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HomeMy WebLinkAbout10822 �... ! —��-- CITY OF DIAMOND BAR i COMMUNITY DEVELOPMENT DEPARTMENT � 1 �,.� 21660 E.Coplcy Drivc Suite 190 (909)860-3I95 Fax(909)861-3117 �'� PRESS '""" BUILDING PERM[T APPLICATION FIRMLY r JOBSITE 'p� � APPLICATION+ � �/�"�J ERMIT r P/C o ADDRESS � DATE ° "��� "` ! NUMBERr � t # � APN LO TRACT D TEE CONST. GROUP p OWNER p ADDRES �' ZONING SETBACKS � CITY i ZIP ? TEL.i� FRONT Ryy (.) _ APPLICANT TEL. REAR n _ zd. SIDEJSIDE STREET _ RW ❑_ a CONTRACTO SIDE s ❑ � ADDRES i r �m�' OQ PROPOSED USE��J�_� V�-j �/l-'°� CITY .a ZIP - TEL. s de� �- wo ARCH/ENG/ �z DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. cn -- �n DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER•BI;ILDER DECLARATION SFR/ADD/REM O p 1 HEREBV AFFIRM UNDEH PENALTY OF PERJURY THAT I AM E%EMPT FROM THE CONTRACTOAS LI- GafA9B/C91p0A W CENSEUWfORTHEFOILOWINGREA50N(SEC.7037.5BUSINESSANDPROFESSIONSCADE:ANYCITYOq (� U COUNiYWHICHREWIRESAPERMIT7000N5TRUCT,ILLTEfi.IMPROVE,OEMOIJSN,ORiiEPAIRANYSTRIJC- W pg(IDIDBCk W TUHE,PRIOR TO ITS ISSUANCE.AL50 REWIqES THE APPUCANT FOR SUCH PERMIT TO FILE A SIGNED w � STATEMENT TFiNT HE OH 9HE IS LICEN9ED PURSIIANT TO THE PROVISIONS OF TME CONTMCTOqS LI- � � CEN3E LAW(CMAPTER 9(COMMENCING WITH SECTION 7W0)OF DIVISION 30F THE 6USINESS AND PRO• POOVSp2 O FESSIONSC.ODE)ORTHATHEORSHEISE%EMPTTHEflEFROMANDTHEBASISFORTHEAILEGEDEXEMP� � U TION.ANYVIOLATIONOF6ECTION7031.SBYANYAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Rooi ACIVIL PENALTY OF NOT MOflE THAN FlVE iIUN�RE�DOLLAR515500)J: � OI.ASOWNEHOFTNEPROPERTV,ORAIVEMPLOVEESWITHWAGESASTHEIqSOLECOMPEN5AT10N, � COffIfilBfC12I Z WILL DO THE WORK,AND THE STRUCtURE IS NOT INTENDED OR OFFERED FOR SALE(BEC.70al,BUSI- J � NESSAND PROFESSIONS GWE:THE CANTRACTORS LICEN5E LAW DDES NOT AVP�Y TO AN OWNEF OF � PROPERTY WHO BUIIAS OH IMPROVES THEREON,AND WHO�OES SUCH VlOqK HIMSELF OR HERSELF OR Q THROUGNHISORHEROWNEMPLOYEES,PHOVIDEDTHATSUCHIMPROVEMENTSAflENOTINTEN�EDOR , m Q OFFEREDFOPSALE.IF,HOWEVER,TiEBUILDINGOflIMPROVEMENTI550LDWITHINONEYEAROFCOMPLE Z TION,THE OWNER�BUILDEF WILL HAVE THE Bl1H�EN OF PROVING THAT HF.OR SHE DIO NOT 9UIlD OR � IMPPOVE FOR 7HF.PURPOSE OF SAIE} � ❑I.ASOWNEflOFTHEPROPERTY,AMEXCLUSIVELYCONTflACTINGWITHLICENSEDCONTpACTORS TO CANSTRUCT THE PRQIECT(SEC.)Oad,BUSINESS ANO PROGESSIONS CODE:THE CANTRAC70RS LI- V81Uet10l1 ADJ.AREA W CENSELAWOOESNOTAPPLVTOANOWNEHOFAPqOPERTYWHOBUILDSORIMPROVESTHEHEON,AND ' �' WHOCONTRACTSFORSUCHPRQIECTSWITHACONTRACTOR�S�LICENSEDPURSUANTTOTMECONTflAC- QUANTITY DESCRIPTION FEE Y TOHSUCENSEUWJ. ¢ fl 1 AM EXEAIPT 11N�ER SEC. _B.8 P.C.FOR THIS REASON Q � U � ------ � DATE__ OWNEfl �- Z �U � � LICENSED CONTRACTORS DECLARATION W I � 14EREBYAFfIRMUNOEfiPENALTYOFPER!URYTHATIAMLICENSEDUN�EflPROVISIOVSOFCHAPTEN Z , �- 9�COMMENCING WITH SFCTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFES610NS CODE,AND � ,� ^ X� MY LICENSE IS IN FULI FORCE AND EPFECI • � �; LICENSEC 5 ___ IIC.NO. � � � J w � ,i'1 y� �,�,e m � _�uA ,� � � . IDATE CONTRACTOR d � I � WORKERS'COMPENSATIONDECLARATION ` a � �: 1 HEREBV AFFIRM UNUER PENALTY OF PEWURY ONE OFTHE FOLLOWING DECLARATIONS: z � Q I �� _I MAVE AND WILL MAINTqIN A CERTIFICATE OF CONSENf TO SE�F-INSURE�OR WOFKERS' _ I CAMPENSATION,ASPROVIUEDBVSECTICN1Jl000F7HEU80RCDDE,FORTHEPERFORMANCE U OF THE WOHN FOR NhiICM THI3 PERMIT IS ISSUED. W IW �I HRVE AND WILL MAINTAIN WOFiKERS'COMPENSATION INSURANCE,AS RFAUIREO BY SECTION � � 3700 OFTHE LABOR CODE.FOR THE PERFORMANCE OF THE WORK WR WHICH THIS PERMIT IS ISSUED.MVWORKER'CAMPEN ATI INSURANCECARRI AN�PO CVNUMBEHARE: CONSTRUCTION j CAqRiER.----- 1 Y����� �, PLAN REVIEW __ — — 0 POLICV NUMBER I { ELECT�� Q � W (IH6SECTK7NNEmNO7BE�DMPIETEDOF7NEPEPMTISPoqONEMRDRFDDOLLARS(61UOI��F ,P,L'UMBING ,.J �� �. Z I C[RTIFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I �`MECHANICAL _ I C3 SHALLNOiEMPLOYANYPER50NINANYMANNEF30ASTOBECOMESUBJEC770THE - ^y � VlOflKEflS'COMPENSIUIONLAWSOFCAIIFORNIA,l1N�AGREETMATIFISNOULDSECOME INSPECTIONFEE •�n I SUBJECiTOTHEWOHKERS'COMPENSATIONPROVISIONSOFSECTION37000FTHELABOR � I � � CO E,ISHAl.LPO THWI7HCOMPLV WITHTHO o is�iocns.�, /s �SSUANCE ��� ' � �:_ y' �<� r � p DATE: � '� APPLICANT: ___`��/[.i''�"r�` ___ SMIP ____ " IJ WAHNIN6:FAILURETOSECUREN'ORKERS'COMPENSATIONCAVERAGEISUNLAWFUL,ANDSHAILBE ENERGYPIC __ �,. �y, SUBJECTANEMPIOYERTOCPoMMALPENAL7IESANDCIVILFINESUPTOONEMUNDREDTHOUSAND � � ;.-�� DOLLAHS(f100.000),IN ADDITION TO THE COSTOF COMPENSATION.DAMAOES AS PROVIDED FOR IN ENERGY PERMIT 3 I �� SECTION37080FTHEUBORCODE.INTEREST,ANDATTOFNEV'SFEES. RETENTIONFEE: I � CONSTRUCTION LENDING AGENCY PREALT FEE: � O � 1 HEPEBY AFFIRM UNOEH PENALTY OF PERJIIRY iHAT THERE IS ACONSTRUCTION LENDWG AGENCY __________ FOR THE PERFORMANCE OF THE WOflK FOfl WHICH 7HIS PEflMIT IS ISSUED(SEC.3a97,CIV.C.�. Z LyA '__—'" � LENDER'SNAME F— LENDER'S AUGHE55_ W I CENTIFY THAT I HAVE HEAD 7HISAPPLICATIONAND STATE THAT THEA90VE INFORIAATION IS CARRECL TOTAL FEES p IAGNEETOCOMPLVWITHALLCINANDCOUNTYORDINANCESANDSTATEUW6RELATINCTO&/ILDING � CONSTRUCTION,ANO HEREBY AUTHORIZE R&PRESENTATIVES Of THIS COUNTY TO ENTER UPON THE / � ABOVE�MENTIONED PflOPEHTY FOR INSPECTION PURPOSES. 0 ������� COMMENTS_ � � m PERMITiEF� PR�T --- D����r�,^ _ �, � /�l l (/) SIONA7UREOF R 1 DATE = RECPT.NO., PAID BY VALIDAT�ON ~ WHITE—Department Copy,YELLOW—Finence Co PINK—Asseasor Ca GOLDENROD--File Co GAEEN— PY. 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