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HomeMy WebLinkAbout12563 �� . � ,J ' J� CITY OF DIAMOND BAR �_ ,.-'� DEPARTMEI�TT OF COMMUNITY&DEVELOPMENT SERVICES � 21660 E.Copley Drive Suite 190 PRESS (909)860-3195 Fax(909)861-3117 FIRMLY ���H�°� BUILDING PERMIT APPLICATION � JOBSITE � J� APPLICATIQ N,� , PERMIT P/C o ADDRESS � ��►y�� DATE IL�+ � NUMBER i�.�b� # c� ISSUE ��. p TYPE OCC APN LOT TR T DATE C� �- Gf CONST. GROUP � OWNER ' � 1�� ���- OO ADDRESS Z t'^Gi `�� F" = ZONING SETBACKS w ' t ,r FRONT _ RW _.i z CITY ZIP � TE �� ` 6 S APPLICAN ✓1Cti./i � ` TE� REAR r z SIDE/SIQE STREET RW C; � CONTRACTOR � b SIDE C; � ADDRESS t !"C f � CITY a .I�-- ZIP - TEL. UA � PROPOSED USE i����7ti � Yli d Q.�'`d w ARCH/ENG/ ; � Sr• � �r �z DESIGNER NO.DWEL. �-�NO. h NO. , , a ADDRESS �— UNITS STORIES BEDRODMS N CITY ` ZIP �Jn.TEI_. � ' DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNEF-BUILDEfl DECLARATION SFR/ADD/REM O 0 I HEFiEBV AFFIRM UNDER PENALTV OF PERIURY THAT I AM EXEMPT FROM THE CONTHACTORS LI- � GaragelCarport W CENSEUIWWR7HEFOLLOWINGREASON(SEC.7o31.5BU5INES5AN�PROFE5510NSCODE:ANYCITYOH U COUNiYWHICHREOUIRESAPERMtTTOCANSTRUCT,ALTEF,IMPROVE,�EMOLISH,ORREPAIRANVSTRUC� W P8ti0/DBCk WTURE,PRIOR 70 ITS ISSUANCE,ALSO REOUIRES THE APPLICANT FOR SUCH PEAMIT i0 FILE A SIGNE� W STATEMEM lHA7 HE OR SHE IS LICENSED PURSUAN7 TO THE PPOVISIONS OF THE CONTRAC70RS LI� � CENSE LAW(CHAPTER B(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESSAND PFlO- � POOUSPa FESSIONSCODE)ORTHATHEORSHEISE%EMPTTIIEREFROMANDTHE6ASISFORTHEALLEGEDE%EMP- (� }1q TION.ANYYIOLATIONOFSECTION7o71.5BYANYAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Roof , j�J�J'� � ACIVILPENALTYOFNOTMORETHANFlVEHUNDREDOOUARS(55a0�.): �-`_ � ❑I,ASOWNEROFTHEPROPERiV,ORMYEMPLOYEESWITHWAGE5R5THEIR50LECOMPENSATION. � COTfIlBfC18I N7LL DO THE WORK.ANO THE STRUClURE IS NOT INTENOED OR OFF'cRFO FOR SALE(SEC.70<4.BUSI- J NESS AN�PqOFES510Ns CO�E:TNE CANTRACTORS LICENSE LAW DOES NO7 APPLV TO AN OYINER OF � PROPERTYWFIOBUILDSORIMPROVESTTIEFEON,ANDWHOOOESSUCHWORKHIMSELFORHERSELFOR � � TNiIOUGHHISORHEROWNEMPLOVEES,PROVIDmTHATSUCHIMPROVEMENTSARENOTINTENDE00H m w OFFEPEDFORSALEIF,FiOWEVERINEOUILDINGORIMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE- TION,THE OWNER-BUILDEH WILL XAYE THE BURDEN OF PHOVMG THAT HE OR SHE DID NOT BUIL�OR = IMPROVEFOflTNEPUflPo5EOF5ALE�, I ❑I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CANTRAC71hG INITH LICENSEO CON7AAC70RS � TO CONSTRUCT THE PRQIECT(SEC.7W4.9t151NESS AND PROFESSIONS CODE:TH'e CONTRACTORS LI- ValU2lion �� ADJ.AREA W CENSELAWDOESNOTAPPIYTOANOWNEROFA�ROPERTYWHOBUILDSORIMPROVESTHEFEON,AND � WFIOCANT FORSUCNPNQIECTSWITHACONTRACTOR(S)LICENSEDPURSUANTTOTHECONfRAC- QUANTITY DESCRIPTI6N FEE Y TORS LI E LAWJ. � 1 EX MFT UND SEG 6 P.C.• REA � �t �- � — � DATE OWNE � z w � LICENSED CONTRACTORS DECLARATION W � I HEREBV AFFIRM UNDER PENALiYOF PERJURY THAT IAM LICENSED'JNDER PROV!SIONS OF CHqPTER � � 9(COMMENCINO WITH SECTION 7000)OF OIVISION 3 OF THE 9USINE55 AND PROFESSIONS CA�E.AND Z _ ��� MY LICENSE IS IN FUIL FORCE AND EFFECT. .�^� �y m � LICENSE CLASS LIC.NO. �J'4'" `�� f"" j V �ATE � CONTRACTOR a W � WORKERS'COMPENSATION DECLARATION Q � U � I HEREBV AFFIRM UNDER PENALTV OF PERJURV ONE OFTHE FOLIAWING DECLARATIONS: Z Q � IHAVEANDWILLMAINTAINACERTIFICATEOFCONSEN7TOSELF-INSUREFORWORKERS' 2 � CaMPENSATION.AS PPOVIDEO BV SEC710N 370o OFTHE LABOR CODE.FOR THE PEflFORMANCE W OFhIE WOPoC FOR WHICH THIS PERMIT IS ISSUED. � G w _I HAVE AND WILL MAIPlTAIN WOHKERS'COMPENSATION INSURANCE,AS RE�UiRE�BY SECTION Q 37000F THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS P'eRMIT!S Q ISSUED.MY WORKcRS'COMPENSATION INSURA�ICECAPRIERAN�POLICY NUMBERARE: CONSTRUCTI ,___ C3�� � CARRIEH � PLAN REVIEW _ _ ZPOLICYNUMBER — ELECTFIC ______ Q � (fHISSECfpfJNE�N0T9E00MPLEfEDOFhFPEFi.14TI5FORONEHV�DRED0011AAS(EtOD)ORLESS) I PLUM6ING Z ICERTIFVTHATINTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITISISSl1E�,I MECHANICAL ____ ___ ___ (,'} SMALLNOTEMPLOYANYPERSONINPNYMANNERSOASTOBECOMESVBJEGiTOTHE � WORKERS'COMPENSATIONUlW50FCAUFOFNIA,ANDAGREETMATIFISHOULDBECOMC- INSPECTIONFEE _ _ � SU&IECT TO?HE WORKERS'COMPENSATION P OVt510N50F SECJ�ON 370a Ot 7 LA60Fu Q�'Y � CO�E,JSHAL FORTHWITHCOMPLVWITHTH EPROVISIONS. S ANCE _______ �� p DATE: �� � APPLIC � M�P ' � J WARNING:FAILURETOSECUREWOFKERS'CO ENSA710NCAVERAGEISUNLAWFII SHALLBE NERGVP/C ,_,______ LL SUBJECTANEMPIAYERTOCRIMINALPENALTIESANDCIVILFINESIJPTOONEHUND THOUSAND ENERGYPERMIT DOLLARS(f100.000�.IN ADDITION TO THE COST OF CO�.SPENSATION,DAMAGES AS PROVIDED FOR IN - —� J SECTION 97oe Of hiE LABOfl CODE,IN?ER'cST.ANDATTORNEY'S FEES. RETENTION FEE: Q p OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: ��F � I HEREBYAFFIRM UNUER PENALTY OF PERJURV THATTHERE IS A CONSTRUCTION LENDING AGENCY � FOaTHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.C.). — Z W � LE�DER'S NAME — —�_ �� . F- LENDER'S1IDORESS __ /��-. Aa W I CEflT�FY iHAT I HAYE READ 7HIS APPLICATION AND STATE THAT THE pBOVE INFORMATION IS CORRECT. TOT/'1S.��CQ' �����ND BC110 '� d IAGflEETOCOMPLVWiTMALLCIlYANDCOUNTYOR�INANCE50.ND5TATELAWSRELATINGTOBUILDING gUII,,DINGANL>SAFETY CANSTRUCTION,AND HEREBY AUT}10RIZE HEPRESENTATIVES OF THIS COUNTYTO ENTER UPON THE � ABOVE-MENTIONED PpOPEHTY FOR INSPECTqN PURPOSES. , � � COMMENTS � M _ � .l iE�' �t t s ` � � . I I �-�� ¢ E ITTEEN PHIM) 0 4 1� �1�� � � e ...� � . . �.., � ..�.. _...i... . ... . � . . � E PE , , . OATE � RECPT.NO.-�y�_—'AID BY VALIDATION S ~ WHITE artment Copy,YELLOW—Finence C opy,PINK—Assessor Copy,GOLDENROo--Fiie Capy,GHEEN—ApplicanYs Copy ��. ������'�'� �:�'�� :�°�:����s's�;j�'�i�� �r.��,i��: �N�.. ..�.-iT;"�" Av. x.? Qa�,'.;,�n.'#4:� R..� .. 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