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HomeMy WebLinkAbout14245 (859) , , v�.� � CITY OF DIAMOND BAR � • DEPARTMENT OF COMMUNITY�DEVELOPMENT SERVICES W zi�o E.coPi�y nr;�e s�c�i90 PRESS 4����� (9UII.DING PERMTT APPLICATION ,'� FIRMLY � JOBSITE APPLICATION _ ERMIT �2 P/ � o ADDRESS � � � DATE UMBE # 5 ISSUE TYPE ` �_`, 1 O C • � D �OOL T TRACT DATE CONST. v � GROUP °C OWNER � ADDRESS ' V ZONING SEfBACKS ' Z CITY ' ZIP / TEL. R�R RW O g APPLICANT TEL. SIDE/SIQE STREET RW ❑ � � CONTRACT R .. SIDE ❑ ADDRESS � PROPOSED USE � CITY ZIP 4l� TEL D � � ARCH/ENG/ � _ . � DESIGNER � r NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP��� TEL(j cn � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� � �OWNER-BUILDER DECLARATION SFR/ADD/REM O I HEREBV AFFlRM UImER PENALTY OF PERNfiV THAT.I AM E%EMPT FROM THE CONTRACTORS LF G8ffl9B/COfPOR CEHSEIAWFORTHEFOILOWMOREI4SON(SEC.7031.6BUSINESSANDPROFESSIONSCODE:ANYq7VOR ' (f� COUNT`/NRIICHREaIARESAPERMR7000NS7RUCT,AL7ER�PROVE,DEMOLISH,ORREPAIRMIYSTRUC- W PfitlO/DBCk lURE,PRIOR TO 1T9 19SUANCE.ALSO REW IRES 7HE APPLICANT FOR SUq1 PERMIT TO FlLE A�SIONED w � STATEMEHT THAT HE OR SHE IS LJCENSED�URSUAHT TO THE FROVISIONS OF THE CON7RACTORS L4 � T� CEHSE UW(CHAPTER Y(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINE55 AND PRO� POOVSpB _ � FESSION9CODE�ORrHATHEORSHEISEXEMPTTMEREFFi0A1/VlD7HEBASISFORTHEALLE�EDE%EMP- (� TqN.AHYV10lAT10NOF5ECT10N7031.6BVANYAVPLICMlTFORAPERMITSU&IECTSTHEMPLICANTTO Z Re-Root � A GVfL PENALTY OF NOT MORE h1AN FNE HUNDRED DOLURS(f600).): - , O ❑4��WNEROFhIEPqOPERTY,OR1AVEAIVLOVEESWI7HWAGESASTHEIRSOLECOMPEN5A710N, � �mmerclal- � – � Z WILL DO iHE WORIC,AND THE STRUCTURE IS NO7INTENDED OR OFFEREO FOR SALE(SEC.70M,BUSI� J N NE93 AI�PROFESSION9 COOE:THE CONTRACTORS LICENSE LAW DOES NOT APPIV TO AN OWNER OF j PROPEHfY NTiO BU0.D5 OR IMPROVES 7HEfiEON,AND NM110 DOES SUCH WORK HIMSELF Oq HERSELF OR Q 7HROUGH MIS OR HER OWN EMPLOVEES,PHOVIDED iHAT SUd7 UAPROVEMENTS AAE NOT INTENDED OR � ' Q OFFBimFORSALEIF.F10riEVER�BUlDP1�ORWPROVEAIENTI550lDWfTMNONEVEAROFCOMPLE- 'TION,iHE OWNER�BUILDER N7LL HAVE THE BURDEN OF PROVINO THAT HE OR SHE OID NOT BUIID OR � � IMPROVE FOR THE PURPOSE OF SALE). . . � �. ❑1,A40WNER OF TME PROPERTY,AM IXCLUSNELV CONTMCTINO WfTM LICENSED CONTMC70R9 � TO CONSTRUCT THE PROUECT(SEC.�Oa1,BUSINE93 AND PROFESSIONS CODE THE CONTMCTORS LJ- , VBIU92 ADJ.AREA W CENSE LAW DOES NOTMPLY TO AN OWNER OFA PROPERTV NR10 BUILDS OR PIPROVES THEREON,AND � WFqOOHTMCT5FOR8Uq1PROJECT5W17HAC0!lfRACTOq�S)LICENSEDPURSUAHT70THEC0lfiRAG � QUANTITY •DESCFlIPTION �E . � TORS UCENSE UW.). �.� J ❑I AM DfOAVT UIIDER SEC. B.8 P.C.FOR TMIS REASON Q 3 ^ �` . ' c' LL DATE • OWNER � � • w ' LICENSED CONTRACTORS DECLARATION � –� � . w I HEqEBY AFFlRM UNDER PENALiY OF PERIURV 7HAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTEP � � Y(COAIMENCWO WITH SECTION 7000)OF OMSION 7 OF THE BUSINE�MlD PROFESSIONS CODE,AND Z - � W LICENSE IS W FULL FORC AND EFFECT. m � UCENSE LASS � LIC.NO. j ^V U DATE ' CONTRACTOR , liJ , . _ 7 , y , � WORKERS'COMPENSATION OECLARATION ��`,I U N I HEREBV,AFFlRM UNDER PENALTY OF PERIURV ONE OF 7HE FOLLOW WO DECURAT�S: , r Z "�.I ,- / �, r�_� , � `_I HAVE ANO WILL'MAINTAN A CEF�IFlCATE OF CONSENT TO SELF-INSURE FOR Nqql(ERS' , _ � COMPENSATION,AS PROVIDED BV SECTION 370o OF TIE 1/�80R CODE.FOR TNE PERFORMANCE U OF TME WORK FOR NM1iN]I TMIS PERMIT I$ISSUED. ' ' W Q . � _I HAVE AND WILL MNMAU!WORKERS'COMPENSATION INSUFANCE.AS REOUIRED BY SECTION , O 37o00F T11E LABOR COOE,f-0R TNE VERFORMMlCE OF THE WORK WH WHICH THIS PERMR IS •Gt"� ISSUED.MY WORKERS'OOM^PEHSATqN INSURMICE CARRIEH AND POLICY NUMBER ARE: CONSTRUCTION a{S > , � cn�+aER � f`" PLAN REVIEW . O � � POLICV NUMBER � � ELECTRIC � p (fF#sSEcna�rE�rloieEoonplE7�oFn#PEaMrisFaaorEFilJrDii�oaleAs(f+aoloalEss�. PLUMBING •�Q � W ' Z I CERTIFY TUT W T1E PERFORMANCE OF THE WORK FOR WMIC/l THIS PERMIT IS ISSUED,I MECHANICAL / ���-�� � .C3 . SM/�LLNOT EMPLOY/VIY PERSON IN ANV A/ANNER SOAS TO BECOME SUBJECTTOTHE � �� (p WOPo(ERS COMPENSA7qN�UWS OF CACIFORNIA,AND AOREE TMAT IF I SHOUID BECOME INSPECTION FEE ' S SUBJEC7 TO THE M/ORKERS'COMPENSATION PROVISIONS OF SECTqN 7700 OF THE L/�BOH CADE,1 SHALL FORT/WITH COMPLV WI7H THOSE PiiON510NS. ISSUANCE 2 UO � � - � SMIP � L p DATE: APPLICANT. " W ENERGY P/C � WARNINO:FAILURE TO SECURE MfORKEFS'COMPENSATION CAVERAOE IS UNLAWFUL,MID SHALI.BE , , � SUBJECT AN EMPLOVER TO CRIMINAL PENALTIES AND,CML FINES UP,TO ONE HUNDRED THOUSAND �'•'f.. • /y � ' ' D�LLARS(ilo0,o00),IN/�ODI710N TO h1E COST OF COMPENSATION,DMUOES AS PHOVIDED FOR IN ENEF,flGY PERMIT . � ��� 'SECTION 370E OF 7HE UBOR CODE,MTEREST,AND ATTORNEY'S FEES. � ' RETENTION FEE: OCONSTAUCTION LENDING AGENCY PRE-ALT FEE: � I HER�Y AFFIRM UNDER PENALTV OF PERIURY THAT THERE IS A CONSTRUCTION LENDWO AGENCV � Z FOR THE PERFORMANCE OF hiE WORK WR WHICH THIS VERMIT IS ISSUED(SEC,30G7,GV.C.). L ` ��`r � ^ W . • ' . ' � �F tA � LENDER'S NAME �' •� / H LENDER'SADDRESS w I AOREE TOHCOMPI.V WITH A�L C1fTV AND CWNTY OPDIN/WCES AND ST�E UWS RELATNJ(i ITOBUILD NO T�(�j/�'T /E� S /�r �19a. VJ� 1 . . •M���V� I � / � CONS7RUC710N,AND HEREBV AUTFIORI2E REPRESENTATNES OF THIS COUNTV 70 ENTER UPON THE .,�' w ` Z ABOVE�MENTIONED VROPERTY FOR INSPECTION WRPOSES. 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