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HomeMy WebLinkAbout17218 (670) f-- � -- CITY OF DIAMOND BAR (�.� -���r�j DF.PAR'TMENT OF COMMUNITY&DEVELOPMENT SERVICES �! °1�`�� 21825 E.Copley Drive PRESS "�� (909)860-3195 Faat(909)861-3117 �`'%����� BUILDING PERMIT APPLICATION FIRMLY } JOBSITE � APPLICATION PERMIT P/C o AD�RESS � . TJ' I ��`� DATE �� � � NUMBER�� # � � ISSUE TYPE APN LQT TRACT DATE CONST. GROUP p OWNER �J K-� p ADDRESS " l� ZONING SETBACKS z CITY ZIP TEL. FRONT RW ❑ � APPLICANT �� ' t_ TEL. REAR ❑ Z SIDE/SIDE STREET RW ❑ � CONTRACTO r ' � ''� SIDE ❑ ADDRE,� �° o CITY ZIP �' TEL. PROPOSED USE � rv -�c1 7.i ,` _< w ARCH/ENG/ _ z DESIGNER � F p w NO.DWEL. NO. NO. � ADDRESS UNITS STORIES I r� BEDROOMS = CITY ZIP TEL. � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADD/REM O p I HEREBY AFFIRM UNDER PENALIY OF PERJURV THAT I AM EX'cMPT FROM hiE CONTRACTORS LI� G3f8CfE/CBIPOrI W CENSELAWFORTHEFOLLOWINGREASON(SEC.'/037.58USINESSANOPROFESSIONSCO�E:ANYCITYOR (n U COUNTYWHICHRWUIRESAPERMITTOCDNSTRUCT,ALTEP,IMPROVE,DEMOLISH,ORREPAIRANVS7RUC� w TURE,PRIOR TO ITS ISSUANCE,AlSO REQUIRES THE APPI.ICANT FOR SUCH PERMI7 TO FILE A SIGNEO W PBtio/DeCk STATEMENT THAT HE OR SHE IS LICENSEO PURSUANT TO THE PROVISIONS OF THE CONTRAC70R5 LI� � CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION�oaoJ OF DIVISION 3 OF THE BUSINESS AND PRO� � POOUSpB 0 FESSIONSCODE)OR7HATHEORSHEISEXEIAPTTHEREfFOMANDTHEBASISFORTHEALLEGEDE%EMP- (� ' U TION.ANVVIOLATIONOFSECTION7o31.iB�ANVAPPLICANTFORAPERMITSU&IECTSTHE0.PPLICANTTO Z Re-Roof ,. �I"D�� ACIVIL PENqLTV OF NOT MORETHAN FIVE HUNDRED�OLLARS�SSaO).)�. ❑I,ASOWNEFOFTHE PROPERTV,ORMV EMPIOYEES WITH WAGESASTHEIR SOLE COMPENSATION, Z WILI DO THE WOflK,AND THE STPUCTURE IS NOT INTENOED OR OFFERED FOF SALE(SEC,7D44,BVSI� � Commercial � NE55 AND PROFESSIONS CODE:THE CONTRAGTORS LIGENSE LAW DOES NOT APPLY TO AN OWNER OF � PROPERTY YJHO BUIIDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK NIMSELF OR HEflSELF OR CC THROUGHHI50RHEROWNEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTENOEDOR m Q OFFEREDFORSALEIF,HOWEVER,THEBUIL�INGORIMPROVEMENTISSOLDWITHINONEVEAROFCOMPLE� � TION,THE OYlNER-BUILDEP WILL HAVE THE BUPDEN OF PROVING TMAT HE OR SHE�ID NOT BUILD OR � IMPfiOVEFORTHEPl1RPOSEOFSALE�. ❑I,AS OWNEfl Of THE PROPERiV,AM E%C W SIVELY CONTRACTING W ITH LICENSED CONTRACTDRS Q TO CANSTRUCT THE PR0.IECT(SEC.�044,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- VeI118tI0f1 . � ADJ.AREA W CENSEVIW�OESNOTAPPLYTOANOWNEROFAPROPERTVWHOBUIIDSOFlIMPROVESTHEREON,ANO � WHOCONTRACTSFORSUCHPROJECTSWITHqCONTRACTOR(5)LICENSEDPURSUANTTO7HECONTRAG QUANTITY DESCRIPTION FEE Y TORS UCENSELAW.). �� ❑I AM E%EMPT UNDER SEC. 6.S P.C.FOR THIS REASON � U ti � DATE OWNER F- � w � LICENSED CONTRACTORS DECLARATION W Q � IHEREBVAFFIflMUNDERPENA�TYOFPERJURYTHATIAM'.ICENSEDUN�ERPROVISIONSOFCHAPTER � � 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 0F THE BUSINESSAND PROFESSIONS COOE,AND Z X MY LICENSE IS IN FULL FORCE AND EFFECT. f �/,/� � IICENSE C SS '� � LIC.NO. ��.J�/��� • j ~ DATE_ ��=�„__ CONTRACTOR y 'IP . � .f� � U a w � WORKERS'COMPENSATION DECLARATION � Q NIHEREBYAFFIRMUNDEFPENA_TYOFPERJURYONEOF7HEFOLLOWINGIJECUIRATIONS; Z Z _I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF�INSURE FOR WORKERS' _ Q COMPENSATION,ASPROVIDEDBVSECTION�70oOFTHELABORCO�E,FOqTHEPERFORMANCE U Q O�THE WORK FOR WHICH THIS PERMIT IS ISSUED. � W _IHAVEANDWILLMAINTAINWORKEFS'COMPENSRTIONINSURANCE,ASREQUIREDBVSECTION p� Q 3700 OF THE LABOR CODE.FOR THE aERF RMANCE OF THE WORN FOR WHICH THIS PEHMIT IS ��.�y�� y ISSIIED.MYWORI E 'COMP NSATION Uq,A/NCECAFJRIERANDPOLICYNUMBERARE: CONSTRUCTION �v � CARRIER � ^ /,y�� � PLAN REVIEW ZPOLICYNl1MBER ! �'� •�� �/ � �� ELECTRIC Q 0 (1HISSECiIONNEmNOTBEQJMREfEDOF1HEPEWv4TI5FORONEHIRJDREDD�LI.ARS�b700)ORLE55). PLUMBING Z I CERTIFYTHAT IN THE PERFORMANCE OF THE VJORK FOR WHICH THIS PERAIIT IS ISSUED,I MECHANICAL C} SHALLNOTENFLOVANVFERSONINANYMANNER50ASTOBECOMESUBJECTTOTHE y WORKERS'COMPENSA710NLAWSOFCAUFORNIA,ANOAGREETHATIFISHOVL�BECOME INSPECTIONFEE � SUBJECTTOTHEWOFKERS'COMPENSATIO�PROVISIONSOFSECTION3]OOOFTHELABOR .�� � � COOE,I SHALL FORTHWITH COMPLY WITH' SE PROVISIONS, �A ISSUANCE �.-�— P" y,�'�'�G�J � �,,►� p DATE�_� APPLICANT: �rl:� '�'I ������ 7v'� ' I SMIP _ i /V J WARNING�FAILURETO SECURE WORKERS'COIAPENSATION COVERAGE IS UNLAWFUL,ANO SHALL BE ENERGY P/C � SUBJECTAN EMPLOYERTO CRIMINAL PENALTIES AND CIVIL FINES UP 700NE HUNDREDTHOUSAND ENERGY PERMIT DOLL4RS(E100,000),IN A�DITION TO THE COST OF COMPEN SATION,DAMAGES AS PROVI�ED FOR IN � SECTION31oeOFTHELABORCOOE,WTERESTANDATTORNEY'SFEES RETENTIONFEE: OCONSTRUCTION LENDiNG AGENCY PRE-ALT FEE: � IHEREBVAFFIRMUNDERPENALTVOFPERJURYTHATTHEREISACONSTRUCTiONLENDINGAGENCY a- FOR THE PEPFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED�SEC.30B7,CIV.C.�. Z W � LENOER'S NAME � LENDER'SADDRE55 W ICE4iTIFVTHATIHAVEREADTHISAPPLICATIONAN75TATETHATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES �2�-�,�,J � I AGREE TO COUPLY WITH ALL CITV AND COUNTY ORDINANCES AND STATE L4WS RELATING TO BUIL�ING � CONSTRUCTION,ANDHEREBVAUTHORI2EREPRESENTATNESOFTHISCOUNTYTOENTERUPONTHE Z A80VE N710NED PROPERTY FO IN PECTION uaaosEs. COMMENTS � ���� ��' ---���- _ - -- m PER E NAME PINT) � � - �G� � SIG A R OFPE ITTEE OATE = RECPT.�'O. PAID BY VALI�ATION ~ WHITE—Department Copy,YELLOW—Finance Copy.PINK—Assessor CoDY.GOLDENROD—File Copy.GREEN—Applican's Copy . , : „.: � , , . ,. �,.. . � . . , . , .. , , r�:,,�,�,.... �.�"�bbv»3.;'�CS: >.�.Ar:t:�*Ptii+„'SuirA'r,d �•'°'-'�!,;t�y+a aa���,�y�:0"',�2' a�.;:..:.� .� . ...,.:i: ,�.... ;y,y.,. ... .. ,�..,� . :..�b�:��� . , :':rs . 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