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HomeMy WebLinkAbout15912 (1111) ... � ._ CITY OF DIAMOND BAR r� - DEPARTMENT OF COMMUNITY dc.DEVELOPMENT SERVICES �� 21660 E.Copley Dri�e Suite 190 (909)860-3195 Fax(909)861-311? PRESS ���''^"�� BUII.DING PERMiT APPLICATION FIRMLY � JOBSITE ,. �j ��^ APPLICATION PERMIT p/C o AODRESS -1 l • DATE �" � NUMHER 'S �� * � APN LOT I TRACT H 7 (� ISSUE 2 ^ ( �O TYpE OCC � OWNER � DATE_ ` CONST. GROUP p ADOAESS ZONING SETBACKS CITYTd��`A�fL� Z�pQdSl�i TEL.��'S1�[�3rf�'D REAR RW O APPLICANT TE�, ❑ SIDE/SIDE STREET RW ❑ CONTRACTOR • C..- I�L [ L. SIDE p ADDRESS � CITY S ZI � Z TEL'L Zb PROPOSED USE � ARCHIENG/ DESiGNER NO.DWEL. NO. NO. ADDRESS UNITS STOFIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFWADO/REM I fffREBY AFF1161 UHDEA PENALTV OF PEIiIl1RV THAT I M/E%EMPT FqOM 7HE CONiqACTORS LI- GBfaaB/GBIpOM CENSEUWFOqhIEWLLOIMNOREA.40N(SEC.70.t1,6BU31NE55ANDPHOFESS10NeCODE:ANYCITYOR (n OOUII�YWMCHR[-0UIRESAPEIWR7000NS7RUCT,ALTER�MPROYE,OEMOLISH,ORREPAIRN/YSTRUG- W P8tlp1DBCk TURE.PRqR TO ITB 189UANCE,AL30 pEWIRE9IHE APPLICINT FOH SUCH►ERNIT 70 FlLE A SIONED W •TATENENT 7HAT HE OR SXE IS IJCENSED PtJRSUAHT TO 7HE PqOYISI0N3 OF TNE CONTMGTORS ll• CENSE tAW(G111PTER Y(COYYENGNO WITH SEC7qN 700D)OF OIVISION 7 OF THE BUSINESS AND PFlO- LL POOUSpB fESS10N5W0EJONTUITMEORSMEIBEXEMPTiHEREFHOMANDTXEBASISiORTXEALLEOEDEXENP� (ry TIDN.NIrVKKATqNOFBECTION7W1.6BYANYAPPLICANTiOR�PERMITSUBIECTBTMEMPLICANTTO z q�q� � A CML►ENALTY OF NOT MORE iNAN FNE HUNDNm�OLLAN31l6aD),I: ❑4�OYJNEROfTHEVROPERTV,OiiIAYEMPtAVEE6WITHWAOE5A3THE1RSOlECOMPEN5A710N, COf�RIB�CI01 WILL DO THE WONt,MO T11E STRUC7URE IS NOT IMENDED OR OFFEHEU FOR SALE(SEC.7a1,Bt151- � y 11E8S AND Pi1OFE8ElON6 COOE THE CONTRACTOfl3 UCEN6E LAW DOES MOTAiPLY TO AN OWqER OF ? ►(WPEpTV Wlq BURD9 OR 6iPROYEB THEREON,AND YYNO ppE$BUGi WORK NINSEIF OR XERSELF OR � TH110UGH/NSORMEROWNENPLOYEES,GROHIOEDTIATSUCIIWFpOYEMEP7r8AHENOTIIJ�N�E�OR m OFFEREO PWtSAIE IF,NOWEVER7ME BUILDINO OR IMVHOVEMEM B Sq,D WITINN ONE YEAROF COIAPLE- TqN,TNE OWNER�UIDER WILL MAVE THE BURDEN OF PROVING THAT YE OR BME�I�NOT BUIID OR YAPROVE Fqi7HE PURPo6E OF BALEI. 0 4 A60WNEROF TME PAOPER'fY,111A EXCLLI9NELV CONTRAC7INO WITH LICQJSED CONTFAMOIi3 � TO CONSTRUCT iHE Ciq1ECT(SEC.704,BUgINE53 IND GpOFESSIONS CODE:THE CaNTRACTOR3 ll- VBIUfl�lIX1 ADJ.AREA CEKSE lAW DOE9 lpTAPPLVTO AN OWNEq OF A PHOPERTYYYYq BUIlDB OH 1►/PROVEB THEREON.AND MM1pOON�NACTeFOR9UCNPRO.lEC76W17HACONfMC1Wi(S)LICENSWPURSUANT70T7ECONiMG pUANTITY DESCRIPTION ions ucpue uw.�. FEE � O I NA EXEMPT UNDER BEC. B.t G.C.fOR THIS REASON � U � DA7E OWNEq � � ��✓ O � � U .. . IICENSED CONTRACTORS DECU4RATION W � 1 HEREBYAFFIRM UMDEH PEN�LTY OF PEMIRY T1AT IAM LICENSEO UNDER PROVISqNS OF CHAPTER � � �(OOEY.IENCMICYlITHSECTqN7o0o)OFDIYISKKISOF7HEBUSINESSANDPROFESSIONSCODE,AND Z � MY LICENSE IS N FULL FORCE MIO EFFEC7. m � UCENSE CtASS G � O LIC.NO. . / ( L �Z� � � oue�2.��d�_catrancroR "�L�3 a = r 'WORKERS'COMPENSATION OECLARATION � � I HEREBYAFFlRM UNDER PENALTY OF OE0.RIRY dJE OF 7HE FOLLOWING OECLAfUTqNS: V y Z � �IHAVEANDWILIMAINTNNACERTIFICATEOF'CONSENTTOSELF-INSUPEFORWORKEflS' COMPEN511710N,As PFlOVIDED BY SEC'f10H JTao OF TME U480R COOE,FOH THE PERFORMIINCE W � pF 7ilE WDRK FOR WHICH MIS VERMIT IS ISSUED. � i/ ��1 NAVE AND WILL MAIMNN WOqKERS'COMPENSATIDN MSURANCE,AS REOUIRED BV SECTION Q 9700 OF THE LABOiI CODE,FOq THE PERFORMANGE OF Tf7E WORK FOR WF71CF1 TT115 PEftMR IS � 159UE�.NY YYDR�K�E.R.y��OyOMP�N`S,ATION INSUHANCE�RIER MIO POLICY NUMBERME: CANSTRUCTION �j CARRIER V •�'�' 1"�� PLAN REVIEW � POIICYNUMBER �Z —GaU �I3�Lf ELECTAIC . "� � � ��lc�'� T w� � T � (nase[crnur+�r+oreemMterEooFnfaEw�r�srz�or����oaur�sg�ao�an�ssl PLUMBING �IAM�I(��t���+[��) ICERTIFVTNATNTHfPERFORNANCEOFTHEWOPoCFORWHICHTHISPERMITI5155UED.l MECHANICAL B����r��{u�7HI•r.11 SNALL NOT EMP�OY ANV PERSON IN M1Y MANNER SO Il5 70 6ECOME SU61EC7 TO Tl1E (q WORKER5 COMPEtdSATION UMf3OF CALIFOpN1A�NO tiGREE THAT IF IBHOULD BECOME INSPECTION FEE SU6IECT TO TNE WORNENS'CdAPENSATION PROVISIONS OF SECTION a700 oF 7HE IABOR s COOE,I BHN1 FORIHWITM CAMPLY WITHhpSE PROVISIONS. {SSUANCE .s � 0 p DATE: 11VPLICANT. SMIP � WARNINO:FARUFlE TO SECURE WORNERS'COMPENSATION COVEHAI3E IS UNLAWFV4�ID SXAL!BE ENERQY WC � SUBJECTANEMPLOVERTOCMAIINALPENALTIESANOCMLFINESUPTOONENUNDREDTFIOU6AIJD ENERGYPERMIT ¢ DOLURS�t10D.000),NI ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIOEO FOR IN SECTION970eOF7HELABORCODE,WTENE3T,NiDATTORNEY'8FEE5. RET�NTIONFEE: 4 CONSTRUCTION LENDINGAGENCY � PRE-ALT FEE: � 1 MEPEBYAFFIRM UNDER PENALTY OF PEfUUHV TLUT THERE IS ACOHSTRUCTION LENDINO AUENCV z FOR THE PER WRMANCE OF TME WOPK PoR WNICH THIS PERMIT IS ISSUEO(SEC.9W7,CI V.C.�. W � LENDER'S NAME �S LENDER51100RE95 �+ ICERTIFVTNA7IHAVEREAOTHISMPLICATIONIWDSThTET1UTTHEABOVEWFORMATqN1900RRECT. TOTAL FEES a ^'� V� � IAOREETOCOMPLYWI7HALLC(fYANOCOUNTVORDIWWCESANDSTATELAWSREUTINOTOBUL�ING � � CONSTRUCTION,AND NEREBY�UT110RiZE REPRESEN7ATIVES Of THIS CIXFI7Y TO ENTEN UPON THE hBOVE•MENTIOIVED PqOPERTY FOH INSPEC7qN PUf�OSE3. COMMENTS � Q 2 S L V' O T`2 � PERMITTEE N (PqINT) � � �p 91�NAlU E ERMITTEE UATE � RECPT.NO. PND BY _VALIDATION WHITE—Depertment Copy,YELLOW--Flnence Copy,PINK—Asaessw Copy,GOLDENqOD—File Gopy,GREEN—AppllCenYe COpy .. CITY G1F D1�4tl1l9f�t�D E3AR � � • I��:���C'i'IdJ'� i�ECC��[� .- . 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