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HomeMy WebLinkAbout12533 - CI1'Y OF DIAMOND BAR COMMUNITY DEVELOPMENT DEPAKTMENT � � .,,.� 21560 E.Copley Drive Suite 190 PRESS (909)860-3195 Fax(909)861-3117 �"'"°� BUILDING PERMITAPPLICATION � � FIRMLY y JOBSITE f ' � " ,� APPLICATION C� `�/ NUMBER 4`✓✓�# � 2� wc o ADDRESS � - f � DATE c� ISSUE TYPE OCC APN LOT TRACT DATE _CONST. GROUP p OWNER {l� 3, .('!� �=r�.la< �'' ADDRESS 1 C�l�`Z.. —�a�;,,rv���a:_��,%� ,_��,� :.��c ZONING SETBACKS z CITY � ,�. ZIP '��: /UJrTEL,_',�i'�,'-���7� FRONT RW ❑ � APPLICANT ��c:x-�-.c 'v� ^, TEL. REAR ❑ � SiDE/SIDE STREE:T RW G � CONTRACTO,Ei � -^� _�n;^`�� ��r"v'��.�� SIDE � � ADDRESS �JC'��. n ' !i�(U , � CITY�i�;-I�F:i ffYx,�%'� ZIP r )a TEL.'�L�'�`{'�\' .� PROPOSED USE Q ARCH/ENG/ W DESIGNER_ NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CI'TY ZIP TEL. � DESCRIPTION SQ.FT FACTOR PSF ADJ.AREANALUATION p� OWNER-BI:ILDER DECLARATION SFR/AD�/REM O — p t HEREBV AFFlRM UNDER PENALTV OF PERJURY TFIAT I AM EXEMDT FHOM THE CANTRAC70RS LI� Gdfd99/C.BfPOfI W CENSELAWFONTHEFOLLOWINGREASON(SEC.7091.SBUSINESSAN�PROFESSIONSCODE:ANYCITYOR (n U COUNTYNMICHREQUIRESAPERMITTOCONS7RUCT,ALTER,IMPROVE,DEMOLiSH,ORHEPIURANYS7RUC- W PaliO/DBCk w TUHE.PPoOp i0 ITS ISSUANCE,AL50 REQUIRES THE APPLICANT FOR SI1CH PERMIT TO FILE A SIGNEO W � STATENENT iHA7 HE OR SHE IS LICENSED PURSUANT TO THE 7ROVISIONS OF THE CONiMCTORS LI- � CENSE LAW�CHAPTER e(COMMENCING WITH SEC710N 7000)OF DIVISION 3 OF THE Bl1SINE55 ANO PRO� � POOIISp2 FESSIONSGODE)ORTHATHEOHSHEISE%EMPTTHEREFROMANDTHEBASISFOHTNEALLEGEDE%EMP• (� � TION.ANYVIOLATIONOF6ECTION7031.SBVANYAPPUCANTFORAPERMITSUBJECTSiHEAVPLICANTTO Z Re-Roo1 � A CIVIL PENALTY OF NOT MORE THAN FIVE HUNORED DOLlAR515500)J: 0 ❑I,ASOWNEROFTHEPPOPERTV.ORM�EMPIOVEESWITHWAGESASTHEIRSOLECOMPENSATION, ❑ Commercial Z N7LL 00 THE WOqK.AND TNE STRI1CTlIRE IS NOT IN7ENDED OR OFFERED FOR SFI.E{SEG 7044,BUSI- J NE55 AND PflOFE5510N5 CODE:THE CONTFACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF � PROPEHTVWNOHULDSORIMPqOVESTHEREON.ANDWHO�0E5SUCHWORNH�MSELFORHERSELFOR m � THflOUGHHLSORMEROWNEAIPLOYEES,PROVIDE�THATSUCHIMPROYEMENTSARENOTINTENDEDOR QOFFEREDFORSALE.IF,HOWEVERTMEBUILOWGORIMPROVEMENTISSOIDWIh11NONEYEAROFCOAIRE- Z TIDN.THE OWNER�BUIL�ER WILI FiIWE THE BURDEN OF GqOVING THAT HE Ofl SHE�ID NOT BUILD OR � IMPROVEFORTHEPURPOSEOFSALE). w ❑I,ASOWNEROF7HEPPOPEf7�Y.AMEXCWSNELYCONTRACTINGWITMLICENSEDCONTRACTORS � i0 CONSiHUC7 TNE PROJECT(SEC.7044,BUSINE55 AND PROFESSIDNS CODE:7HE CONiRACTORS Li- ValUati011 AU.I.AREA W CENSEL4WDOESNDiAPPLVTOANOWNEROFAPpOPERTVWND6111LU50RIMPROVE5h1EREON.ANO � NM1IOCONTRACTSFORSUCH�R0.1EC1'6WITHACONTRACTOR(S)LICENSEDPVRSUAMTOiHECONTRAP Q�JANTITY DESCRIP710V FEE Y TORS UCENSEIAW.�. � J O ❑I AM E%EMPT UNDER SEC. 8.8 P.C.FORTNIS REASON Q � U � LL DATE OWNER V Z W � LICENSED CONTRAC70RS DECLARATION —� � I HEREBYAFFIflM UNOEFl PENALTY OF PERJURV 7HRT I AM LICENSEO UNDEft PROVISIONS OF CHAVTER � � 9� d 9jCOMMENCINOWITHSECTION7000�OFDIVISION30FTHE8USINE55ANDPROFESS�ONSCODE,AND Z `X MV LICENSE IS IN FULL FORCE AND EFFEC7. m � LICENSE ClASS �'��' UC.NO.�C3 �S�� � � /� � J ' U �AiE �� "'�,r�]t' CONTRACTOR �—�- • W � WORKERS'COMPENSATION DECLARAT�DN —r = U � I HEREBYAFFIRM UN�ER PENALN OF vERJURV ONE OF iHE iOLLOWING OECIaRATIONs: � Z Q 0 _IHAVEANDWILLMAINTAINACEfiTIFICATEOFCONSENTTOSELF-MSUiiEF'OFWORKERS' _ CAMPENSATION.AS PHOVIDED BY SECTION 37ooOF THE LABOR CO�E.FOR THE PERFORMANCE U ¢ OFTHE WORH FOR WHICH THIS PERMIT IS ISSUED. � 0 w �t NAVE AND W�LL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION � 9'IOOOF THE LABOR CODE,FORTHE PERFOfiMANCE OF THE WORK FOR WHICHTHIS PEAA�R IS ISSUED.MY WORKERS'�CO,MpENSATION INSUFANCE CARRIER AN�POLICV NUAlBERARE CONSTRUCT�ON _ � CARRIEq �J� PLAN qEVIEW Z POLICYNUM6Efi i. � "�% ELECTRIC � ¢ V 0 (iHISSECTIONNE�NDTBEOJNAEfmOF7HEPERMITSFOHONEFiU�DREDDOl1ARSKtO�)ORLESS} PLUMBING 1 ! + Z 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PEHMIT IS ISSUED.I MECHANICAL �� (} SHALLNOTEMPLOYANYPEHSONINANYMANNERSOASTOBECOMESUBJECTTOTHE �� � WORKERS'COMPENSATIONLAWSOFCALIFORNIA.ANOdGREETNATIFISNOIIL�BECOME INSPECTIONFEE _ SU&JECT TO TY,E WORKERS'GOMPENSATION PROVISIONS OF$ECTpN 370o OF THE LABOR ' � CO�E,ISHALLFORTHWITHCOMPLYWITHTHOSEPROVISIONS. �SSUANCE �� � SMIP _� p �ATE: APPLICANT. W ENERGY P/C J WARNING:FAILUREiOSECUREWOPKERS'COMPENSAiIONCAVERAGEISUNLAWFUL,AN�SHALLBE LL SU&IECTANEMPLOYER70CRIMINIILPENALTESAN�CIVILFINESUPTOO4EMUNDRED7HOUSAND ENEflGYPERMIT ('��,�� DOLLARS�51oD.o00),IN ADDI7ION TO THE CO57 OF COMPENSATION.DAMAGES AS PROVIDE�FOH IN �Lfej� J SECTION37090FTHElA80RCADE.W7ERES7ANOATTORNEY5FEE5. RETENTIONFEE: � . a CONSTRUCTION LENDING AGENCV pRE-ALT FEE: � I HEfiEBV AFFIRM UNDER PENALTY OF PER/URY THATTHEflE IS AGONSTRUCTION LEND�NG AGENCY d FOR THE PERFORMANCE OF THE WOW(FOR WHICFITHIS PERMIT IS ISSUED�SEC.3097,CIV.C.). Z W � LENDER'SNAME_ 1— LENDEi7SADORE55 � ICEH7IFYTHATIHqYEREADiHI5APP4�CAT10NANDSTRTETHATTHEABOVEINFORMATIONISCORRECT. TOTAL FCES � 4 w IAGflEETOCAMPIVWITHALLCIT/A�CAUNT'OR�INANCESANOS7ATELAWSRELATINGTOBUILDING �� � CONSTflUCTION,ANDHEREBYAUTHORIZEREPRESENTATIVESOFTHISCOUNT'70ENTERUPONTHE z ABOVE-MENTIONE�VROPERT'FOR INSPECTION PURPOSES. 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