'FECi. `� LICENSE CLA55 G/ �7�` LIC.NO. �" ���� � V DATE___�1°'�/ CONTRACTOR _ d W � WORKERS'COMPENSATION DECLARATION � � � �HEREBYAFFIqMUNDERPENAITYOFPERJUHVONEOFTHEFOLLOWING�ECLAMTIONS: Z � I HAVEAND WI'_LMAINTAIN ACERT!FICATE OF(:ONSENTTO SELF-INSURE FOR WORKERS' _ COIuMEN ,A$PROVIOEO BY SECTION 310U OF THE IABOR CODE,FOR THE PERf-0qlAANCE W O ORK FOR NMICH THIS PEPMIT IS ISSUEO. � d _,_{MRVEANDWILLMAIIYrA1NWORKER5CAMPCNSATIUNINSU1iANCE, R IREDBYSECTION p 37000FTHElABD FORTHEPERFORMANCEO �WO O ICHTHISPERMITIS ISSUED.�AV WORK 5' MPENSATION INSURANC AF 1 H V NUMBER E� CONSTRUCTION � CAHq1ER_„_. _ , PLANREVIEW � POLICV NUMBER__ _ �' � EI.ECTRIC �� Q (iH155ECTqNNEWt�JTBECDMREiEDOFThEPEW+YiISFnR EHUNDRED � oO�ORLESSF PLUMBING � Z I CERTIFY THAT M THE FERFORMANCE OF THE VdORK F RMIT ISSUEO,I MECHAMCAL (3 SHAlLNOT EMGI.OY ANV PEF50N IN ANY IAA COME BJEC O THE � � WOPNERS'COMPENSATION LAWSOF CALiF T I SHO � ECOME INSPECTION FEE ~^� � SUBJECT TO THE WORKERS'COMPENSATI O S OF S C a F E LABOR -' �� ^ -�-"'=� � CODE,ISHALLFORTHWih1COMPLYW1T11 H SE I iONS. ISSUANCE i O SMIP �P R !1 � � �1 ' p OATE:�yL� APPLICANT: ��t� i J WARNIN�:FAIWRE TO SECURE WORKERS'COMPENSATItlN AGE IS UNLAWFUL,AN�SHALL BE ENEFiGY P/C �y SU&IECTANEMPLOYERTOCRIMINALPENA�TIESANDCIVII.FINESUPTOONEHUNOfiEDTHOUSAND ENERGYPERMIT DOLLARS(i1o0.o00).IN ADDITION TO THE COST Of COMPENSATION,DAMAGES AS PROVIDED FOR IN � � SECTION37oeOFTHELABORCO�E,INTEREST,ANDATTOANEI"SFEES. RETENTIONFEE: � ---_ a CONSTRUCTION LENDlNG AGENCV PRE-ALT FEE: O � INEREBVAFFI0.MUNDEROENALTYOFPERJURYh1ATTHEREISACONSTRUCTIONLENDINGAGENCY FORTHE PERFOPMANCE OFhIE WORK FOR WHICN THIS PEPlAITIS ISSVEO(SEC.3oel,CIV.CJ. Z W � lENOER'SNAME F- LENDER'SAD�RESS W ICERTIFYTHATINAVEREADTHISAPPLICATIONANOSTATETHAtTHEABOVEINFORMATIONISCARRECT TOTAL FEES � � I AGREETO COMPIV WITH ALl CITY AND CQUNTY OROINANCES ANO STATE LAWS RELATING TO BUILDING � CONSTRUCTION,ANDHEPEBVAUTHORIZEREPRE TIVESOFTHISCOUNTVTOENTERUOONTHE Z ABOVEMENTKKJED PROGER7Y FOR INSP URP ES. 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