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HomeMy WebLinkAbout16937 (1109) CITY OF DIAMOND BAR � -- �'� -- DEPARTMENT OF'COMMiJIVITY&DEVELOPMENT SERVICES I I I � 21825 E.Copley Ihive �r (909)860-3195 Fax(909)861-3117 PRESS ``'%HM�'�" BUILDINGPERMITAPPLICATION FIRMLY � JOBSITE �']�� p,� J f / APPLICATION �;.>��e{�� PERMIT �� � �1C � ADDRESS s7S c.o/ L1� o DATE NUMBER � � ISSUE TYPE OCC � APN LOT ' TRACT DATE CONST. GROUP p OWNER ����f ���� p ADDRESS '�- ZONING SETBACKS Z CITY I ZIP EL. FRONT RW ❑ � APPUCANT i TEL. REAR ❑ Z SIDE/SIDE STREET RW ❑ m CONTRACTO '.r . SIDE ❑ oCDTD1RES���� I Z�P �� ' TEL. PROPOSED USE ^'r a ARCH/ENG/ �z DESIGNER Ii NO.DWEL. NO. NO. a ADDRESS = CITY I ZIP 7EL. UNITS • STORIES BEDROOMS � cn I DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION Q OWNER-BUILDER DECLARATION SFR/ADD/REM O � I HEREBY AFFIRM UNDER P NALTV OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- G8f89B/CBfPOfI W CENSELAWFORiHEFOLLOWING�tEA50N(SEC.7031.5BUSIN[SSANOPROFESSIONSCODE:ANVCRYOR (f� C.� COUNTYWHICHRE�UIRESAPER ITTOCANSTRUCT,ALTEft,IMPROVE,DEMOLISH,ORREPAIRANYSiRUF M W patiolDeck W TUqE,PRIOR TO ITS ISSUANCE,l�L50 REQUIflES THE APPLICANT FOFi SUCH PERMIT TO FILE A SIGNEU W � STATEMENT THAT HE OR SHE IS LICENSm PURSUANT TO THE PFOVISIONS OF THE CONTRACTORS LI- � � CENSE LAW(CHAPTER 9(COMMENCING WITH SECiION 7ooa)OF�IVISION 3 OP THE BUSIN'cS5 AND PRO- POOI/Sp2 � FESSIONSCODE)ORTHATHEORSHEISEXEMPT7HEREFROMANDTHEBASISFOfiTHEALLEGEDEXEMP- (� V TIDN.ANYVIOLATqNOFSECTION7U31.58YANYAPPLICANTFORAPERMITSUBJECTSTHEAPPUCANTTO z Re-Raof A CIVIL PENALTY OF NOT MORE T AN FIVE HUNDRE�DOLLARS(SSoo).): Q ❑I,ASOWNEROFTHEPROP�RTY,ORMYEMPLAYEESWITHYJAQESASTHEIRSOL'cCOMPENSATION, � COfTIRIB�CIBI - ;Z WILL DO THE WORK,AND THE S7�iUCTUflE IS NOT'INTENDED OR OFFEREO FOF SALE(SEC.7044,BU51- J � NE55 AND PROFESSIONS CD�E: HE CONTRACTORS UCENSE LAW DOES NOT APPLY TO AN OWNER OF � PftOPER7YWH09UILD50RIMPR VESTHEREON,ANDWHO�OESSUCHWORKHIMSELFORHERSELPOR Q 'THROUGHHISORHEROWNEMPL YEES,PROVI�EDTHATSUCHIMPROVEMEMSARENOTIMEN�EDoq m � �OFFERWFORSALE.IF,HOWEVER, EBt11L01NGORIMPROVEMENTI55DL�WITHiNONEYEAROFCOMPLE- .Z TION,THE OWNER-BUIL�ER WILL HAVE THE BURDEN OF PROVING THAT HE OR S4E OID NOT BIIIL�OR IMPROVE FOR 7HE PUIiPOSE OF ALE). �w �I.ASOWNEROFTHEPROfjEflTV,AMEXCLt1SIVELVCONTFACTINGWITHLICENSEDCONTRACTORS '.� TO CONSTRUC7 THE PROJECT(S�C.7044,BUSINESS ANO PROFE55{ONS CODE:THE CONTftACTORS LI- V8IIJflYlOf1 ADJ.AREA W CENSEUIWDOESNOTAPPLYTO NOWNEROFAPROPEHTYWH06UIlO50RiMPROVESTHEREON,AND .Y WHOCONiRACTSFORSUCHPRO.�ECTSWITHACONTRACTOR(5)LICENSE�PURSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FEE Y TORS LICENSE LAWJ. , �� ❑I AM E%EMPT UNDER S�C.II B.&P.C.FORTHIS REASON Q ,}y U �� DATE OWNER � 0 I W .F LICEN3�ED CONTRACTORS DECLARATION W ¢ CC IHEREBYAFFIRAAUNOERPENAL OFPERJURYTHATIAMLICENSEDUN�ERPROVISIONSOiCHAPTER � d �9�COMMENdMGWIiNSECiION]o00)OFDIVISION30FTHEBUSINESSAN�PROFESSIONSCODE,AND Z 'X MY UCENSE IS IN FULI F CE EFFEC7. m � LICENSE C LIC.NO. � / _ ,� V DATE CONTRACTOR a j,/ d . W I � WOFKERS'COMPENSATION DECLARATION Q NI HEREBV AFFIRM UN�ER PENAL OF PERJURV ONE OF THE FOLLOWING DECLARAilON5: Z 'Z _IHAVEANDWILLMAINTAI ACERTIFlCATEOFCONSENTTOSELF-INSUREFORWORKEflS' ¢ 2 ¢ COMPENSATION,AS Pfl0 IOED BV SECTION 3]0o OFTHE LABOR CODE,FOfl THE PERFORMANCE U OF?HE WORK FOfl WHIC THIS PEFMIT IS ISSIJED. W O I � � _I HAVEAND WILLMAINTAI WOflKERS'COMPENSAiION INSURANCE,AS flE�UIRED BV SECTION QQ 370o OFTHE LABOF COD,FOF THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS J ISSUE�.MY WO 5'C M EN TION INSU ANCE CARRIERAN�POLICY NUMBER ARE: CONSTRUCTION _ j cnRaiEa PLAN REVIEW z roucvNuhteER , — ELECTRIC 1 � (iHI55ECTKKJNEmMDTB�OJMRE�EDOFhiEPEFlMfTISF-0RONEHUNDREDOOLLARS�StO�ORLESS). PLUMBING _ d �( � Z I CERTIFYTHAT IN THE PE�SFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUEq l MECHANICAL (�T SHALL NOT EMPLDY ANV�ERSON IN ANY fAANNER SOAS iD BECOM=SUBJECT TOTHE }-�.-�.._�a � � WORKERS'COMPENSATIONLAWSOFCALIFOFiNIA,ANDAGREETHATIFISHOULDBECOME INSPECTIONFEE 3 _'�"�� 'S""'^=- F SUBJECTTOTHEWORKEF�S'COMPENSATION ROVISIONSOFSECTION3�ooOFTHELpBOR E� �_ � �",e= ' � , � � CO E,I HALL ORTHlMT�1GOMPLYWITHT SE OVISION. ISSUANCE - -- - �"�"� � d �p DATE: ApPLICANT: SMIP �l6 i.�i' ' J WARNIN�:FAILURE OSECUREV�IORKERS'COMPENSATIONCOVERpGEISUNLAWFUL,ANOSHALLBE ENERGYP/C ,�'�°'�� . ,, � LL SUBJECTANEMPLOYERTOGRIMI�JALPENALTIESANDCIVILFINESUPTOONeHl1NDREDTHOUSAND ENEAGYPERMIT ' /� { � DOILAflS(51oo.oa0),IN AO�ITION O THE GOSi OF COMPENSATION,DAMAGES AS PFiOVI�ED FOft IN �__ . J SECTION 370B OF7HE L4BOR CO E,INTEREST,AN�ATTOR�EY'S FEES. �'�a � � RETENTION FEE: �+.��� � d CO STRUCTIONLENDINGAGENCY ���y���Y��� ���� � ��-� �� Q PRE-ALT FEE: � 1 HEREBYAFFIRM UNDER PENALT OF PEPJURY T�IATTHERE IS A CONSTRUC710N LENDING AGENCY FOR THE PERWRMANCE OF THE ORK FOR WHICIi THIS PEPMIT IS ISSUED(SEC.3a97,CIV.C.]. . Z i w � LENDER'S NAME � F— LENDER'S ADDPESS I � TOTAL FEES ����� � ICER7IFVTHATIHAVEREADTHISAPPLICATIONANDSTATETHPTTHEABOVEINFOPMATIONISCORRECT. � 1 AGREE TO COMPLY W1TH ALL CITIrAN�CAUNTV OflDINANCES AND STATE L4W5 RELATING TO BUILDING ' � CONSTRUCTION.ANDHEflEBYAUTHORREREPRESEMATIVE50FTHISCWN7YTOENTERUPONTHE Z ABOV-AAENTIONED7ROPERiVF�ORINSPECTIO ruaaosEs. COMMENTS - ' � ���� ��� �. m PER E NAME( INT� I (°y�� �� � Q —_ ., C/� '� / CJ �" . � SIGNATUREOFPERMITTEE ' DAT i = RECPT,NO. PAID BY � VALIDATION ~ �'� WHITE—De artment Co YELLOW—Finance Co PINK—Assessor Co GOLDENROD—File Co GREEN—A IicanYs Co �� P PY. 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