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HomeMy WebLinkAbout10526 I I — CITY OF DIAMOND BAR ! COMMUNITY DEVELOPMENT DEPARTMENT 21660 E.Copley Drive Suite 190 PRESS (909)860-3195 Fax(909)861-3117 """'� BUILDINGPERMITAPPLICATION FIRMLY N J08SITE / APPLICATIONr/ q PERMIT / P/C d ADDRESS ����o L� S�[,Yl}n�/[h /���r.y � /�) p DATE / I�I / � NUMBER�v� J� # � APN LOT TRACT D TEE �"I 7`- I, ONST. GFiOUP pOWNER f=�si's��;".Z.� ��-�-r^'�. � ADDRESS 1 4,37w «" 3X�vlYt�y���� �-�+w,3� ZONING SETBACKS 0 WZ CITY j�itY"wJ�v?IT1��t ZIP ��� TEL. .�j�- '�.1�d FRONT RW ❑ Q APPLICANT /g:'�-�•�'�<f i J'lF�v'c. TEL. _ REAR ❑ � SIDE/SIDE STREET RW LI_ r� CONTRACTOR .>����L`r _ SIDE ;� ADDRESS � CIN ZIP TEL. PROPOSED USE ^ o ARCH/ENG/ W DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL._ � � OESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BI:ILDER DECLARATION SFqIADD/REM O I HEREBY AFFlRM UNDEfl PENALTY OF PERJURY iHFT I AM EXEMPT PROM THE CONTi7ACTORS LI� G3fd96/C81POR W CENSEUIWFORTHEFOLLOWINGNEASON�SEC.7037.SBU6INESSANDPROFESSIONSCADE:ANVCIT'OR (n �+ C.7 CAUNTYWHIGHREQUIflESAPERMITTOCONSTRUCT.AL7Eft.IMVROVE,�EMOLISH,ORREPAIflANYSTRUC• �(,( patiolDeck � /;� Z TURE.PfllOfl TO ITS ISSUANCE,ALSO RE�l11R[S THE APP4�CANT FOR 9UCH PERMIT TO FlLE A SIONED W STATEMENT THAT HE OH SHE IS LICENSED PUHSUANi 70 THE PROVISIDNS OF THE CONTRACTORS LI- W � CENSE LAW(CH�PTER e(COMMENCINO WITH SECTION 7a00)O�OIVISION 3 OF THE BU9INESS AND PRO� LL' POOUSPB � FESSIONSCODE)ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEOASISFOATHEALLEQEDEXEAIP- � V TION.ANYVIOLATIONOFSECTION7031.SBVANYAPPLICANTFORAPERMITSUBJECTSTNEAPPLICANTTO Z Re-Roaf A CIVIL PENALTV OF NOT MORE THAN FIVE HUNORED DOLUflS(5500).). 0 LII,ASOWNEROFTHEPqOPERTY,ORMYEMPLOVEESWITHWAGESMSTHEIR50LECOMPENSATION, � COf111110fC18I Z WILI DO THE WORK,AND THE STRUCTUflE IS NOT INTENDED OR OFfEFED FOR SAIE(SEC.�014,BUSI- J N NESS ANU PROFESSIONS CfJUE:THE CONTRACTOqS LICENSE LAW OOES NOT APPLY TO AN OWNER OF � PflOPERTV WHO BUIL�S OR IMPROVES THEREON,AND WI�i000ES SUCH WORK HIMSE�F OR HERSELF OR Q THflOUGHHI50RMEROWNEMPIOYEES.PROVIDEDTNATSUCHIMPRWEMENTSARENOTINTEN�EDOR m ' QOFFEREDfORSALEIF,HOWEVER,iHEBUILDINGORIMPqOVEMENTISSOIDWITHINONEYEAAOFCOMPLE- � � TION,THE OWNEN-BUILOER WILL HAVE iHE Bl1R0EN OF PROYING THAT HE OF SNE DI�NOT BUIL�OR � W. IMPROVE fOR THE PURPQ4E OF SALE). ❑I,AS OWNEfi OF THE AROPERTV,AM E%CWSIVEIY CONTRACiING W�TH LICENSED CONTRRCTORS Q TO CONSTqUGT THE PROJECT(SEC.7044,BUSINESS AND PROFESSIONS CODE:THE CONTPACTORS LI• V81U811011 ADJ.AREA W CENSELAWDOESNOTAPPLYTOMIOWNEROFAPROPERTVWHOBUILPSORIMPROVESiNEREON,PND -- � VMOCONTR4CTSFORSUCNVR0.IECTSWITHACONTRACTOR(5)LICENSEOPURSUANTT07HECONTRAG ' QUANTITY DESCRIPTION FEE Y TORS LICENSE LAWJ. �� ❑I AM EXEMPT UNDER SEC. _________8.8 P.C.FOR THIS REASON Q �i _ __'--_ _'—'___ V LL � ATE .� � '_„�_'_OWNEH -�_ U Z W � LICENSED CONTRACTORS DECLARATION W � �. I HEflEBYAFFIRM UNDER PENAL7Y OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OP CHAPTER � d B(COMMENCINO WITH SECTION 7000)OF DIVISION�OF THE BUSINESS AND PROFESSIONS COOE,ANO z �, MY LICENSE IS IN FULI FORCE ANO EFFEGT. m � LICENSECLASS _LIC.NO.^ ___ � U — � DATE CONTFACTOR____ a. W � WORKERS'COMPENSATION DECLARATION Q �' IHER[BVAFfIRMUNDERPENALTYOFPERJURYONEOFTHEFOLLOWINGDECLARATION5: z Z� ____111AVEANDWILLMAINTAINACEflflFlC.4TEOFCONSENTTOSELF-INSUREFORWORKEPS' _ COMPENSATION,AS P{iOVI!]ED BY SECTION 3l0o OF THE:ABOR CO�E,FOfl THC-PEHFORIAANCE U � OF THE WORK FOR WHICM THIS PERMIT IS ISSUED. � � W _,_I HAVEAND WILIlAAINTAIN WORKERS'O�MPENSATION INSURANCE,AS REOUIRED 9V SECTION ��ry Q 3]ooOF TNE LPBOR COD[.FORTHE PEflFOflMM10E OF THE WOflK WF WHICH T1115 PEflM1T IS ��' °�//,' L/ � ISSl1E�.MY WORKERS'COMPENSA710N INSURANCE CARflIERMD POLICY NUMBERARE: ONSTRUCTIO y� / W'�� j CAqRIEfl __—.._.. P REVIE , l�.St�L � POIICV NUMBER______._. RIC __ Q � ��ss[cinraNe�rare[eonur.�ooFncrEw.rT�sroracriEtar�ooal.�sR�ro)oa�ss�. PLUMBING W I CERTIfY THAT IN THE PEHFORMANCE OF THE WORK FOR WHICH 7HIS PERMIT IS ISSUED,I MECHANICAL Z _ � SHALLNOT EMPLOYANY PERSON IN pNY MANNER SOAS TO BECAME SU&1C-Ci TO THE � WORKERS'COMPENSATIONIAWSOFCALIFOf3NIA,ANDAGREF.TNATIFISHOULDBECAME INSPECTIONFEE _ = SUBJECTTOTHEWORNERS'COMPENSATIIXJPROVISION50FSEC710Y7/000FTN[LABOR ''+, � CADE,1 SNALL.FOflTHWITM COMPLY WITH THOSE PROVISIONS. CE ?' �d7 r C1 C.� 0 p DATE:__'__ APPLICANT: __'_ SMIP _.. e T Cl J WqqNINp;FAILURETOSECUREWORKEf75'COMPENSATIONCOVEflAGE1SUNLAWFUL,ANOSHALL6E ERGYP/C _ � SU&IECT AN EAIPLOVEN TO CRIAIINAL PENALTIES AND CIVIL FINES UP TO ONE HUN�FED THWSAND ENERGY PERMIT Dq.URS(S1o0.o00).IN ADUITION TO THE COST OF COMPENSATION,DAMAOES AS PqOVIDEO FOR IN --- J SECTION 37o90F THE IABOH CODE.�NTEi7E5T,ANO ATfORNE�"5 FEES. RETENTION FEE: Q OCONSTRUCTIONLENDINGAGENCY PRE•ALTFEE;�j�,� ;, � IHEHEBVAFFIqMUNDEflPENpLTVOFPENURYTHATTHEREISACONSTFUCTIONLENDINOAGENCY � '�I � FORTHE PEflFORMANCE OF THE WOPo(FOR WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.C.). '--'�'— t�4 , Z W -- � LENDEN'SNAME_______ __ _ _ �-- LENDER'SADDRESS___.___�_ ____,_ � 1 CEflTIFYTHAT I HAVE READ THIS APPLICATION ANO STRTE THl�T TNE ABOVE INFORMATION I5 CORRECT, TOTAL�FEES � `�t .Z� W IAGflEETOCOMPLYWITNALLCITVANDCOUNTYORDINANCESAND6TATElA'NSflELATINGTOBUIL0INO L � CONSTRUCTION,ANOHEFE9YAUTHOFIZEflEPflESENTATNE50FTHI5COUNTVTOENTERUPONTHE J Z A00VE-AIENTIONE�PROPERNFORINSPECiqNPURPO5E5. 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