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HomeMy WebLinkAbout17216 CITY OF DIAMOND BAR -� �`' --� DEPAR'I`MENT OF COI�'IIv1UNTTY&DEVELOPIvIENT SERVICES 21825 E.Copley Drive ��� ^'�� (909)8603195 Fax(909)861-3117 PRESS ��"%���� BUILDINGPERMITAPPLICATION FIRMLY ¢ JOBSITE �'�"���,�,�� � � - � APP�ICATION /,�{! �� 'I PERMIT �'-3" � �,, P/C��,.- J o ADDRESS_ % . DATE t� NUMBER 1 � # � � �� ISSUE TYPE OCC APN LOT TRA T DATE h - � CONST. GROUP p OWNER �e�:� ��',a�'��� ��(Ir��' .�_ � o ADDRESS ZONING SETBACKS z CITY ". ZIP�_ TEL�� ' �;-. { REORT qW ❑ o APPLICANT �u'_�_��"�_� TEL" � � ¢ SIDE/SICE STREEI' RW ❑ Q CONTRACTOR _ SIDE p ADDRESS � CITY ZIP TEL. PROPOSED USE G (�': oARCH/ENG/ z DESIGNER w NO.DWEL. NO. NO. a ADDRESS = CITY ZIP TEL. UNITS STORIES BEDROOMS � � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUIL�ER DECLARATION SFR/ADD/REM O p I HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THc CONTRACTORS LI� G8fd90/COfpolt W CENSELAWFOP7HEFOLLOVJINGfiEA50N(SEC.7C31.58USINESSANDPROFESSIONSCODE:ANYCITYOR (f� U COUNTYWHICHRE�UIRESAPERMITTOW.USiRUCT,ALTcR,IMPROVE,DEMOLISH,ORREPAIRANYSTRUG W TURE,PRIOR TO ITS ISSUANCE.ALSO HEQUIRES THE APPLICANT FOR Sl1CH PERMiT TO FILE A SIGMD W P8SI0/DBCk c� STATEMENT iFNT HE OR SHE iS IICEN5E0 PURSUAN7 TO THE PROVISIONS oF THE CONTRACTORS LI. .� CENSE LAW(CHAPTER 9(COMMENCING WITH SECTIDN 7000)OF DIVISION 3 OF THE BUSINESS AND PRO� LL' POOUSPB � FESSIONSCODE)�iTHATHEORSHEISE%EMPTTHEREFROMAN�THEBASI5=0RTHEALLEG[�E%EMP� (� U TION.ANYVIOLATIONOFSECTION7031.SBYANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO 2 Re-Roof � ACIVII.PENALTV OF NOT MORE THAN FIVE HUNDREO DOLLARS(E500).): � OI,ASOINNEROFTHEPROPERTY,ORMYEMP�OYEESWITHWAGESASTHEIF50LECOMPENSATION, 0 COIItfIl8fCi8I Z WILL DO THE WORK,ANO THE STRUCTURE IS NOT INTENDED OF OFFEREO FOR SALE(SEC.7044,BU51� J � NE55AND PROFESSIONS CODE:THE CIXJ?RACTORS LICE4SE LAW DOES NOT APPLY TO 0.N OWNER OF = FqoPERT/NM110 BUILDS OR IMPROVES THEREON,AND NMO DOES SUCH WORK tUMSELf OR HERSELF OR � THROUGHHISORHEROWNEMPLOYEES,PRDVIDEDTHATSUCHIMPROVEMENTSARENOTWTENDEOOR LO � OFFEREOFORSA:.E.IF.HOWEVER,THEBUIlD1NGORIMPROYEMENTISSOLOWI7HINONEVEAROFCOMPLE� Z TION.THE OWNER-BUILDER WILL HAVE THF BURDEN OF PROVMG TNAT HE OR SHE DID NOT BUILD OR = IMPROVE FOR THE PURPOSE OF SALE). �y,� ❑1,AS OWNER OF THE PROPERTV,AM EXCI.USIVELY CONTRACTING WITH LICENSED CONTRACTORS � TO CqNSTRUCT THE PROJECT(SEC.7044,BUSINESS AND PROFESSIONS CO�E'.THE CONTRACTORS LI� V0It1flIlOf1 ADJ.AREA W CENSELAWOOESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUILDSORIMPROVESTHEflEON,AND � WHOCONTRACTSFORSUCNPflOJECTSWITMACONTRACTOfl(5)LICENSEDPURSUANTTOTHECONTRAC- QUANTITY DESCAIPTION FEE � TORS LICENSE LAWJ. � ❑I AM EXEMPT UNOEfi SEC. B.&P.C.FOR THIS REASON Q � U � � DATE ONTJER F— Z U � LICENSED CONTRACTORS DECLARATION W ¢ � I HEREBYAFFIflM UN�Efl PENALTV OF PERJURV THAT I AM LICENSED UNDER PROVISIONS OF CHqPTER � � e(COMMENGNGWITHSECTION7000�OFDIVI510N30FTHEBUSINESSANDPROFE5510N5CODE,ANO Z �X MY LICENSE IS IN FULL FORCE AND EFFECT. m � UCENSE CLASS LIC.NO. � U �ATE CONTRACTOR d W � WORKERS'COMPENSATION DECLARATION ¢ � IHEREBVAFFIPMUNDERPENALTVOFPERJUqYONEOFTHEFOLLOWING�ECLARA710N5: z Z _I HAVE ANO WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELFINSURE FOR WOqKERS' ¢ 2 ¢ CAMPENSATIDN,AS PROVIDED BV SECTIDN 370o Of THE LABOR CO�E,FOR 7HE PERFONMANCE U Q OF THE WORK FOR WHICH TMIS PERMIT IS ISSUED. � � _I HAV'c ANO WILL MAINTAIN WORKERS'CONPENSATION INSURANCE,AS REQUIRED BV SECTION QQ 370o OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORH FOR WHICH hIIS PERMIT IS I � -�M �� ISSUEO.MV V✓ORKERS'COMPENSATION INSURANCE CARRIER AND PDLICY NUMBERARE CONSTRUCTION a J j caaaiea PLAN AEVIEW ZPOLICVNUMBER ELECTRIC Q p (iHISSECTIONNEmNOTBECOMPLEfEDOF1}iEPERMTISFORONEHUNCdiE�D�LIARS1E10010FilESS). PLUMBING Z I CERTIFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSl1E�,I MECHANICAL L} SHA�LNOTEMPLOVANVPERSONINANVMANNERSOASTOBECOMESUBJECTTOTHE (n WOFiKERS'COMPENSATIONLAWSOFCALIFORNIA,ANOAGREETHATIFISHOVL�BECOME INSPECTIONFEE � SUBJECTTO THE WORKERS'COMPENSATIOM1 PftOVISIONSO=SEGTION 37000F THE LABOR ���. � GODE,I SHAIL'rORTHWITH COMPLV WITH TrypSE PROVISI0A5. ISSUANCE F��+ 0 p DATE: APPLICANT. SMIP � WARNING FAILURETO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWN'_,AND SHALL BE ENERGY P/C � SU�JECTANEMPLOVERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT DOILARS(S�00,000?.IN ADDITION TO THE GOST OF COMPENSATION,DAMAGES AS PROVI�ED FOF IN J SECTION3�oeOFT4ELABORCODE.INTEREST,AN�ATTORNEY'SFEES. r d p� RETENTION FEE: y J } � CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � I HEflEBV AFFIRM UNDEfl PENPLTY OF PERJURV THAT THERE IS A CONSTRUCTION LENDMG AGENCY FOR THE GERFOflMANCE OF THE WORK FOR WHICFI THIS PEfiMIT IS ISSUED(SEC.309],dV.C.). Z W � IENDER'S NAME 1—� LENDER'SAO�flE55 W� TOTAL FEES ���' , ��' ICERTIFVTHATIHAVEqEAD7HISAPPLICATIONANDSTATETHATTHEABOVEWFOftMATIONISCORRECT. � I AGREE TO COMPLY WITH ALL CITV AND COUNTY ORDINANCES AND STATE LAWS RELATINO 70 BVILOING � CONSTRUCTION,ANGHEREBYAUTHORIZEREPRESEVTATIVESOFTMISCOVNTVTOENTERUPONTHE Z ABOVE-MENTIO EO PROPERTY FOR INSPECTION PURPOSES. COMMENTS �----'T �' �� p' e-- �� � o f' �"�f�.� � m 17TEE NAM�.(PRIN'n{ c¢!� ~._'f.' �'41✓��c.,'1 � ,IGNA RE"F ERMITTEE OATE _ � RECPT.�O. PAID BY VAUDATION ~ WHITE—De artment Co YELLOW—Finance Co PINK—Assessor Co GOLDENROD—File Co GREEN—A IicanPs Co P PY. PY, PY, PY. PP PY .. .. .. �.:.:..... .:..: :.. �:..: ,.:, ...., ..w. .. . _ ..,.' I a.. ..rs< . Cv.. . - ... -� ' . -.. ,.. 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