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HomeMy WebLinkAbout10643 r ---� CITY OF DIAMOND BAR ���!��� COMMUNITY DEVELOPMENT DEPARTMENT ���� � � ���Q 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3I17 PRESS � � ,'""' BUILDING PERMIT APPLICATION FIRMLY , � JOBSITE � P APPLICA O PERMIT P/C o ADDRESS�����„i/�"4,.� ,��i DATE NUMBER I���-3 # � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER r - ' a ADDRESS 20NING SETBACKS Z CITY ZIP/��_ TE � FRONT RW L] _ � APPLICANT TEL. REAR r7 ' z SIDE/SIDE STREET RW LI � CONTRACTOR � SIDE ❑ � ADDRESS � pROPOSED US � � CITY ZIP. TEL._�� V wo ARCHIE / _ Z DESIGNER w N�.DWEL. , ` NO. � ADDRESS UNITS � STORIES -� BEDROOMS� � CIN ZIP_ TEL. cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER•BI;ILDER DECLARATION SFR/ADDlREM O p I HEREBY AFFIRM UNDEF PENALTV OF PERJURY iHA7 I AM EXEMPT FROM THE CONTRACTORS LI- GdfdyB/C2fpOff W CENSELAWFOR7HEFOLLOWINGREASON(SEC.7a31.5BU51NES3ANDPROFESSIONSCADE:ANMCITVOR (n C1 COUNTYWMICHRE�UIREShVERMITTOCONSTRUCT,ALTER,IMPROVE,OEMOLISH.ORREPAIRANYSTflUP w TUHE.PRIOR TO ITS ISSUANCE,ALSO RE�UIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W Petio/DBCk STATEMENT THAT HE OR SHE IS IICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS U- � CENSE LAW(CHAPTER 8(COMMENCINO WITH SECTION 70D0)OF DIVISION 30F THE BUSINE33 AND PRO- � Pool/Spa FESSIONSCODE)ORTMATHEORSHEISEXEMPTTHEREFROMAN�THEBASISFOflTHEALLEGEDE%EMP- (� V TbN.ANYVIOlAT10NOFSFCTIDN7031.5BVANVAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO Z Re-Roof ACIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(5500).): ❑I,ASOWNEROFTHEPROPEHTY,ORMVEMPLOYEESWiTHWAGESAS7HEIR50LECOMPENSATION. � O Commercial � Z WILL�O 7NE WORIC,RNO THE STRUC7URE IS NOT iN7ENDED OR OFFERED FOR SALE(SEC.7044,BUSI- J � NESSAND PROFESSIONS CODE:THE CONTRACTOHS LICENSE LAW OOES NOT APPLY TO AN OWNER OF ? PROPEflTV WHO BUILDS OR IMVPOVE57HEREON.AND NM110 DOES SUCH WORK HIMSELF OR HERSEIF OR � THROUGHHISORHEROWNEMPLOYEES,PROVIDEDTNATSUCHIMPROVEMENTSARENOTINTENOEDOR m w OFiEREDFORSALE.IF,HOWEVER,7HEBUILDINGONIMPROVEMENTISSOLDWITHINONEYEAROFCOMPIE- 0 TION,THE OWNER�BUILDER WILL NAVE TME BUFlOEN OF PROVING THAT NE OFl SHE OID NOT BUIID OR Z� IMPROVEFORTHEPURPOSEOFSALE). _ ❑I,ASONMEHOFTHEPROPERiV,AMEXCLU6IVELYCANTflACTINGWITHLICENSEDCONTflACTORS W � TO CONSTRUCT TME PROJECT(SEC.701C,BUSINE55 AND PROFESSIONS CODE:THE CONTRIICTORS LI� V2IUBIlOf1 ADJ.AREA W CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUILDSORIMPFiOVESTHEREON,AND � F NMOCONTRACTSiORSUpiPRQIECTSWITHACANTRACTOR(S�LICENSED�URSUANT70THECONTRAC- QUANTITY DESCRIPTION FEE Y 70HSLICENSELAW.�. � LI I AM EXEMPT UNOER SEC.__ B 3 P.F FOfl THIS REASON Q O. --- V �' ¢ LL DATE OWNER ___ U Q W � LICENSED CONTflACTORS DECLARATION W ¢� i HEREBYAFFIRM UNDER PF.NA47V OF PERJl1RV THAT IAA1 LICENSED UNDER PROVISIONS OF CHAPTER � � d� 9(COMMENCIN6WITHSECTION7000)OFDIVISION30FTHE9USINESSANDPFlOFESSIONSCODE,AND z — X MV LICENSE IS W FULL FORCE AND EFFECT. m L1J �, LICENSECLASS ,_ LIC.NO.,_ j V DATE _ CONTRACTOR a a w � WORKERS'COMPENSATION DECLARATION Q � I HEREBYAFFIHM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECURATIONS: Z � __ IHAVEANDWILLMAINTAINACERTIFICATEOFCOPiSENiTOSELFINSUFEFORWORKEf75' a S � COMPENSATION,AS PROVIOED 6Y SEGTION 37000F TNE 1A90fl CWE.FOR THE PEFWHMMICE w OF THE WORK fOR WHICH THIS PERAl1T IS ISSUED. � O w _I HAVE AND WILL 1AAINTAIN WORKERS'COMPENSATION INSURAhCE.AS REOUIRED BY SECTION Q 31000FTHE LABOR CODE,FOR THE PERFORMANCE OF THE WORK WR WHICH THIS PERMIT 13 ��a �'j � ISSIlEO.MY WORKEfiS' MVE SATION INSURANCE CARRI R AN�POLICY NUMBERARE: CONSTRUCTION J � j CAPRIER .� PLAN REVIEW _ � POLICYNUMBEfl /��M "�4 ELECTRIC Z Q 0 (IHISSECTIONNE�NO7BEOOAIPLE7EDOF7F�PEM4�ISFORCNEHIMINiEDWLLARS(EIW)ORLESS� PLUMBING Z I CEHTIFYTHAT IN THE PEFFORMRNCE OF iHE WDRN FOR WHICN THIS PEflMIT IS ISSUED.I MECHANICAL C}' SHAIL NO7 EMPLOV ANV PERSON IN ANY MANNER SOAS TO BECOME SUBJECi T07HE (n WORKER9'COMPENSATIONlAW50FCAUFORNIA,RN�AGREETHATIFISHOULOBECAME INSPECTIONFEE �l:% '�'�`""� __ __ � SUBJECT TO TME WOFKERS'CAMPENSATION PflOVI510NS OF SECTION 37000F iHE LABOR � CADEr,ISHALLFORTHWITHCAMPLYWITHTHOS' ROVISIONS. ISSUANCE _�' ,.rtc �� � �/ SMIP I . h('� p DATE:'�[7�� APPLICANT: — .— � WAPNINGFAILURETOSECUREWORKERS'COMPENSATIO VEHAGESUNLAW L.ANDSHALLBE ENERGYP/C �y SUBJECTANEMPLOVERTOCRIMINALPENAlTIESANDCIVILFINESUPTOONEHUNUREDTHOUSAND ENERGYPERMIT ���� � DOLLARS(51oD.0001,IN A�OI7ION TO THE COSTOF COMPENSATION,DAMAGE3 AS PROVIDED FOR IN R � SECTION 37080F THE LABOR COOE,INTEREST,AND ATTORNEV'5 fEES RETENT�ON FEE: a CONSTRUCTION LENDING AGENCV PRE-ALT FEE: O . � I HEREBY AFFIRM UNOER PENALTY OF PERJURY TNAT THERE IS A CIXJSTRl1CTION LENDING AGENCY _ _ FOHTHE PERWiiMANCE OF 7HE WONK FOR WHICH THIS GERMIT IS ISSl1ED�SEC.3o97,CIV.C.). 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