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HomeMy WebLinkAbout10366 a - CI'I'Y OF DIAMOND BAR COMMUNITY DEVELOPMENT DEPARTMENT { 21660 E.Copley Drive Sui[e 190 ! PRESS• � (909)8b0-3195 Fax(909)861-3117 ` '"""~w BUILDING PERMIT APPLICATI0�6 �'a� FIRMLY � JOBSITE ����-� S-�y���� creeK APPLICATION � E� �•.� PERNIIT �����„ P/C ¢ ADDRESS o b DATE NUMBER N � APN LOT TRACT ISSUE �' J'�� / � 6 TYPE OCC DATE ..9 f . * �,f_CONST. GROUP p OWNER � r �✓• " ADDRESS � ZONING SETBACKS w ,? FRONT RW G Z CITY��� Y ZIP TEL� .. Z APPLICANT /�.ts/V��TE REAR ❑ SIDElSIDE STREI=T RW ❑ ¢ CONTRACTOR c'�/1f� O SIDE _ ❑ o ADDRESS '"� PROPaSED USE ' � '" �� CITY ZIP TE �- C�� � G• ` �—�� oARCH/ENG/ �r� , � -. ',� ,a �Y----- �z DESIGNER NO.DWEL. �t40. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � cn DESCRIPTION SQ.Fl: FACTOR PSF ADJ.AREANALUATION p� OWNER•B�ILDER DECLARATION SFR/A�D/REM O p I HEHEBY AFFIRM UN�ER PENALN OF FERJURY THAT 1 AM El(EMPT FROM THE CONTRACTORS LI- GLfe981C8fpoR W CENSELAWFORTHEFOLLOWINGREASON�SEC.7oat.5Bu51NESSANDPROFESSIONSCODE:ANYCINOR (n U �pUNTYWHICHREOUIRESFPERMITTOCONSTRUCT,ALTER,IMPFOVE,DEMOLISH,ORREPAIRANYSTRUG W PylI0ID8Ci( TURE,PpIOR TO iTS ISSUANCE,AL50 qE4UIRES THE AVPLICANi FOR SUCH PERMIT TO FIIE R SIGNED w STATEMENT 7HAY HE OR SHE IS UCENSED PURSUANT TO THE PROVISIONS OF THE CONTPACTORS LI- W � CENSE LRW(CHFPTER 9(CAMMENGING WITIi SECTION 7000)OF OIVISIpN 3 OF THE�BUSINE$S AND'pF10- LL POOUSpa FESSIONS CADE�OR THAT HE OR SHE IS EXEMPT THEAEFROM AND THE BASIS fOR THE ALLEGED EXEMP- � iION.ANVVIOLATIONOFSEGTION7o31.5BVANYAPP4ICANTFORl1PERMITSU&IECTSTFIEAPPUCANTTO Z Re-Raof ��� A CIVIL PENALN OF NDT MORE THAN FIVE HUNORED DOLLARS(5500).): - Z ❑I,ASOWNEROFTHEPROPERTY,ORMYEMPLOVEESWITHWAGESASTHEIRSOLECAMPENSATION, Q COfl1RI8fCl81 WILL DO7HE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOF SALE(SEC.70aa,BU51� J � NESS AND PqOFESSIONS CODE:THE CONTRACTOPS LICENSE LAW DOES NOT APPLV TO IW OWNER OF � PROPFATV WHO BUILDS OR IMPROVES 7HEREON,ANO WHO DOES SUCH WORK HIMSELF OR HERSELF bR Q THROUGH HIS OR HER OWN EMPLOYEES.PROVIDE�TNATSUCH IMPROVEMEN75AqE NOT INTEWDED�OR m w OFFEREDFORSALE.IF,HOWEVER,7HEBUII.DINGORIMPROVEAIENTISSOIDWITHINONEYEANOFCOMPLE- � TION,7HE OWNER�BUIIDER WILL MAVE iHE BURDEN OF PROVING 7HAT HE OR SNE DID NO7 BUILD OR Z WIPiiOVE FOR THE PURPOSE OF SALEJ. _ ❑I,ASOWNEROFTHEPROPERTY,AMEXCLUSIVELYCONTRACTINGWITHUCENSE�COMRACTOR$ W � TO CONSTRUCT TME PRQIECT ISEC.106A,BUSINE55 ANO PROFESSIONS CODE:THE CON7RFCTORS LI- VflIU8�l0f1 1�' ADJ.ApEA W CENSEL4WDOESNOTACPL�TOANOWNEROFAPflOPERTYWHOBUILDSORIMPROVE5TFIEAEON,AND � WHOCONTRAGTSFORSUGHPROJECTSW�THACONTRACTOR(S)LICENSEDPURSUANTTOTHECONTflAG QUANTITY DESCRIPTION FEE � 70RS LICENSE LAW.). Q ❑I AM E%EMPT UNOER SEC. B.8 P.C.iOR THIS REASON Q � U LL � DATE OYJNER U Z W , � LIGENSED CONTRAC70RS DECLARATION W � I HEREBY AFFIRM UNOER PENALTY OF PERJURY TMAT 1 AM LICENSED UNDER PHOVISIONS OF CF7APTER � d 9(CAMMENCING WITH SECTION 7000)OF DIVISION 30FlHE BU5INESS AND PROFESSIONS CODE,MID Z iX MY LICENSE IS IN FULL FORCEANO EFFECT. � � � m � LICENSE CLA `�`� LIC.NO. � l➢ J V DATE � CONTRACTOR �'/V� O $ a LtJ � WORKERS'COMPENSATION DECLARATION Q � i HEREBY AFFIqM UNDER PENALTV OF PEHJURY ONE OF THE FOLLOWING DECLARATIONS: Z z _IFLNEANDWILLMAINTAIkACER7�FICATEOFCANSENTTOSEIF-INSUflEFORWOqKERS' _ ¢ CAMPENSATION.AS PROVIDE�BY SECTION 37o00FTHE 1A80H CODE,FOR THE PERFORMANCE W OF THE WORK FOR WHICH THIS PERAIIT IS ISSUED. � O w �IHAVEANDWILIMAINTAINWORKERS'COMPENSATIO41NSI1RANCE,ASREWIREDBYSECiION d Q 37000F THE LABOR CODE.FOR THE PEFFORMANCE OF THE WOflK FOR WHICH THIS PEflM1T IS "' / �^'�' � ISSUED.MY WORKERS'COMPENSATION INSURANCECARRIERAND POLIC NUM6ERARE: CONSTRUCT � '� J �-7r+� s+�-i . o � CARRIER_��' / L' /� +PLAN REVIEW _ 0 POLICYNUMBER '�t�,��-- � ��D � � ELECTRIC � Z � ' � - Q 0 (1HISSEC�IONNE�NOiBECOh1PlETEDOF7HEPERMfTISFORONEHUPDfiE000LlPAS�510o)ORLE55�. PLUMBING Z I CEflTIFY THAT IN THE PERFORMANCE OF TNE WORK FOR WHICH hi15 PERMIT IS t55UE�,I MECHANICAL (,'J SHALLNOTEMPLOYANYPERSONINANYMANNERSOASTOBECOMESUaIECTT0TI:E @�� W� � WORKERS'COMPENSATIONLAWSOFCAL'FORNIA,AN�AGREETHA7IFISHOUL�BECOME INSPECTIONFEE �IIi il � j SU&IECTTDTHEWORKEFS'CAMPENSATION7ROVISIONSOFSECTION3�OOOFTHEUIBOR "'0 — DE,ISHqLLFORTHWITHCOMPLYWITHTHOSEPRWISyIO`NS �f�,,3 �--.ISSUANCE�. ��� ��� �'�• p DATE: S' APPLICANT: ���L��LJ [o�-�C� S P._.� `� �_� J WAqNING:FAILURE TO CURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUI�AfdO SHALLBE ENERGY P/C � SUBJECT AN EMPLOYEfl TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE MUNORED THOIJSAND ENERGY PERMIT DOLLARS(5100,000}.IN ADOIT�ON TO THE COST OF COM7ENSATIWJ,DAMAGES AS PROYIDED fOR IN � SECT�ON37o60FTHELA80RCADE,INTEPEST,ANDATTORNEY5FEE5. RETENTIONFEE: a CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � 1 HEREBY AFFIPoN UNDER PENALTY OF PERJURY THATTHERE IS ACONSTRUCiION LENDMG AGENCY FOR THE PENFOflMANCE OFTHE WORK FOR WHICHTHIS PERMI715ISSUE��SEC.3097.CIV.C.). Z W � LENDER'S NAME F- LEN�ER'SADORE55 ¢ ICERTIFY7HA7IHAVEREAO7HISAPPLICATIONANDSTATETHATiHEABOVEINFOFlMATIONISCORRECT. TOTAL FEES ��a �� � IAGREE TO COMPLY WITH AI.L CITY AND COUNTYORDINANCES AND STATE LAWS'REUTING TO BUILDING � CONSTRUCTION,ANDHEHEBYAUTMORIZEREPRESENTATIVESOFTHISCWNTVTOENTERUPONTHE Z ABOVE�MENTIDNE�PROPERiV FOR INSPECTION PUFPOSES. 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