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HomeMy WebLinkAbout16554 (34) ----�. -- CITY OF DIAMOND BAR � �� DEPARTI+,L�NT OF COMMUNfI'Y&DEVELOPMENT SERVICES _� _h„�„� 21825 E.Copley Dr'sve �f (904)860-3195 Fax(909)861-3117 PRESS ` ""���� � BUILDINGPERMITAPPLICATION FIRMLY o� JOBSITE APPLICA ION PERMIT �r��j /C ADDRESS���`� �����'��'���S� �� pATE ;�°'°�,�� "`�,� NUMBEFl '�^'/ � # � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER���e!$� 24�A��i��" ADDRE�S1S� .��� ���L�t'd.C` C`a50(�,S'� �s� � ZONING SETBACKS Z CITY��ri�9�'YAB:� �$Irr1A ZIP �� . TEL.��g" �� FRONT RW ❑ � APPLICANT TEL. REAR ❑ Z ,+ SIDE/SIDE STREET RW ❑ m CONTRACTOR L � ���� ��l`1Q,I'� SIDE � ¢ ADD ESS� '� � CITY ' �ZIP b TEL.P"`��A�'° PROPOSED USE oARCH/ENG/ ���`� iz DESIGNER NO.DWEL. NO. NO. � ADDRESS � CITY ZIP TFL. UNITS STORIES BEDROOMS v� v� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-6UIL�ER DECLAFIATION SFR/ADD/REM � O 0 I HEREBY AFFlRM UNOER P€NALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI� Gef29EICefPOff W CENSELAWFOflTHEFOLLOWING�F1EA50N(SEC.�o31.5BUSINESSANDPROFE5510N5CO0E:ANYCITYOR (n U COUNTYWHICHREQUIRESAPERMITTOCONSTRUCT,ALTER.IMPROVE,DEMOLISH,ORflEPAIRANYSTRUG W_ Patio/DeGk W TUqE,-PRIOFi TO ITS ISSUANCE,ALSO RE�UIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W � � STA7EMENT THAT HE OR SHE IS LICENSED PURSUANT TO iHE PFOVI5loN5 OF THE C�N7RACioRS LI- � � CENSE LAW(CHAPTER 9(CAMMENCING WITH SECTION 7000)OF DIVISION 3 0F THE BUSINESS AN�PR0- POOVSpB � FESSIONSCODE)ORTHATHEORSHEISIXEMPiTHEREFROMANDTHEBASISFOR7HEALLEGEDEXEMP- (� . V TION.ANYVIOLATIONOFSECTIOt�7031.5BYANYAPPUCANTFORAPERMITSUBJECTSTHEAPPLICANi'O Z Re-Root ACNIL PENALTY OF NOT MOfiE THAN FNE HUNDRED�OLLARS($500).): . Z~ ❑I,ASOWNEROFTHEPROPEflTY,ORMVEMPLOYEESWI7HYJAGE5A5THEIR50LECOMPEN5ATI0N, Q WILL 00 THE WORK,AN�THE STRUCTURE IS NOT INTENDED OA OFFERED FOR SALE(SEC.7044,BU51- � Comme�Cial - � NESS ANU PROFESSIONS CODE:THE CONTRACiORS LICENSE LAW OOES NOTAPPLV i0 AN OWNER oP � — PflOPERNWH09UILDSORIMPROVESTHEREON,AN�NMODOESSUCHWORKHIMSELFORHERSELFOR CC THROUGHHISORHEROWNEMPL,'OYEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTENDE�OR m Q OFFEREDFORSALE.IFHOWEVER,i7�{EBUIL�INGORIMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE- Z TION,THE OWNER-BUILDER WILL1�HAVE THE BURDEN OF PROVING THAi HE OR SHE DID NOT BUILD OR � IMPROVE FOR iHE PURPOSE OF qALE). W LJI,ASOWNEROFTHEPROPEHTV,AMEXCLUSNELYCONTRACiINGWITHLICENSEOCONTRACTORS � TO CANSTRUCT THE PflOJECi(SECJo44,BUSINESS AND PRDFESSIONS CODE:THE CONTRACTORS�I- ValUatlon ADJ.AREA � W CENSELAWDOESNOiAPPLYTOANOWNEROFAPROPERTYWHOBUILD50RIAAPROVESTHEREON,AND � WHOCONTPACTSFOFSUCHPRO:IECTSWITHACONTRACTOR�SjUCENSEDFUaSUANTTO?HECONTRAC- QUANTITY DESCRIPTION FEE � TORS LICENSE LAWJ. ' � �AM EXEMPT UNDER SEC.; B.8 P.C.FOR THIS REASON Q � � r-- � ti � �ATE OWNER F- � r � �� o W F LICENSED CONTFACTQRS DECLAAATlON W � , � I HEFIEBYAFFlFM UNDER PENALT�Y OF PEF7JURYTHAT I AM LICENSED UNDER PFOVISIONS OF CHAPTEF � ' p„ . 9(COMMENCINGWITHSECTION7S00)OF�IVISION30FTHEBUSINE'oSAN�PROFESSIONSCADE,AND z X�' MY UCENSE IS IN FULL fORCEAND EFFECT. � � LIGENSE CLASS �A!� LIG.NO. ��/ �-� j�- j V� DATE �I CONTRACTOR���� �(.�� ��a . w �I✓�y� � ,� � ���y � WORKERS COMPENSATION DECCARATION a,�j ���� a � IHEREBYAFFIRMUNDERPENALT�fOFPERJURYONEOFTHEFOLLOWINGDECLARAT16A5: Z � _IHAVEAImWILLMAINTAIN�ACERTIFlCATEOFCONSENTTOSELF-INSUREFORWORKEf15' a ¢ COMPENSATION.AS PRO�I�ED BY SECTION 37�o OF 7HE LABOR CODE,FaF 7HE PERF�RMANCE U Q OFTHEWOqKFORWHICI3THI5PERMITI5ISSUE�. � �� _IHAVEANDWILLMAINTAI WORKERS'COMPENSATIONINSURANCE,ASREQUIRE�BYSECTION 37000FhIELABORCOD�,.FOqTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS ISSUED.MVWORKERS'CQMPENSA'fIONINSURANCECARRIEFANDPOLiCYNUMBERARE, CONSTRUCTION J — j cqRaiEa �'' PLAN REVIEW �.�,�.�a--¢-;�.,"�«"' = ,.....- ZPOLICYNUMBER ELECTRIC A '` �{"^'^°��'.��F r Q Y � (MISSECTIONNEmNOTBE�MPLEfE�OFiHEPEFMfTISFDPONEHIJIJ�REDDOLLARS(g7oo)OR�ESS). PLUMBING �� ++� � � W � _ p Z I CERTIFVTHAT INTHE P FORMANCE OF hiE PlOflK FOR WHICHTHIS PERMIT IS ISSUED,1 MECHANICAL � ' i ('3 SHALLNOTEMPLOYANY,�ERSONINANYMANNERSOASTOBECOMESUBJECTTOTHE P (J) WORKERS'COMPENSATIqNLAWSOFCALIFORNiA,ANOAGREETHATIFI OU.�BECOME INSPECTIONFEE e � SUBJECTTOTHEWORKEAS'COMPENSATIONP VISIDNSOFS TION ooOFTHELA80R I p_ 4 � CODE.I SHALL FOflTHWITH COMPLY WITH SE PROVISION �, ISSUANCE 6---.� �_� p DATE:� ry�°'� A�PLICANT. � �� � .f� � SMIP '��_-_-�--�_ J WARNING FAILURE TO SECURE ryOfiKERS' MPENSATION VERAGE IS UNLAWFUL,AND SHALL BE ENERGY P!C � SUBJECTANEN.PLOYERTOCRIMINALPENALTIESANDGVI INESl1PTOONEHl1N�REDTHOUSAN� ENERGYPERMIT D�LLARS(51oo,oaoJ,INADDITIONS'OTHECOSTOFCOMP SATION,DAMAGESASPRWIDEDFORIN � SECTION 3�o80FTHE LABOR COdE,INTERESi,ANDA aNsrs FEEs. RETENTION FEE: � OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: � IHEREBVAFFIRMUNDERPENALT�OFPERJURVTHATTHEREISACONSTPUC710NLENDINGAGENCV FORTHEPERFORMANCEOFTHE ORKFORWHICHTHISPERMITISISSUED�SEC.309],CIV.C.). Z W ? LENDER'S NAME � H LENDER'SAD�RESS /. wICERTIFYTHATIHAVERE4DTHIS��AAPLICAT70NANDSTATETHqTTHEABOVEINFOFMAilONISCORRECT. TOTAL FEES �/�'j�/{ � IAGREETOCOMPLYWITHALLCITlANDCOUNTYOFIDINANCESANOSTATELAWSRELATMGTOBUILDING � �-/��Ls' � CONSTRUGTION,ANDHEREBYAUTHORIZEREPRESENTATIVESOFTHISCOUNTYTOENTERUPONTHE � ABOVE-MENTIONEDPftOPERTYFORINSPECTIONPURPO5E5. COMMENTS � � ��� q� ��T� dd'�"�ad � — m PE NAME(PRINT� � � :r� .����-��� � (/� ATUREOFPERMI � DATE = RECPT.NO. PAID BY VALIDATION ~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—Fle Copy,GFEEN—ApplicanYs Copy , , . � ,.. ,. , , , , . _ . _.. ,,. ,._ . - : . ..��,...: .� .,�:... _ -; .. �_ fi # � ` _ _ � ��'�. 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