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HomeMy WebLinkAbout15871 ���� CITY OF DIAMOND BAR G;,y`��. ��,/ �, DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � ,� 21660 E.Copley Drive Suite 190 (909)860-3195 Faa(909)861-3117 ���� PRESS �"�' BUII.DING PERMIT APPLICATION FIR Y } __ A � JOBSITE `� PPLICATION PERMIT '`� P!C o ADDRESS ���� �I����?!�! 7��R f� DATE NUMBE��� 6 # � ISSUE p�-jp TYPE OCC APN LOT TRACT DATE � �'�'' CONST. GROUP p OWNER P D o ADDRESS ' p� ZONING SETBACKS �W CITY ZIP ! EL. FRONT RW ❑ APPLIGANT TEL. REAR � � SIDE/SIQE STREET RW ❑ CONTRACTOR `� W SIDE ❑ ¢ ADDRESS o CITY ZIP f TEL. � -- PROPOSE�USE o ARCH/ENG/ z DESIGNER � ADDRESS UNITSWEL S ORIES BEDROOMS � CITY ZIP TEL. � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADDIREM O p I HEREBY AFRRM 11NDER VENALTY OF PERJURV THAT I AM EXEMPT FROM THE CONTqACTORS Lb Gef898/C81P01T W CENSELAWFORTHEFOLLOWINOREASON(SEC.7031.6BUSINESSRNOPROfESS10N5CODE:ANVCITVOR (n �.7 COUNTYNMICHREIXIIRESAPERMITTOCON5TRUCT,µTER,IMPROVE,DEMOUSH.ORREPAIRANYSTRUC- W PdtiO/DBCk Z TURE,PRpR TO ITS ISSUANCE,ALSO PE�UIRES THE APPIICANT FOR SUCH PERMIT TO FILE A SiGNED W � STATEMENT THAT HE OR SHE IS LICENSED PURSUANf TO THE PROYISIONS OF THE CONTRACTpRS ll- � � CENSE UW(CHAPTER B(COMMENCINa W1TH SECTION 7000)OF DIYISION 30F THE BUSINE55 AND PRO- Po01/Spa FESSIONS CODE)OR711ATHE OR SHE IS EXEMP77HEREFROMAND THE BA515 FOR THEALLEGED EXEMP- 710N.ANYVIOI.ATIdJOFSECTION7031.6BYMNAPPUCANTf-0RAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Root � ACIVIL PENALT(OF NOT MORE THAN FIVE HUNDRED OOLUIRS(5500)J: ❑I,A504MEROFhIEPPOPERTV,ORNVEAIPLOYEESWITHWAGESAS7HEIFiSOLECOMPENSATION, 0 CommOfCial g riiLL DO THE WOPoC,ANO THE STRUCTURE IS NOT INTENDED OR OPFERED FOR SALE(SECJ04�,BU51- J � � NESS AND PROFESSIONS COOE:7HE CONfRACTOR5 LICENSE UW DOES NOT APPLV TO AN OWNER OF = PROPERTV N'Fi0 BUILAS OR IMPROVES THEREON,ANO VMO OOES SUCH WORK HIMSELF OR HERSELF OR � 7MROUGHHI90RHEHONMEMPLOYEES.PflOVI0E0THAT3UCHIMFROVEMENTSqRENOTINTENDmpR C� � OFFEREDFORSALEIF,FiOWEVEFLTHEBUIID�NGOqiMPROVEMEMI550LDWITFIINONEYEAROFCOMPLE- Z TION.7HE OWNER�BUILDER WILL HAVE THE BURDEN oF PROVINO THA7 ME oR SHE DID NO7 BUIIA OR � IMVROVEFORMEPURPO5EOFSAL.E�. W ❑I.ASOWNEROFTHEPROPERTY,AME%CLUSIVELYCOMRACTINGWITN(JCENSEDCONTRACTORS Q TO CONSTPUCT THE PRQIECT(SEC.7oN,BUSINESS ANO PHOFESSIONS CODE:THE CONTRACTORS LI- Velu�.fio0 ADJ.AREA W CENSE UW DOES NOTMpLYTOAN ONMER OFA PROPERTV WHO BI11L05 OR IMPROVES THENEON,AND � NM1IOCONTRACTSFORSIICHPROJECTSWITNACONTRACTOR(S)LICENSEDPURSUAMTOTHECONTMP QUANTITY DESCRIPTIDN � masuc�sEUw.�. FEE ^ ❑IAMEXEMMIIN�ERSEC. B.6P.C.FORTHISRFASON d �JE S LL DATE OWNER H � � �S • � � LiCENSED CONTRACTORS DEGLARATION � � � w � 1 HEREBYAFFIRIA UNOER DENALTV OF PER.IURV THAT 1 MA LICENSED UNOER PROVISIONS OF CHAPTER � � G(COMMENCINO WITH SECTION 9000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND Z MY UCENSE 161N FULL FORCEAND EFFECL �y �� � lLl �� (n ff � LICENSE CUSS�� LIQ NO. � i WDATE i�."" �=�,M�p�_ CONTRACTOR d ( o � WORKERS'COMPENSATfON DECLARATION P ��/� Z �O 1 MEREBY AFFIRM UNDER PENALTY OF PERJURY qVE OP THE FOLI.OWING DECLAflA�Ib s: � � Q I � IHAVEANUWILLMANTAINACERTIFICATEOFCONSENT705ELF-INSUREFORWORKEFS' _ e`' '-.a f/� COW�ENSATION,ASFHOVIDEOBVSECTON31000FTHEUBORCODE,FORTHEPERFORMANCE �U Yv C GV"• Q OFTHE WORK FOR WHICH THI6 PERMIT IS 16SUE0. � w f �, _I HAVEMID WILL MAIMAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BV SECTION O 370oOFTHELA60qCODE,FORTHEAERFORMANCEOFTHEWORKFORWHICHTHISPERMii15 ISSUED.MVWOPKEAS'COMPENSATIONINSURANCECARRIERANDPOUCYNUMBERARE: CONSTRUCTION � CARRIER PLAN REVIEW � POLiCV NUMBER ELECTRIC � �nuss[tnardrYE�rvoraEm�PtEreooFn�PErvx115waaueHuroaE�oav�As(S�ao)ORLESS� PLUMBING � Z i CEHTIFYTHAT INTHE PERFORMPNCE OFTHE WOPK FOR WHICH THIS PERAAIT IS ISSUED,1 MECHANICAL �J SHALL NOT EMPLOV ANY PERSON IN ANY MANNER SOAS TO BECOME SUBJECTTO THE (/� WORKERS'COMPENSATIONlAW50GCAlIFORNIA,A� AGREETHATIFISHOULDBECOME INSPECTIONFEE � SU&IECTTOh1EWORKERS'COMPENSATIONPR �SOFSECTION37ooOFTHElA9(((777R CODE,ISHALLFOqiHWITHCOMPLYWITHTNO � V�SqNS. � ISSUANCE 0 p DATE:���2,�'+CJ4PPLICANL � SMIP J WMNMGFMLURETOSECUREWORKERS'COMPENSATIONCOVERAGEISUNLAWFUL,ANDSHALLeE ENERGYP(C __ �y SU&IECTANEMPIOYERTOCRIMINALPENALTIEbANOCNiLFMESUPTOONEHVNDREDTHOUSAND ENERGYPERMIT � DOLLARS(i100,000�.IN ADDITION TOTHE COST OF COMPENSATION,DAMAQES AS PflOVIDED FOR IN J SECTpN 37oe OF THE LABOR GOOE,INTEREST,AND ATTORNEV'S FEES. p� RETENTION FEE: OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: � IHEREBYAFFIRMUNDERPENALNOFPERIURVTHATTHEREISACONSTRUCTIONLENDINGAGENCV f-0R THE PERFORMANCE OF TNE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3oel,CIV.C.�, Z W � LENDEWSNAME — - I— IENDER'SADDRE55 � TOTAL FEES L��'�, 2�� � ICERTIFVTHATIHAVEREADTHISAPPUCATIONAN�STATETHATTHEABOVEINFORMATpNISCARRECT. � IAGREE TO COMPLV WITH ALLCITY AND CAUNTY ORDIMANCES ANO STATE IAWS RELATING TO BUILDING � CONSTflUCTION,AND HEPEBV AUTHORRE REPRESEMATIVES OF THIS COUNTV TO ENTER UPON THE _ ABOVE-MENTIONED PROPERN FOR i SPECTION PURPOSES. 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