HomeMy WebLinkAbout17067 (669) 1
, � _!�_ CITY OF DIAMOND BAR �������
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190 �U� 1 9 1���
(909)86a3195 Fax(909)861-3117 �RESS
�����^� BUILDING PERMIT APPLICATION '' �� FIRMLY
� JOBSITE n 1� 1' ���7 , 'n APPLICATION PERMIT P/C
o ADDRESS �l "'�l� ��G'�'r/l`�' W 1 DATE NUMBER���#
� ISSUE TYPE OCC
APN LOT TRACT DATE CONST. GROUP
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v� DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION
Q OWNEF-BUILDER DECLARATION SFR/ADD/REM
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I HEREBY AFFlRM UNDER PENALTY OF PE0.IURY THAT I AM E%EMPT FROM THE CONTRACTORS LI- GefeJO/CBfpOR
W CENSEUWFORTHEFOLLOWINOHEASON(SEC.7031.5BUSINESSANDPROFESSIONSCODE:ANVCITYOR (J)
U COUNTVWHICHREOUIRESAPERMRTOCONSTRUCT,ALTERIMPROVE,DEMOLISH,ORREPAIRANVSTRUC- W P8110/D6Ck
TURE,PRIOR TO ITS ISSUANCE,AL50 REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
w STATEMEM THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- W
� CENSE UW(CHAVTER 0(COMMENCINO WI7H SECTION 7000)OF DIVISION 3 OF 7HE BUSINESS AND PRO- � PooVSpa
fESSqNSODDE)ORTHATHEORSHEISEXEMPThiEREFROMANDTHEBASISFORTHEALLEGEDEXEMP- C7
TION.AHVVIOLATIONOFSECTION7031.SBVANYAPPLICANTFORAPEHMITSU&IECTS7HEAPPIICAN770 Z Re-Roof
� A CIVIL PENALTV OF NOT MORE hIAN FIVE HUNDRED DOLUPS(5500).): .
� ❑I.ASOWNEROFTHEPROPERTY,ORMVEMPLOYEESWITMWAGESASTHEIRSOLECOMPENSATION, � COrt1rtIBfCl81 �
YVILL DO THE WORI(AND THE STRUCTUFE IS NOT IMENDED OR OFFERED FOR SALE(SEC.70at,BUSI- J
N NE55 AND PROFESSIOHS CODE:THE CONTMCTORS LICENSE LAW DOES NO7 APPLY TO AN OWNER OF �
PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OH
Q h1iqUGH HIS OR HER OWN EM7LOYEES,PROVIDED THAT SUCH IMPROVEMEMS ARE NOT INTEN�ED OR m
� ,OFFEREDFORSKEIF,HOWEVERTNEBUILDIN�ORIMPROVEMENTISSOIDWITNINONEYEAROFCOMPIE-
Z 'TIOH,7HE OWHEH�BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUIID OR
� IMPROVE WR THE PURPOSE OF ShLE).
w ❑1,AS OWNER OF THE PROPEHTV,AA1 EXCLUSNELY CON7MCTINO N7TH LICENSED CONTMCTORS
Q TO CONSTRUCT THE PRO,IEC7(SEC.10a�,BUSINE55 AND PROFESSIONS CODE:THE CANTRAC70R5 LI- V81U8fI0f1 ADJ.AREA �
W CENSE UW DOES NOTAPPLY TO AN ONMER OF A PROPERTY NM1iO BUILDS OR IMPROVES THEREON,AND
� WIqCONTRACTSFORSUCHPR0.1ECT5WITMACONTMCTOR(SjIICENSEDPURSUANTTOTHECONTRAG pUANTITY DESCRIPTION FEE
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O I AM EXEMPT UNDER SEC. B.i P.C.FOR THIS REASON J
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DATE OWNER U
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� IICENSED CONTRACTORS DECLARATION w
� I HEREBY AFFIRIA UNDER PENALTY OF PERIURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER �
� Y(COMMENCINO WITH SECTqN 7000)OF DIVISION 9 OF THE BUSINESS AND PROFESSIONS CA E,AND Z
MY LICEHSE IS IN FULL FORCE AND EFFECT.
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[� �� 1 WORKERS'COMPENSATION DECLARATION Q
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N1 MEREBY AFFIRM UNDER PENALTY OF PERIURY ONE OF THE FOLLOWING DECU . Z
� _I HAVE AND WILL MAINTAIN A CERTIFICA7E OF CONSENTTO SELF-INSURE FOR WORKERS' S
COMPENSATION,AS PROVIDED BV SECTION 37000F THE LABOR CODE,FOfl THE PERFOFMANCE `U
OF THE WORK FOR NMICH THIS VERMIT IS ISSUED. �
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W _I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION
Q 37000F THE LABOH OOOE,FOR THE PERFORMMICE OF THE WORK FOR WHICH THIS PENMIT IS
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0 (fHSSECfqNNE�NOT8E001.�LE'fIDOFhEPERMTLSinRONEVAA�bFiEDDOLLkiS(5100)ORLESS} PLUMBING o
Z 1 CERTIFV THAT IN hiE PERFORMMlCE OF hiE WOi1K FOR WHICH IS RMIT IS ISSUED,I MECHANICAL
(,'} SHALL NOT EMPLOY ANY PERSON IN ANY MANNER 50 AS 70 E ECT TO THE
� �WORKERS'COMPENSATION UWS OF CALIFORNIA,AND AG AT SHOULD BECOME INSPECTION FEE
(� SU&IECT TO THE WORKERS'COMPENSATION PROVISIO 5 CT 370a OF THE LABOFi ""^"^��'tT,y'.�.�—.-_
OV CADE.I SH FORTHWITH COMPLY WITH THOSE P ISSUANCE �� �� �� ��� �'�� _
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DATE:"V APPLICANT: SMIP
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� �� ENERGYP/C ���j� fi � �nn� I
WA O: E TO SEC FE WORKERS'CAMPENSA710N CO R WFUL,AND SHALL BE �
� SUBJECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFIN OONEHUNDREDTHOUSAND ENERGYPERMIT
DOLLARS(i1o0,000),IN/�DDI710N 70 THE COST OF CAMPENSA710N,DAMAGES AS PROVIDED FOR IN /�
¢ SECTION 370E OF THE LABOH CODE,INTEREST,AND ATTORNEY'S FEES. � RE7ENTION FEE: � ! ' +
a CONSTRUCTION LENDING AGENCY Iy��l. �
PRE-ALT FEE: i
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� I HEREBV AFFIRM UNDER PENAL7Y OF PERIURV THAT THERE IS A CONSTRUCTION LENDINO AGENCY
fOH THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.30v7,CIV.C.). .
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� LENDER'S NAME '
F_ LENDER'SADDRESS
W I CERTIFV THAT I HAVE READ TMIS APPLICATION AND STATE THAT 7HE ABOVE INFORMATqN IS COHRECL TOTAL FE ES - � � J'�
� I AGREE TO CAMPLV N7TH ALL CfTY M1D COUNTV ORDINANCES AND STA7E UWS REUTING TO BUILDING .
� CANS7RUCTION,AND HEREBV AUT}IORIZE REPRESENTATIVES OF THIS CAUNTY TO ENTER UPON 7HE
Z ABOVE-MENTIONED PROPER7V FOR INSPECTION PURPOSES. COMMENTS
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¢ PERMITTEE NAME(PRINT) � /Z �� � � . � . . � .
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� SIGNATURE OF PEPMITfEE DATE U,
= RECPT.NO. PAID BY VALIDATION
~ WHITE—Department Copy,YELLOW�inence Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant' Copy
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TEMP POWER I FIREPL•ACE'BOND BEAM �
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