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HomeMy WebLinkAbout15448 , ,,:. �: ��� _��_ CITY OF DIAMOND BAR / DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �` d�� a 21660 E.Copley Ihive Suite 190 � (909)860-3195 Fax(909)861-3117 � PRE$S �`'A�'�' BUQ.DTNG PERMIT APPLICATION ` FIRMLY _ � JOBSITE �� C�t,��`��� �, DATE CATIQN �.� (� '�� NUMBER�_ #/C o ADORESS � � APN LOT TRACT �SSUE TYPE OCC DATE CONST. GROUP p OWNER /�1tJi.. C4.��"zh� � ADDRESS ZONING SETBACKS � CITY ZIP TEL RE�RT RW � APPLICANT TEL. $IDE/SIDE STREET RW ❑ � CONTRACTOR � �'����'�'aLC.i�2S SIDE ❑ ¢ ADDRESS 3Pa'L� �S"Tvc.`-/ �� -' � CITY �'Zcu`^siS ZIP�'C°i712 TEL.�E:� PROPOSED USE a ARCWENG/ � DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � v� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUIL�ER DECLARATION SFRlADDlREM O Q I HEREBY AFFlRM UNDER PENA�TV OF PERIURV THAT I AM EXEMPT FROM THE CANTRACTOflS LI� G$fOJB/CBIpOfI LLJ CENSELAWFORhiEFOLLOV/MGREA90N(SEC.7031.SBUSINESSANDPHOFESSIONSCADE:ANYCITYOfl (n C.7 COUNTYWHId1REWIHESAPEFM�fTOCONSiAUC7,AI.TER,IMPROVE,DEMOLISH,ORREPNRANY5TRUG Z TUflE,PFIOR TO ITS ISSUMICE,M.50 RE-0U�RES TFiE APPIICANT FOR SUCM PERMIT TO FILE A SIGNED W Patio/�eck � STATEMENT'fHAT HE OR SHE IS LICENSE�PUR5UANT TO THE PROVISIONS OF THE CONTRACTORS L6 � � CENSE LAW ICHAPTER 9(COMMENCINO WITH SECTION 100D)OF ONISION 3 OF THE Bl1SINESS AN�PRO� POOUSpB FESSIONSOODE)ORTHATHEORSHEISEXEMPTTHEflEfROMANDTHEBASISFORTHEALLEOEDEXEFAP� C7 TION.ANVVIOLATIONOFSECTION7031.SBYANYAPPLICANTFORAPERMITSU&/ECTSTHEADPLICANTTO Z Re-Roof F ACIVIL PENAL7V OF NOT MORE hIAN FIVE HUNDREO DOLLARS(f5aa).): � ❑I,ASONMEROFTHEPROPERTY,ORMVEMPLOYEESWITHWAGESASTHEIFSOLECOMPENSA710N, � COfI1RlefCl81 � WILI DO THE WORK,AND 7HE STRUCTURE IS NOT INiENOE�OR OFFEFED FOR SALE(SEC.70a4,BUSI� J � NE55 AND PHOFE3310N5 CODE:THE CONTMCTORS LICENSE UW DOES NOT APPLV TO AN OWNER OF = PROPER7Y Yh10 BUILDS OR IMPROVES TMEREON,ANDMMO DOES SUCH WORN HIMSELFOR HERSELF Ofl � TMilOUOM MIS OR HER OWN EMPLOVEES,PF�VIDED THAT SUCH IMPROVEMENTS ARE NOT INTENOED OR � � ,OFFERWFORSPLEIF,FIOWEVER,iHEBUILDM00HIMPHOVEMENTI550LDWITHINONEVEAROFCOMPIE� Z TKKi,THE OWNER�BUILDER WILL HAVE TNE BURDEN OF PROVIN6 THAT HE OR SHE DID NOT BURA OFl = IMPROVE FOR THE PURPOSE OF SALE). �y ❑I.ASONTIEROFTHEPPOPEHTV.AIAEXCWSNELVCONTRACTINOWfIHLICENSEDCONTRACTOR3 � TO CONSTpUCT THE PRQIECT(SEQ 7041.BUSINESS AND PROFESSIONS CODE:THE CONTRAC70RS Lb ValUBfion ADJ.AREA � CENSELAWDOESNOTAPPLYTOANOWNEROFAiHOGERTYN7VOBUILDSORIMPROVESTNEREON,AND WFqCONTRACTSFOR6UCHPR0.IECTSWITHACONTMCTOR�S)LICENSEDPURSUANT?OTHECONTRA6 QUANTITY DESCRIPTION FEE - � TORSLICENSELAWJ. ❑I AM EXEMPTUNDER SEC. 8.8 P.C.FOR THIS REASON Q 3 � � � DA7E OWN[R U J � LICENSED CONTRACTORS DECLARATION W � I HEREBY AFFIRM UNOER PENPLTV OF PERIURY THAT I AM UCENSED UNDER PROVISIONS OF CHAPTER � � Y�COMMENCINOWITHSECTION700o)OF�IVISION30FTHEBUSINESSANDPROFESSIONGCODE,AN� Z � MYUCEN9EISINFULIFOR�RNOEFFECT. C^,–��7�C� m � � LICENSE CL4SS �� LIC.NO.= / ` � F V �ATE �'"���'�� CONTRAC70R 0- W � WORKERS'COMPENSATION DECLARATION Q � I HERE$V AFflqM UNDER PENALT'OF 7EiiJURY ONE OFTHE FOLLAWING DECLARATIONS: Z O IHAVEiINOWILLMAINTNNACERTIFICATEOFCONSENTTOSELF-INSUFEFORWORNERS' 2 Q COMPENSATION,AS PROViDED BV SECTION 3�0o OF THE LABOR CODE.FOR THE PERFORMANCE `U OFTHE WORK FOR WHICH THIS PERAIR IS ISSUED. � � � _IHAVENV�WILLMAINTAINWORKERS'COMPENSATIONINSl1RANCE.A5RE0UIREDBYSECTION Q 37000FhIE LABOH COpE,FOR THE PERWHMANCE OF THE WORK FOR WNICH THIS PERMIT IS IS9UED.MV WORKER' PENSATION INSURANCE CARRIER AND PoLICY NUMBER ARE: CONSTRUCTION � CARRIER ���'�.'�C7�7 ��.-L�YE�'�.S PIAN REVIEW Z vouCY NUMBER������'���_—_—.. ELECTRIC ¢ 0 (fH55EGT10NNE�NJTBECOMPLETEDOFTHEPEM1fTISFORON:HUNDHmDo�WiS(S�ao)ORLE551 PLUMBING._. 1 � I CEflTIFY THAT IN THE PEPFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEO.I MECHANICAL Xyy�rr� SHALLNOT EMPLOYANV PERSON INANV MANNEF SOAS TO BECAME SUBJECT TO THE _""" '.J � WORKERS'COMPENSATION IAWS OF CALIFOPNIA,AND AGREE THA7 IF I SHOULO BECOME INSPECTI�N FE +• � = SUBJECTTOTHEWORKERS'COMV NSOFSECTqN3']DOOFTHEL4BOR ) CODE,ISHALLFOflTHWITHCOhiB WI7HTHOSEPROVI 'pS. ISSUANCE 1� � �-ic�-�u:� 1�"�Ie��.---.-..���G. SMIP ft�t�7 tl r nn�H p DATE: APPLICANT: J WANNINa:FAIUIPE TO SECURE WORKERS'COMPENSATION CAVERAGE IS UNLAWFUL,AND SHALLBE ENERCaY P!C LL SU&IECTANEMPLOVERTOCRIMINALPENALTIESANDpVILFWESUPTOONEHl1NDREDTHOUSAND ENEFGYPERMIT DOLIARS(5100,OD0).IN AD�ITION TOTHE COST OF COMPENSATION,DAMAGES AS PROVI�ED FOR IN � � SECTION37080FTHELABORCODE.INTEREST,ANDATTORNEY'SFEES. RETENTIONFEE: a CONSTRUCTION�ENDINGAGENCY PRE-ALT FEE: Q � I HEREBV AFFIRM UNDER PENALN OF PERJURV 1'HAT THFRE IS R CONSTPUCTION LENOING AGENCV FOR TNE PERFORMANCE OF THE WORK FOR W HICH THIS PERMIT IS ISSUED(SEC.3oe7,CIV.C.). Z w � LENDEP'S NAME F— LENDEH'SADDRESS � TOTAL FEES Z� C/D W I CER7IFY TMAT 1 HRVE READ THIS APPLICATpN AND STATE THATTHE ABOVE INFORMATION IS COHREC7 � IAGREE TO CAMP�.V WRH ALLCRV AND COUNTY ORDINANCES AND STATE UWS RELATING TO BUIL�ING W ! � CONSTPUCTION,AND HEREBV AU7HORRE PEPRESEMATNES OFTHIS COUNTV TO ENTER UPON THE ABOVE-MENTIONED Pq0 ORINSPECTION PURPOSES. COMMENTS � � � QPERMITTEE NMAE(PRI ' r � ��\�� � SIGNATUHE OF PERMITTEE ATE = RECPT.NO. 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