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HomeMy WebLinkAbout16075 ` �'"'`' CITY OF DIAMOND BAR �1� �--��-- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �Y 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS �'�%N'� BUILDING PERMIT APPLICATION FIRMLY o ADr�RIESS/S� � DATE CATION"� �� �_NUMBER��� � � #,C � ISSUE TYPE OCC APN LOT TRACT DATE _CONST. GROUP p OWNE� ,� -- p ADDRESS �SOG , ZONiNG SETBACKS � CI7Y -- /� ZIP����`fEL.���"I S��/:i REAfiT_ Rw r APPLICANT TEL. SIDFJSIQE STREE'T RW C � CONTRACTOR �^' SIDE C ADDRES Q PROPOSED USE � "�"`" lf.rt� Q CITY ZIP EL. � ' � �,� � ���- o ARCH/ENG/ , z DESIGNER w NO.DWEL. NO. NO. � ADDRESS � CITY ZIP TEL. UNITS __ STORIES BEDROOMS � v� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER•BUIL�ER DECIARATION 0 SFR/ADD/REM 1 HER�Y AFFIHM UNDER PENALTY OF PEFJURY THAT 1 MA EREMPT FRON THE CONTRACTORS LI- GafBg@/CBfpoR W CENSEUWFORTHEFOLLOWINGREASON(SEC.7o31.5BUSINESSANDPROFE5510N5CODE:ANYCITYOR (n _ V COUNTYWWCHRE�UIRESAPEHMITTOCONSTRUCT,ALTER.INPROVE,�EM.OJSH,ORREPAIRANYSTRIJC• W Patio/Deck Z TUFE,PRIOR TO ITS ISSVANCE,PL50 RE�UIRES THE APPIICANT FOR SUCH PERMIT TO FILE A SIGNED W STATEMENT hIAT HE OR 6ME IS LICENSEU PURSUANT TO THE PROVISIONS OF THE CONTRRCTORS LI- W � CENSE UW(CHAPTER B(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS ANO PRO- u' POOUSPB FESSIONSCDDE)ORTHATNEORSHEISE%EMPTTHEREFROMANOTHEBASISFORI}IEALLEGEDE%cMP- (� +� TION.ANYVIOUTIDNOFSECilON7031.5BYANYAPPIICANTFORAPERMIT5U9JECTSTHEAPPUCANTTO Z Re-Root �i � ACMLPENALTYOFNOTMORETHANFIVEHUNDREDDOL'�ARS(f5a0).): � CI,ASOWNEROfTHEPROPERTY,DRMYEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, � Commercial � WILL DO THE W00.K NdD 7HE STRUCTIIRE IS NOT IMENDEO OR OFFERED FOR SALE(SEC.7o3d,BUSI- J � NF55 AND PROFESSIONS CODE:THE CANTRACTORS LICENSE LAW OOES NOT APPLY TO AN OWNER OF = PROPERTY WI10 BUILDS OR IMPROVES THEREON,AND MMO�OES SUCH MlOPoC HIMSELF OR HERSELF OR � THROUGH WS ORHER OWN EMPLOYEES,PROVIDED T:U1T SUCH IMPROYEMEMSARE NOi INTEI6DEDOR m QOFFEflEDFOR5ALEIF,ltOWEVER,THEBUILDINGORIMPflOVEMF7VTI550IDWITHINONEYEAROFCOMPI_E- Z TpN,iHE OWNER-BUILDER VALL t1AVE THE BURDEN OF PROVING THAT FiE OH SHE�I'J NOT BUILD OR � IMPI�VE FORTHE PURPOSE OF SALE). C I,AS OWNER OF THE PRODER7V,AM EXCLl157VELV CONTRACTW G WRH LICENSE�CANTRACTORS � TO�kSTRUCT TNE PROJECT(SEC,7CM.BUSINESS ANO PROFESSIDNS CODE:7HE C(NJTRACTORS U- VdllldliOfl _____, /��! ADJ.AREA W CENSEUWDOESNOiAPPLYTOANOWNEROFAPROPEATVWHOBUIt.D50RIMPqOVESTHEflEON,MD +.�--_ _ � WFIOCONTRnCTSFORSUCHVROJECTSWRHACONTRACT.OR(S)LICEYSFDPURSUANTroTHECONTRAG Q��qNTITY oEscRianorv FEE � TORS LACENSE LA%). O �I AM EJ(EMPT UNDER SEG B 8 P.C.FOR THIS REASaI Q� __ � U � -- — OC — — OATE OWNER__ �� O --'__' I W _ � LICENSED CONTRACTORS CECLARATION I W � I HEREBV AFFIRM UN�ER PENALTY OF PERIURY THAT I AM UCENSED UN�ER'BOVISIONS OF CHAPTER i � —� � 9�COMMENGNGWITHSECT:ON7o0o)OFDIVISIOY3OFTHEBtJSWc'SSAN�PROFcS510tiSCOOF,AND Z _ 94 MY IICENSE IS IN FUIL'•ORCE AND EfFECT. m c" ' �^ ,.— � ! � � UCENSE CLASS �� � _ LIC.NO.� � ~ DATE�_ " ' CONTRACTOR � � Q. W j �� WORKEFS'COMFENSRTION OECLARATION Q � � IHEREBYIIFFlRMUNDERaEWLLT'OFPERJUflYONEO�TNeFO;.IOWING�EC;ARATIONS. Z —r 0 IHAVEANDWI�AiAMTA1NACERTIFICATeO:CANSENTTOSc'LF-INSUREFORWOqKERS' _ � COMPENSATION,AS PROVIOED eV SECTION 37o00F THE LABOR COJE,FOR'fHF PERFORMANCE U I _ OF i>:E W lFN FO:1 WH!CH iM15 PEAMIT IS ISSUED. W � � W 1 HAVE AN�W!LL MAINTAIN WJRKERS'WMPEDISAT�ON INSURANCF,AS REOL'IRED BY SECP.ON ' � '� /'1 Q 370o UF THE LABOR COOE,FOF'.^.-;E PERFOAMANC'c C:TNE'�JORK FJR WH�CH TNIS PERMIT IS � U � ISSUED.A!Y W FiKER SATION IN 1RANCE CARR� t AND 70L�CY tiUM116ER ARE. CONSTRUCTIDN Z jcaawer�_�i� - —.. PLAN REVIEW -------- — � POLICYliUMBER��� � � --._—_ ELECTRIC _ _ 4 r� � (rr+�sEc�.Ner�Hore�r:r�r_�ooFn�=aEre�rru��a�ei�,r�w_nocuus�e�oo�aa��sa PLUMBING --- w Z ICERTIFYTHATiNTHEPERFORMANC�CFTHELVOP%FOFWHICMTHISPERMITISISSJcD,I MECHANICAL _ _�� 'r"o-�'�a. CJ SHALL IJOT ELIP.OY ANV PERSON IN ANY iAANNER SO AS TO BECOMF.SUBJECT TO'HE �."g�,y��� � WOFiK-RS'CCkr^ENSAT:CNLAWSOiCAL:iOFNIA0.NDAGflEETHATIFlSHOULAOECOhSE INSPEC?IONFEE � SVBJECTTO?ricWORKE4iS'COAIPEPISATIONPROVISIOASOFSECTION37000FTr/EIABOR � :.ODE,ISHALLFORTHWITHCOMPLYWITHTHOSEPROVISIONS. �SSUANCE ___ p DATE:__ ____ APPL.CANT: _ __'_.__. ---- R�� r� �q � e.4� � _ � i SMIP � ':`t'S 7 s'i %;:_,,V; � • ENERGY P/C ��'`�3''F"�s�,�-... c J WAflNING FAILURE TO SECl1RE WORKERS'CDMPENSATION COVERAG'e IS UNL4WFUL,AND SHALL BE ----,,,,.� , � A� SUBJECTANEMPLOVEHTOCRiMINALPENALTIESANDCIVIIFINESUPTOONEHUNDRE�THOUSAND 8 � ji� �9rr:��e.�� �� � ENERGY PERMIT — ��''� •• � DOLLAPS(510C.00o;,IN HDO!iION TO THE COSTOF COM?ENSATION,DAMAGES AS PHOVIDED FOR IN —� a,�,�i � SECTION37080FTFIELABOFiC��E,INTEREST,ANDATTORNEY'SFEES. ���'"'�"'^' ��h'.L�iw.��p�y���,�y�e-%,^'�, RETENTION FEE: �,_ d CONSTRUCTION LENDING AGENCY PRE•ALT FEE: O — — � IHEREBYAFFIqMUNOFRPENALiYOFPERJURYTHATTFIcRE15ACON5TRUCTIONLENDINGFGENCY � FOR THE PERFOiiMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.309],CIV.C.). --"—"— -- W � LENDER'S NAME_ _ _ __ F_ LENDER'S ADDRESS_ ___._ � TOTAL FEES 1 �� r �� � 1 CERTIFV THAT I HAVE READ THIS APPLICATION AND STATETMATTHEABOVE INFORMqTION IS CORRECT. � I AGREE TO COMPLY W1TH ALL CI7V AND CAUNTV ORDINANCES AND S7ATE:AWS RELATING TO BUILOING � CONSTRUCTIDN,AR�HEREBY 0.UTHORRE PEPFESENTATIVES OF THIS CDUNTY TO ENTER UPONTHE � ABOVE-MENTANED PqOP'eRTY FOR INSPECTION PURnOSES. 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