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HomeMy WebLinkAbout15276 (658) 1,,�, l CITY OF DIAMOND BAR � '" DEPARTMENT OF COMMUNTTY&DEVELOPMENT SERVICES W 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS "��' BUII.DING PEIltMIT APPLICATION FIRMLY o� JOBSITE -7 M �. PERMIT � �� P/C ADDRESS�/ ��/ �jf��I��I 7IZl�/A6� DATE CATiO . NUMBER # � APN LO ` TRACT D TEE ��(�' TMPE OCC p OWNER �i CONST. GROUP � p ADDR� ZONING SETBACKS �W CITY Z E I, - FRONT _ RW ;1 APPLI ANT TEL. SIDE/SIDE STREET R�n/ � � CONTRA�T SIDE � ADDR SS g ��N ZI • � TEL PAOPOSED USE,____ � ARCH! G/ -- � DESIGN R �'�� ADDR SS NO.DWEL. NO. NO. � C�N Z�P E� UNITS _ STORIES BEDRODMS �n �•. � � DESCRIPTION SQ.FT. FqCTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADD/REM Q I HERE6Y AFFlRM UNOER PENPLiY OF PERNqY?XqT I AM EXEMPT FROM THE CONTMCTORS LI- G8f89B/C�OR � � CENSEUWFOHhIEFOLLOWINGREA50N�SEC.7031.58USINE55ANDVFCFE5510�SCODE:ANVCRYOR (n COUNTVNMICHqEOUIflESAPERMRTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIPANYSiflUG � patio/Deck NRE.7RIOR TO ITS ISSUANCE.ILLSO REOUIRES THE APPLICAIrT FOR SUCH PERMIT TO FILE A SIGNED � STATEMEN?THAT HE OR SHE IS UCENSED PURSUANT?O TIiE PROYISIONS OF THE CONTRACTORS LI� CENSE UW(CNAPTER 9�COMMENCINp WITH SECTION 700�)OC DIVISION 3 OF THE 8l1SINE5SAND PRO� LL Poo�Spa FESSqNS CODEy OR THAT HE Oq SHE IS E%EASPT NEAEFqOM,AND THE BA515 FOR THE ALLEGED E%EMP� TION.MIYVqLATIONOF5ECT10N7031.56YANY�APPL�CAYTFOqAPEqMIT5U8JECTSTHERoPLICANT70 ZI qe_po�f �" ACML PENALTY OF rypT MORE iHAN FIVE NUNDRED DO��ARS(t5oo).): � CI,ASOWNEROfTHEPROPERTY,ORMYEMPLOYEE5W17HWAGE5A57HEIFiSOLECOMPF.NSATION. �• Cr �mR;gfC�81 VALI p0 THE WORK,AND lHE STRUCTURE IS NOT INTENDED OR DFFERFO FOR SALC:(SEC.�oa4,BU51� J ��� NESS UJO PqoFE5510NS CODE:THF CONTRAC70R5 LICENSE UW DOES NOT APPLV TO AN OWNER OF � PROPERTYNM1IOBULLD50RIMPqOVESTNEFEON,ANDYMO00E5SUCHWORNHINSE:FORHERSELFOR W 7HRIXIOHHISORHERONMEMPLOYEES,PAOVIDEOTHATSUCHIMPROVE�.IEN?SAqENO7MTENDEDOR N Q OFFEREDFORSKEIF,HOWEVERTMEBUIIDINGOlilA/PROVEMENT15S0',DWIhiINOhEVE4ROFCOMPLE- Z 71ON,7HE OWNEFI-BUILDER WILL HAYE TNE BUHOEN OF PROVING TNAT HE OR SHE DIO NOT BUIID OR — 7 IMPROVE FOq THE PURPOSE OF SRLE). �y,� CCAEOWNEqOFTHEPROPEAT'/,AMEXCLUSIVEI.YCONTRACfINGM'ITHL%:FNSED.^,OIJTRqGTOq3 � TO fANSTRI;CT THE PRQIECT(SfC.70/4,BUSINESS 0.N0 PROFESSIONS CADE:TNE CONTRACTORS LI� V21U8IIOf1 _,ADJ.AREA W CENSEIAWDOESNOTAPPLYTOANOWNFROFAPROPERTVWHOBUILOSORIMPROVESTNERfON,AN� - ----- -- WHO CONTRACTS FOR SUCH PqOJEC7s NF7HA CANii7ACTOfi(5�LICENSEC PUFSUANTTO THECONTRAG � QUANTITY DE CHIPTION � TORS UCENSE LAW.). �� FEE �]IRMEJ(EMPTUNOERSEC._ �.&P.C.FOQTHISREASON Q � � '--- U � DATE OWNEFl_ �' " {S- - Z --_"_-'_.'_ � Qs[ UCENSED CONTRACTORS DECLARATIOY W ¢ IHEflEBYAFFIRtAUNDERPENAL7YOFPEiiJUftY?Hh�IAMLtCENSE�UNDES7r70VISiONSOFChAPTEF � B(COIAMENCINOW:THSECTION�000�OFDNISION3OFTHEBUS�YESSAMDPROFESSICNSCODE,AND �I 1C MY IICENSE IS IN FULL FCaCEaND EFFEGT. z�"---' LL! m � UCENSE CIASS_ LIC.NO, � O � � � � J DATE '�_ CONTRACTO W I ✓ ' � WORKERS'COMPENSATION DECLARATION ¢ � 1 HEiiEB�AFFIP.IF UNOER PENAL?"V OF PERI:!RY ONE OF7H'c FOLLOW:NG DECLARATIOYS: V � Z � __IMAYEANDWILIMAMT0.1kACEFTIFICATECFO]NSFNi?�SELF-WSURcFOFN'CRKERS' ¢ -__ S Q CAMPENSAT'.ON,AS PROVID[�6Y SECTIDN 370a GF?HE LAHOR CO:lE,FOR THE PERFOPoNANCE U O OF TNE WORK FCR WHIC4 THIS PEHMIT IS ISSUED. � � __7 HAVE AND iMLL MAINTAIN N10RKER5'CCMPENSATION INSURAACE,AS REQU�RED BY SECTION Q 9700 0F�HE iA40A C.�E,FOR THE PERFOAMM'CF OF THE WORK FpR WHIC4 TH!S PERMIT IS � ISSVED.A!Y WORKERS'C��,MP�N T ON iM�F�fiANC[C RR1ERlWD PoiICY YUMBER ARE: CONSTRUCTION �______ ____ y j G>HWER._� �� -• ,�--�— PLAN REVIEW ----- — - ! � POLICVNUM6ER !F ��-a`�� ELECTRIC _____ 0 (IH65ECIK1NNc�N076EtCMPLEfi:JOF1}EfMFhSfSF'ORpJEF,u�D;iED�LLPAS(Siao)09L�"..SSj. PLUMBING ______ W - Z ICERTIFYTHATINTHEP[R�ORN�ANCEOFTNEWORKfO�WN!CHTf+ISPFflM1T!SISSUED.I MECHANICAL C,� SWLLL NO7 EMPLCV AW PERSON i!:aNY NANNER SOAS TO BECOMe SU�iJECT TO TH[ ! INSPECTION FEE ` � WORKESIS'COMPENSATIONLAWSOFCALIFORNI4,AHOAGHEETNATIFISHOUlOBECOME � SU&IECTTO THE WORKERS'COMPENSATION P�OVISIOUS OF SECTION 97000F THE LAROFl � � � CA�E.I SHALL FORTHWITiCOM7LY WITH TFpSE vqOV15�ONS. ISSUANCE � � p �ATc:__�APPLICANT ___.___ _'____ SMIP _ �-�_' L Jw � ENERGY P/C _,��'7'�{',r�,� � WARNING:FqILURE TD SECURE WOflKERS'COMP�NSATIDN COVERAGE IS UN:AWFUL,AND SHALL BE �y, SUBJECTAN EMPIOYF.R TO CRIMINA�PENALTIES nND CIVIL FlNES UP TOONE HUNDRED THOUSANO ENERGY PERMlT Bi��� � DOLLARS�f100.000,IN ADDITION TO THE CO57 OF COMPEhSA710N,DAMAGLS AS PROVIDE7 FOR IN SECTION 370B OF TiE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. RETENTION FEE: ` OCONS7RUCTION LENDING AGENCY PRE-AlT FEE: �___ _ � IHEREBYAFFIRMUNDERP'eNALTYOFPFP.JURVTHATTMEREISAGON5TRl1CTIONLENOINGAGLNCV � a- FORTHEPENWRMANCEOFTHEWOFKFORWHICMTMISPERMITISISSUEC(SEC.9oB'I,C:v�,�. `----'—"----- - Z W —_ . � IENDEA'S NAME '_-__'-- �__-_"_—_'_'__� , __�___ " .. _. . 1- LENOER'SAODRESS � � —'_' _ _._-"_ �, . ¢ 1 CERTIFY 7NAi I NAYE fieAD TNIS APP'.ICATION AN�STATe THAT THE ABOVE INFORMPTpN IS GqRRECT. TOTAL FE ES W IAGREE TO COMPLV WIiN ALLCITY AND CAI:NTY ORDINqNCES ANO STA;E IAWS RELATING TO BUP.DING a. � CONSTRUCTION,AKDHEqEBVAVTHOR2EREPRESENTATNE50FTHISCOUNTYTOEMERUPONTHE OABO -�IONE�PHOPER{:ORINSPE(:TIONVURPOSES �� COMMENTS_ __ � m P MITTEE 1iAME(R1N � 'Q � — cn ' y S AT P �1 E 'OATE F ! 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