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HomeMy WebLinkAbout10975 CITY OF DIAMOND BAR COMMUNITY DEVELOPMENT DEPARTMENT ,,.w 21660 E.Copley Drive Suite 190 PRESS (909)860-3195 Fax(909)861-3117 4 """' BUILDING PERMIT APPLICATION FIRMLY o ADDR SS '�=� L� ��"�^" DATEICATION NUMB R� � S #/C $ ISSUE -I��{, TYPE OCC APN OT TRACT DATE =CONST. GROUP p OWNER .s' o ADDRESS f3 %��� � P� K� ZONING SETBACKS Z CITY/�/� !'✓�v'17 ZIP !' TE �"'� FRONT RW ❑ p APPLICANT ' TEL.�/�1—�L�� S�E/SIDE STREE:T RW ❑ � CONTRACTOF/�/ILIr'Ai'1��'�'!Z ��?Goh�/!�� SIDE ❑ � ADDRESS� �- - PROPOSED USE���E RC�t3�/': f��/��I� �/ /�7,C � o CITY��1Ss'1� ZI TE� 5�.���� \ w ARCHlENG/ M z DESIGNER `� " 'o ��. � �' r W NO.DWEL. NO. p� NO. a ADDRESS UNITS STORIES ��• BEDROOMS � CITY ZIP TEL. � ua DESCRIPTION SQ.FT FACTOR PSF ADJ.AREANALUATION p� OWNER-BI:ILDER DECLARATION SFRIADD/REM O I HEREBY AFFIRM UNDER PENAL7Y OF PERJURY THAT I AM EXEMPT fHOM THE CONTRACTORS LI� Ge/2yB/C2fp01f W CENSELAWFORTHEFOLLOWINGREASON(SEC.7031.59USINESSANDPROFESSIONSCO�E:ANYCINOR (n U COIINTYWHICHFEOUIRESAPEHMITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPNRANYSipUC- �j,� p9t10/DBCI( w TURE.PRIOR 70 ITS ISSUANCE.ALSO RE�UIRES THE APPLICqN7 FOR SUpi PERMIT TO FILE A SIGNEU w � STATEMENi THAT NE OR SHE IS LICENSED PUqSUANT TO THE PROVISIONS OF 7HE COMRACTORS LI- � � CENSE LAW�CHAPTER 9(CAMMENCING WITH SECTION 700U)OF DIVISION 3 OF THE BUSIIJESS AND PRO• POOI/S(� FESSIONS CODE)�THFT HE OR SHE IS EXEMP7THEREFHOM 1WD 7ME BA515 FOR THE ALLEGED E%EMP- V TION.ANVVIOUTIONOFSECTION7037.SBYANVAPPUC/WTFORAPERMITSUBJECTSTHEAPPL�CANTTO Z Re-Rooi ��' A CNIL PENAlTY OF NOT MORE 7HAN FIYE HUNDREO DOLlARS(5500�.$ G I,AS OWNER OFTHE PROPEH7V,OR MV EMPIOVEES WIiH WAGESAS 7HEIR SOLE COMPENSATION, O � Commercial z WILL DO 7HE WORK,PlJD THE SiHUCTUIiE IS NOT IMENOED OR OFFERED FOR SALE�SEC.7o4a,BUSI- J N NESS qND VflOFE5510N5 CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLV TO AN OWNEH OF vROPEHTVWHOBUILOSORtMPROVESTHEREON,ANOWHODOESSUCHWOqKHIMSELFORHEqSELiOR � � THRWGHHISORHEAOWNEMPLOVEES.PRONDEDTHA7SUGHIMPROVEMENTSAqENOTINTENDEDOH m � OFFEREDFORSALE.IF.HOWEVER,THEBUILOINGORIMPHOVEMENTISSOIDWITHINONEYEAROFCOMPLE- z 710N.THE OWNER-BUtLDER WILL HAVE THE 9UROEN OF PqOVING THAT HE OR SHE DID NOT BUIID OH � IMPROVEFORTHEPURPO5EOFSALE). W ❑I.AS OWNER OF THE PROPERTY.AM EXCWSIVELV COMRACTING WIiH LICENSW fANTMCTORS � TO CANSTflUCT THE PROJECT(SEC.70A4,BUSINESS AND PROFESSIONS CODE:7HE CONiRACTORS LI- V81U2[i �O � _ADJ.AREA W CENSE LAW DOES NO7APPLV 70AN ONMEH OFA PROPERTY WHD BUILOS OR IMPRtlVES THEREON,AND � VlHOCONTRACTSFOpSUCNPRQIECTSWITHACONTRACTOR(5)UCENSEDPURSUANTTOTHECONTRAG QUANTITY DESCRIPTIO!V FEE Y TORS UCENSE LAW.j. �� ❑I AM EXEMPT UNDEFl SEC. B.6 P.C.FOR THIS REASON Q U � � - DAiE OWNER U Z W � LICENSE�CONTRACTORS DECLARATION W ¢ � I HEflEBYAFFIRM UNDEft PENALTY OF PEPJURY TNAT I AM LICENSED UNDEH PROYISIONS OF CHAPTER � d 9(CAMMENCING WRH SECTION 7000)OF�IVISION 30FTHE BUSINESSAND PROFESSIONS CODE,AN� Z X MY UCENSE IS IN FULL FORCE AND EFFECT. /r � � � � LIC.NO. • C=� /7U � � � LICENSE/CU155 ✓ � V DA7E/�� CON7RACTOR JC d W � WORKERS'COMPENSATION�ECLARATION� � -� NI HENEBVAFFIqM UNDER VENAL7V OF PEfiJURV ONE OF THE FOLLOWING DEC4ARATIONS: Z z _IHAVEANDWILLNAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' a 2 Q COMPENSA7IDN,ASPROVIOEDBYSEC710Na7ooOFiHElA80flCODE.FORTHEPERfORMqNCE W _ O OF THE WORK FOR WHICH THIS PERMIT IS ISSUEU. � W _IHAVE/WDWILLMAIN7AINWORKERS'CAMPENSATIONINSURANCE,ASREOUIREDBVSECTION Q37000FiHE LA60R GODE,FOF THE PEiiFORMANCE OF7HE WORK FOH WHICH THIS PERMITIS �I�� J ISSUED.MV WORKFfiS'COMP NSATION INSURANCE CARR�ER AND POLICV NUMBER ARE: CONSTRUCTION � �� „ -���., i / j CARRIER �" TJi fs �t''L/'�'b PLAN REVIEW �n� F"��"�Y,W Z POIICYNUMeEA` � � ELECTRIC � �'����� Q / Q (fH�5SEC710NNE�NOT8E00MRFfEDOFTIEPERMtiI5R7RONENUrDFiEDM �� �j� PLUMBING Z �CERTIFY TMAT IN THE PERFORMANCE OF THE N�OHK FOR WHICH THIS PEFMIT IS ISSUE,I � MECHANICAL + � � (� SHALLNOiEMPLOYANYPERSONWANYlMNNERSOASTOBECOMESUBJECTTOTHE "'' / , N WORKERS'COMPENSATION LAWS OF GALIFOF7JIR,AND AGflEE THAT IF I SHOULD BECOME INSPEC710N FEE SU&IECT TO THE WORKERS'COAIPENSATION PROVISIONS OF SECTION 37000FTHE UBOR I � ,�D�S�LL �HWITHCOMPLVV1ryT R�OSEPFOVISION�� ISSUANCE _ �� G � // � �_�/ �] DATE:'� � APPLICANT:� f_ �^�'7 5MIP _ W J WARNINGFAILURETOSECVREWORNERS'COMPENSATIONCOVERAOEISUNLAWFUL,ANDSNALLBE ENERGYP/C LL SUBJEC7ANEMPLOYERTOCRIMINALPENALTIESAN�CIVILFINESUPTOONEHUNOFEDTHOhlSAND ENERGYPERMIT DOLUlRS(5100.Oo��,IN ADDITION TO THE C0.ST OF CAMPENSATION.DAMAGES AS PROVIOE�FOR IN ¢ SECTION 37080F THE UBOR CODE.INTEREST,AND ATTORNEV'S FEES. RETENTIDN FEE: OCONSTRUCTION IENDING AGENCY PRE-ALT FEE: � I HEREBYAFFIRM UNDER PENALTY OF PENUHY THIR TNERE IS A CONSTRUCTION LENOING AGENCY FOq THE VERFORMANCE OF TNE WORK FOH WHICH THIS PERAIIT IS t55UED(SEG 10D),CIV.C.). Z W � LENOER'SNAME C LENDER'SAODRE55 w ICERTIFYTIIATIHAVEREAOTHISAPPLICATqNANDSTATETHATTHEA80VEINFORIAATION15CARRECT. TOTAL FEES . ' d IAGREETOCOAAP4YWITi7ALLCITYANDCAUNTYORDINANCESANDSTATELAWSRELATINGTOBUILAING � CONSTRUCTION,AND HEfiEBY AUTHOR2E REPRESENTATIVES�F 7HI5 CDl1NTY TO EMER UPON THE ABOVE-MENTIONEDPROPER7VF ECTI PURPOSE6. COMMEM'S ,.. ..... . .. . ..._.. .....,.. � �, � ' � " � C,���, J _ . .. ..... ........•:�����: � QPERMITT E(PRI ��� , � � SIGN FP I DA = RECPT.NO. 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