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HomeMy WebLinkAbout16147 (1116) _ � CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY 6c DEVELOPMENT SERVICES . �; 21660 E.Coplcy Orive Suitc 190 (909)860-3195 Fax(904)$61-3117 PRESS �� ��^���� BUQ.DING PERMIT APPLICATION FIRMLY �o ADDR'ESS �� V • /��' I � Q � DATECAFION � ��(�_1�NUM6 R ' 11� � ISSUE v v TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER �,A�LI�iA'itJ� ADDRESS ZONING SETBACKS � CITY ZIP TE � FRONT RW ❑ APPUCANT TEL. REAR ❑ � SI�FJSIDE STREET RW ❑ CONTRACTOR OL L't � SI�E O g ADDRESS �ROPOSED USE ���7� �M � 8 D S GNER �IP TEL. �Z NO.DWEL. �� � . � ' O. � � ADDRESS UNITS STORIES K BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUAT70N � Q OWNER-BUILDER DECLARATION SFRIADDIREM O p 1 FIEREBY AFFlFWI UNDER PENRLN OF PEILNRY THAT 1 NA EXEMPT FAOM THE CONTRACTORS Lt• G8f8QB/C8ry0R GJ CENSEIAWiORiNEFOLLOWiNCiREASUN(9EG7W7.66USINESS�NDPROFESSIONSCOOE:ANYCITIDR (n CJ COIM�YNMICfIREOIARESAGENMfTTOCONSTRUCiALTER,0.1PflOVE,UEMOL.ISM.�RREPAIRANY6TRUG IW patio/Deck � 7UNE,MION M RS 6SUMICE,I1L.S0 REW IRES THE APVLN'.MIf FOR SUpi PERMIT 70 FILE A SIONED iTATEMENT iHAT NE OR 8HE i5 IICEN5E0 PURSUANT TO 1HE PROVISIONS OF THE CONTRACTORS lF S CENSEUW([]iMTERY(COAIMENCIN(iWITMSECTIDN70U0)OFDIVISION9OFTHEBUSINESSANDPRO• � P��Pe � FESSqN6CO0E)ORhIATHEOR6HEISE%bAPTT1EREFROMANOTNEBASISFOfI7HEALLE0E�E7�MP• (7 ls iqN.ANVV10lATIONOF8ECT10N7081.6BV/�M'MPLICANTFORAPERMITSUBJECTSTHEAPPUCANTTO Z Re-Rool � A qVIL►ENALTY OF NOT MOqE TNp FNE FA/NDRED DOlLMS(t6o0�.r OI./uOWNEROFTHEPROPEAiY.ORMYEMPLOYEE9WITHWAQE5A9i11E1RSOlECOMPENSATION, � COR1RIBfC18I WILL DO TME MADRK,ANO THE STRUCTURE IS NOT MlTEfi�ED OR OFFEREO FOR BALE(SEC.70a/,BUSI• J NESS MA VNOFESSIONS OWE:TNE CONTIUCTORS LICEN9E lAri UOES NOT APPLY TO AN OWNER OF y CROPERTYYYFpBU0.0SORNAPROVESTNEREON,NI�WNODOESSUCHWOHKMIlASELFORHERSELFOR = � 7XROIJGIiMSdiNEROWNEMPLOYEE8.PH011DE�THAT5Uqi1MPRDVEMENTSAREND7INTENDE00R m OFFERED�OR 311LE IF,f10MfFVER TMEBUIlDINfiOR IMPROVEMEM IS SOLO YlITMN ONEYEIIROFCOMPIE- TION,T£OWNERSULDER MIILL/UVE iHE BURDEN OF PROVINO THAT XE OR SNE 00 NOT BUND QR WPNOYEFORTHEPUNPOSEOFSA:.EF O LA3 ONR�ER DF T1E PROPERIY.M1 E%CLUSNELY CONTRACTINO WIfH LICFNSED CONTRACTOqS r��,�.� � TO CONSTtiUCT T/IE PHO.IECt(SEC.7Wl,BUSINESS AND YROFESSION9 COOE.THE CON7RACTORS LI- 48N91IOfl �Y V ADJ.AREA CENSE UW DOES NOiMPLY TO JW OMMER Of A VROPEflTY NR7D BUXAS Oq IMVROVES TIEREON,/NO WFiOCONTMCT6FOHSUCNPROJECTSWITHAODNTRACTOR�S)UCEN9EDPURSUANTiDTXEWNTMG QUANT OESCRIPTION FEE � fORSUCEN6EUWJ. . . ❑I AN D(EMPT UJDER SEC. B.�P.C.FOR THIS REASON Q � U �= DATE OWNER r � W � LICENSED CONTRACTORS DEGLARATION –� � w IHEIIEBYAFFIiWINDEHVQJALTYOFVE0.IURYTHATIAMLICENSEUUNDEAPROV1510N50FCHAPTER � s •(CddMENCNOYYITHSECTICW700D)OFO�v1510N90FTHF.BUSINfSSANDPROFESSIONSCODE,ANO Z !G MY�ICENSE IS IN FULL FORCE AN FFECT. � LLl 0 LICENSE dAS LIC.NO. ^ - ��j�����' j � DATE CONTFlAC � 1/(�o�� a WORKERS'COMPENSATION DECIARATION Q � U � INEREBVAFFlRMUHDERPENlLL.TYOFPERIURYONEOF7HEFOLLOWINGDECLMATIDN9: � d � _IHAVEANDM/ILLMMNTAINACERTIFlCATEOFCONSENTTO6ELFdNSUFEFORWORKERS' _ ODAIPENSATqN,AS PROVIDED BY SECTION 37a0 Oi iHE UIBOq COOE.FOR h1E PERFORMMlCE W OF THE YVORY.FOR WHlpl tM15 PEflMIT IS ISSUED. � � _IHAVEANDWILLMA�I.TAWIVORKEHS'CAMPENSA710NINSUMNCE,A9REWIRED9YSEC710N n .�C� Q �7Da OFTHE LABOR CO�E,FMiTNE PERFORMANCE OF THE WORK iOR WHICHP.115 VERMIT IS � t LSSUED.MY WORNE "COMPETSATqN INSUAANCE GRRIEH LICY NUMBER ARE: CONSTRUCTION jGARRIEH_ �G �� PLAN REVIEW _ Z aoucVNUMBER �� ELECTRIC .Q 0 (M59ECroNNE�No7'BE OFnEPFi'MRSibRduEFMDREDDd1Nu1E1m�aRtESS} PLUMBING Z 1 CERTIFV 7HAT NJ TNE PERFORMANCE OF TNE WORK FOH W WCN THIS PERMIT IS ISSUE�,1 MECHANICAL (� SNALL NOi EMPLAY ANY FERSON W ANY 1AJWNEfl 50 AS TO BECOME&UBJECT TO THE � WOR1(ERS'GOMPEN511TqNLAri30PCALIiORNIA�NDAGREETHATIFISFIOULDBECAME INSPECTIONFEE BIIBJECf TO 7NE YK)RKERS'COMPENSI1TqN PROVISIONS OF SECTION 9t0o OF TME UBOR � COOE S FONTNW�TNCOMPLYWITH7F105EVROVI910N5. � ISSUANCE — _ � p pqTE: APRICANT: �� � G�'�–� SMIP ._��r� � ENERGY P/C _ WIIRNINO FAILU TO SECURE WORKERS'COMP[NSATqN CAYERAGE IS UNLAWFUL,AND 91MLL EE �y SUBJECTANEM VERTOCRIMINALPEN/L7IESANDCNIIFINESUPTOONEMUNDREDTMWSAND ENERGVPERMIT DOLLARS IifOD,000).IN ADOITION TO TiE COSTOF COMPENSI1TpN,DAMAGES AS PROVIDE�FOR IN � SECTION 970!OF iHE UBOR CODE.WTEREST,AN�AITORNEYS FEES. RETENTION FEE: � CONSTRUCTION LENDING AGENCY pRE-ALT FEE: � 1 HEREBV AFFIRAI UNDER PENALTY OF iEAJURY TNAi THERE IS A COPtSTRUCTION LENDINO A�ENCY � Z FOR THE VERFORMMlCE OF THE WORN PDR WHICH TMS GERMIT IS ISSUED(SEC.7oY7,CIV.C.). W � IENDEWSNAME � LENDER'SADDRESS � ICERTIFYTHATIWNEREADTH19MPlJGTIONANDSTRTETHATTHEABOVEINFORMAiqNISCORHECT. TOTALFEES 0 • I AGREE TO OOEIPLV WRH ILLL CrtY AND CIXINTY ORDIIUNCES AND STATE lANS REIATMlG TO BU0.DING CONSTRUCTION.AND MEFE6Y AIIf{IORIZE REvqESENTATIYES�F THIS CW NTY TO ENTER UPON 7NE � ABOVE-MENTlON PFIOCERTV FOR INSPECTION PVRVO5�5., �� COMMENTS ' � r�� � � J � m VERMITTEENNAE(PRINT� � �^ 4 tn ' y SIQNANR O HMITfEE OATE � RECPT.NO.' PAID BY VALIDATION WHITE-0apertment Copy.YELLOW--Finence Copy.PINK—Assessor Copy.GOLDENROD—File Gopy,GREEN—ApplicenYs Copy CITY OF DI�'attt�QNlJ E'sAR � �;� � `� �. �r��P��-��a� R�co�� , .. _� , ���.� .-� �.-�,-�..,�..,rA ` .aC�n'R.�� F4 ' � � �.���, rt.�_ �.�,.� M;���' eLL��� �'�^ ���. "��+i <!�€::��� . . . . 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