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HomeMy WebLinkAbout12183 CITY OF DIAMOND BAR —'—� -- -�� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICErS. �. } � 21660 E.Copley Drive Suite 190 � �.- / (909)860-3195 Fax(909)861-3117 PRESS ��9��� BUILDING PERMIT APPLICATION --� FIRMLY � JOBSITE �* , / APPLICATION - `�_-' PERMIT P/C` o ADDRESS L �•f DATE ��" NUMBER # c� ISSUE TYPE OCC APN LQT TR T DATE CONST. GROUP p OWNER f LL ADDR ZONING SETBACKS Z CITY � I TEL ' FRONT RW C g APPLICANT r�IIJ _ TE } � S DE/SIDE STREET RW ❑ � CONTRACTOR � SIDE [. � C17Y IP EL' .PROPOSED USE , V ��C > �S w ARC Gl ����,,, �,'Z - � Z DESIGNSR NO.DW� NO. � h NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT: FACTOR PSF ADJ.AREANALUATION � p� OWNER-BUILDER D�CLARATION SFR/ADD/NEM O Q I HEREBY AFFlRM UNDER PENALTY OF PERIURV THRT 1 AM E%EMPT FROM THE CONTRACTORS LL Garege/CarpoA W CENSELAWfOHTHEFOLLOWIN6REASON(SEC.7o31.5BU5ME55ANDPROFE55lON5CODE:ANVCITYOR (n � COUNTYWHICNNEOUIRESAPERMITTOCONSTflUCT.PLTER.IMPROVE.DEMOLISH,ORflEPAIRANVSTflUG � TUP.E.PRIOR TO ITS ISSUANCE,ILL50 REOUIRES 7HE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w PatiolDeck W STATEMEM THAT HE OR SHE IS LICENSED PURSUANT 70 THE PpOVISIONS OF THE CONTRACTORS LF " �S CENSE UW(CHAFTER 9(COMMENCINO WITH SECTION 7000)OF DIVISION 30F THE BUSINESS AND PHO- LL' Pool/Sp2 7S FESSpNSCODE�OFTHATHEORSHEISE%EMPT7HEREFROMAN07HEBASISFORTHEALLEGEDEXEAIR (� V TWN.ANYVIOUITIONOFSECTION7031.SBYANYAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Rooi � A CINL PENALT/OF NOT MORE iHAN FNE HUNORED DOLLARS(f6Do))� � ❑I,ASONMEROFTHEPROPERTY,ORMVEMGLAYEESWITHWAGESASTHEIRSOLECOMPENSATION, � Commercial WILL 00 7HE WORK,M1D THE STRl1CTURE IS NOT INTENDED OR OFFEfiED FOR SALE(SEC.70aa,BU51- J NES£AND PqOFE551IXJ5 COOE:THE COMTRACTORS LIGENSE LAW DOES NOT APPLY TO AN OWNER OF � PROPENfYWHOBUILDSORIMPROVESTHEREON,AN�WHO00ES5UCHWORKHIMSELFORHERSELFOR = � 7HRIXIOHHISORHEROWNEMPLOYEES.PROVI�EDTHATSUCHIMPROVEMENTSARENOTINTENDEDOH m QOFFEREDFOHSALEIF,FIOWEVERTMEBUIL�INGORIMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE� z TION,THE OWNER-BUILDER N7LL HAVE THE BURDEN GF PROVWG THAT HE OR SHE DID NOT Bl11LD OR � IMPROVE FORTHE PURPOSE OF SALE�. W ❑I,ASOWNEROFTHEPflOPEATY.AME%CLUSIVELYCONTRACTINGWITHLICENSEDCOMRACTORS ¢ TO CONSTRUCT TNE PROJECT�SEC.70M,BUSINE55 AND PROFESSIONS CODE:THE CONTMCTORS LI- VdII182i0f1 _ �, ADJ.AFEA W CEN5ElAWDOESNOTPPPLYTOAfJOWNEROFAPflOPERTYWHOBUILD50RIMPROVESTHEflEON,AND � WFIOCONTMCTSFORSUCHPHQIECTSWITHACANfRACTOR�S�LiCENSEUFURSUANTI'OTMECONTRAG QUANTITY DESCRIPTION FEE � TORS LICENSE L+1W.{. O ❑IAM E%EMM UNDER SEG_ ,B.8 P.C-FOR THIS ReASON U � — � LL DATE OWNEfi____ � 2 W � LICENSED CONTflACTORS DECLARATION W � I HEREBV AFFIRM UNDEF PENILLTY OF PERJURY THAT I.U.I LICENSED UNDEH PROVISIONS OF CHAPTER �. d 9(COMMENCINCi WITH SECTION 70oD)OF DIVISION 3 0F THE BUSINESS AND PROFESSIONS CODE.AND Z X MY LICENSE IS IN FVLI FOR E AND EFFECT. m lll ,"//� � 0 LICENSE LIC.NO. � • � � V OATE CONTWiCTOR 'w d W �vy O a� WORKERS'COMPENSATION DECLARATION ')J�J � NI HEREBY AFFIRM UNOER PENALTY OF GEflJURY ONE OF THE FOLLOWING DECLARATIONS:�,c�a l'�a "'� Q � IiVAVEANDWIIIMAMTAINACERTIFICATEOFO�NSENTTOSELF�IN511REFORVJORK RS' _ � COMPENSATION,AS PROVIDED BV SECTION 37000F THE LABOR CODE,FOR THE PERFORMANCE �U OF THE WDHK FOH WHICH THIS PERMIT IS ISSUED. � � W _I HAVE AND WILL MAINTAIN WORKERS COMPENSATION INSURANCE,AS REQUIRED BY SECTION ' Q 37000FTHELABOR E,FORTHEPERWRMANCEOFTHEWORNFORWHICNTHISPERMITIS . , ISSUED.MY WORK COMP Sp'I�ION INStl�1ANC RRIER AND P LICY NUMBEPAFE� CONSTRUCTION __________ _______________ � CARRIER / � 'J PLAN REVIEW ______ � POLICYNUMBEH , ' �� ELECTRIC ___._______,_ _,________ Q � (il-0SSECiIONNE�NJTBECO�.�LEIEDOF'R.EPEi�AMISFORONEHUWfiEDD01J�1R5�5f00)ORLESS). � PLUMBING ---- W Z I CERTIFY THAT IN THE PEFFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISS:iE'�,1 MECHANICAL _______.__, ___ C,�} SHALL NOi EMPLOY ANY PERSON IN ANY MANNER SO A570 BECOME SUBJECTTO iNE � woRKERs'COMPENSATIONLAWSOFCALIFORNI0.0.NDAGHEE7HAiIFISHOULDBECOME �NSPECTIONFEE ____ � Sl1BJECTTOTHEWORKERS'COMPENSATIONPROVISIONSOFSECTION370 OGIHELABOR i �' CA E, SH L F WITHCDMPLY WIT SE PROVIsw�ys. ISSUANCE - � � � Q' _� Y� SMIP ---- � 1p �ATE: APPLICANT: �- - . � ENERGY P/C _______ J WARNING FAILVRETO SECURE WORKERS'COMGENSATION GOVEAAGE IS UNLAWFUL.Ah SHALL � SUBJECTANENPLOYERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNOFEDTHOUSA ENERGYPERMIT _ DOlURS(f1oo,000),IN ADDITION TO THE COSTOF COAIPENSATION,DAMAGES AS PROVIDED FOR IN --�-�- � SECTION37a80fTiELABORCODE,INTEREST,ANDATTORNEYSFEES. RETENTIONFEE: ______ a CONSTRUCTION LENDING AGENCY PRE-ALT FEE� O � IHEREBYAFflFMUNDERPENALTYOFPERJURYTHATTHEREISACONSTRUCTIONL'cNDINGAGENCY � FOH THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEO(SEC.308�,CIV.CJ. Z W � LENDER'S NAME _ .__ F- LENDEH'SA�DHESS - _.— . — � � � w ICERTIFYIHlQIHAVEREADTHISAPPUCATIONPN�STATETHATTHEABOVEINFORMATIONiSCORFECT. i OTAL FEES � � I AGREE TO CAMPLY WITH ALL CITV AND COUNTY ORDINANCES AND STATE LAWS RELATIN6 TO BUILDING CONSTRUCTKKJ,AND HEREBY AUTFIORIZE REPFESENTATIVES OF THIS COUNTY TO ENTER UPON THE Z ABO �MEHiIONED PROPERN FOR INSPEC?ION PURPOSES COMMENTS _____ _ � �' C.�'T'^C�Ca ' '- — .. . . .. m P Ml EE NAME�PRI � �i � -fiL — ° — - 6•� a �s P 1 / . � SNiNATUREOFPERMITTEE � �A ,ji ,j _ � RECPT.NO. • _PAID BV � VAIJDATION : ~ WHITE-De arlm t Co YELLOW-Finence Co PINK-Assessor Co GOLDENROD�-Fle Co GREEN- licant's C P PY. PY� pY. PY. APP oPY .. .. .,.,. . .�.. .. . . .. . ..... . . . , . , . . :��. , . . ,. . . . . „,�'i<,���.'�; �,�'� X.�ii����a'<'�'ix�6..� �3k'�:�'� i�✓n;:i$'`:i:«.�.,,�'��9�..'�7 �"}���F�'p+�w 3�.< . .....__........ ........... ,.�,-, .......�,��.m - - �� � .. . 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