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HomeMy WebLinkAbout11374 /^i ��,���..������ - CPfY OF DIAMOND BAR ' ` COMMUNITY DEVELOPMENT DEPARTME IT %. ' �,.W 21660 E.Copley Drive Suice 190 (904)860-3195 Fax(909)861-3117 PRESS M"'' BUILDING PERMIT APPLICATION (3 L(�I.,,��j.t.l.' `��Z,F�j � �E) � FI RM LY � JOBSITE APPLICATION �P '�j o ADDRESS �D�v W�uL�lOi�3 �R-Aln) L,El.i�1E DATE �-" �1�� NUMBER � ! #,C - � ISSUE TYPE � OCC APN LOT �-� TRACT � c`��- DATE__ CONST. GROUP p OWNER � � P ' o ADDRESS 4'y2C �.. i'11"�. ZONING SETBACKS z CITY 7, QA� ZIP dI��Z � TEL.� � Z FRONT _ qW �7 g APPLICANT MI���Z9 Mi\ TEL._b.�io�ji2i?i1Zj REAR _ ❑_ Z SIDE/SIDE STREET RW C � CONTRACTOR A Li�E�11. S�Pr11'V-� Ai��`��E�IDtyC`��,1 iV G. SIDE ❑ ADDRESS �`� �5� ' � #� o=a � CIN 1Ni�ite'T�V ZIPRi7�t5S TEL.E �5 �ra l PROPOSEDUSE���/�`�4'/C.e� �./�'O�r w ARCWENG! z DESIGNER 37�Hi�S g�Q�ER- W NO.DWEL. NO. NO. � ADDRESS C�A cL • UNITS _ STORIES BEDROOMS � CITY ' � ZIP ��Iv2� TEL.`f f ' �O � cn DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION � OWNEF-BI:ILDER DECLARATION $FR/ADD/REM O I NEREBY AFFlRM UNDER PENALTV OF PERJURY THAT I AM EXEMPT FROM THE CqNTRACTORS LI� G8f89PJC8fpOR W CENSEUWFOH7HEFOLLOWMGREASON(SEC.7031.SBUSINESSANDPROFESSIONSCODE:ANVCITYOR (n U COUNTYWFiICHREWIRESAPERMITTOCONSTflULT,ALTER,IMPROVE,�EMOL15H2OflHEPAIflANYSTPUC- W PBfiD/DBCI( w TURE,PRIOR 70 ITS ISSUPNCE,ALSO REDUIRES THE APPLICANT FOR SUCH PERMIT TO FIIE A SIGNED W STATEMENT 7HAT HE OR SHE IS LICENSED PURSUANT TO 7HE PROVISIONS OF 7HE CONTRACTOfiS Lb � CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESSAND PqO. u' POOUSpB FESSIONS CODE)OR iHAT NE OR SHE IS EXEAAP7THEREFROA/ANDTHE BASIS FORTHE ALLEGED EXEMV- (� � TION.ANYVIOLATIONOFSECTION7091.SBVANYAPPLICANTFORAPERMITSU&IECTSTHEAPPIICANTTO Z Re-Root A CIVIL 7ENALTV OF NOT MORE TMAN FlVE NUNDRED DOLLARS(5500).): ❑I,ASOWNER OF TME PROPERTV,OR MY EMPLOVEES WITH WAGESAS THEIR SOLE COMPENSATION, O � Commercial Z WILL DO THE N10RK,AND hiE 57FUCTURE IS NOT INTENOED Ofi OFFERED FOR SALE(SEC.7044,9U51� J � NESS AND PROFESSIONS CADE:THE CONTRAC70RS LICENSE LAW DOES N07 APPLY TO AN OWNER OF � PqOPERTV WHO BUILDS OR IMPHOVESTHEREON.AND WNO DOES SUCH WORN HIMSELF OR HEFSELF OR C[ THROl1GNHI50RNEROWNEAAPLOVEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTIMENOEDOR m QOFFEREDF-0RSALE.IF,HOWEVER'�NEBUILDINGOqIMPROVEMENTI550IDWITHINONEYEAAOFCAMPLE- Z TION,THE OWNER-BUILDEfl WILL HAVE THE BUFDEN OF PROVING THAT HE OR SHE�I�NOT BU4D OH � IMPROVE FOR THE PURPOSE OF SALE). w ❑I,ASOWNEROFTHEPROPERTV,AMIXCWSIVEIYCONTRACTINGWfiHLICENSEOCONTRACTORS � TO CANSTHUCT THE PROJECT(SEC.7040,BUSINE55 AND PROFESSIONS CWE:7HE CANTHACTORS LI� V8IIJ81t011 ADJ.AREA W CENSELAWDOESNOTRPPLYTOANOWNEROFAPROPEATYWHOBUILDSORIMPROVESTHEREON,AND - � WHOCONTRACTSFORSUCHPROJECTSWI7HACONTRACTOR(5)LICENSEDPURSUANT70THECONTRAC• QUANTITY DESCRIPTION FEE Y TORS L�CENSE LAW) � 'u I AM E%EMPT UNDER SEC.____. 8.8 P.C.FOR THIS REASON � � � DATE_ __OWNER Z � LICENSED CONTRACTOFiS DECLARAT�ON � ¢ CC I HEREBV AFFlFM UNDER PENALTY OF PEqJURV THqT I AM LICENSE�UNOER PROVISIONS OF CHAPTER d, 9(COMMENCWG WITH SECTKKJ 7000)OF DIVISION 3 OF TFIE BU31NE53 ANO PROFESSIONS CODE.AND X MY UCENSE IS IN FULL FORCE AND EFFEC?. W q � LICENSECLASS �(� � LIC NO. �� �d 1 V DATE _�I�,71[__—__— CONTRACTO _ � .y-�1` ��� w � l✓ ///;;; � WORKERS'COMPENSATION DECLARATION `� 3,�� U / �� �� ,,3 ��r7� � I HEREBV qFFlFM UNDER PENALTV OF PERJURV ONE OF THE FOLLOWING DECLARATIONS: Q `.� �/r r�'`,��� �n�'A 1/�� � +.J ♦� N _.1 �/ � _I HAVE AND NALI MAINTAIN A GERTIFICATE Oi CONSENT 70 SELF�IN3URE FOR WORKERS' _ '�J d�yjJl/�g �✓"/,/�){d� ' ¢ CAMPENSATION.AS PflOVIDED BY SECTION 37000FTHE IABOR CO�E,FOR THE PEFFORMANCE U � �'�'/��/'� /"°� �� �� Q OF 7HE WORK FOR WHICH 7HI5 PERMIT IS ISSUED. � i/ '�77 6/�1� �/GL i•T � ?'S r'�/�A� W/v / [J w �t HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE.AS REOUIRED BY SECTION Q 370o OF TME LABOF CODE,FOR TME PERFORMANCE OF THE WORK F'Ofi WHICN TMIS PERMT IS ISSUED.MYWORKERS'COMPENSATIONINSURANCECARRIERANDPOLICYNUMBERARE: CONSTRUCTION __ _ j cnaqieq ��-�,�-'e�'���G �u�• C"� PLANREVIEW _ � POLICY NUMBER � �� �, ����^ ~ N L1f�� �S�I���. ' Z ELECTRIC ___ ¢ (�F115SECi�ONNEmNOTBEWA�PLf�EDOFTHEPEPMf�iSFORONEHUlDREOOOLLAFiS(51a0� lESS PLUMB{PJC.i' 0 DR . W r Z I CERTIFV THAT IN THE PERFORMANCE OF THE WOHN FOR WHICH THIS PERt11T IS ISSUED, � � A`��HANICAL �� (�J SHALI NOT EMPLOY ANV PERSON IN ANV MANNER 50 AS TO BECAME SUBJECT TO TNE r-.� . ` � WORKERS'COMPENSATIONLAWSOFCAL'FORNIA,ANDP.GREETHATIFISFIOULDBECOME INSPECTIONFEE SU&IECT TO THE WOflKERS'COMPENSATKKJ PROWSIONS OF SECTION 3700 0F TNE LABOR " /. i � CO�E,I SHALL FORTHWi7HCOMP WITH HO PROVISIONS. ISSUANCE __ � � SMIP p DATE: �"'�Z� APPLICANT: �„�,/ — � ENERGY P/C .!!a w F tt!� J WARNING:FqILURETOSECUREWORKEFiS'COMPENS COVERAGEISI/NLAWFUL,ANDSHAlLBE 6���� �,�r � SUBJECTANEMPLOYERTOCRIMINALPENAL7IESAN�CIYILFINESUP700NEHUNDHEDTHOUSAND Se�t��`. C - DOLLARS(SIa0.0001.IN AODITION i0 THE COSTOF COMPENSRTIOY,DAMAGES AS PqOVIDED FOR IN ENERGY PERMIT _ � SECTIDN]]OBOFTNELABORCODE,INTEREST.ANOATTORNEY'SFEES. RETENTIONFEE: _ d CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O -- � I HEREBV PFFIRM UNDER PENALTV OF PERIURY THAT THERE IS ACONSTRUCTIDN LENDING AGENCY _ FOR THE PERFORMANCE OF THE WONK FOR WHICH THIS PERMIT IS ISSUED ISEC.3087,CN.CJ. Z W '—. —' � LENDER'S NAME _ _ ___ h_- LENDER'SADDRE55 � ICERTIFVTMATIHAVEREADTHISAPPLICATIONIWDSTATETHATTHEABOVEINFORMpTIdJISCORRECi TOTAL FEES � �� � W I AGREE TO COMPLV WITH ALl CITV AND COUNTY ORDINANCES AND STATE LAWS RELAiING TO BUR�ING � � CONSTPUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUMV TO eNTER UPON THE ZA60VE�MEMIONED PROPERT'FOR INSPEC710N PURPOSES. � Q COMMENTS -� �.�� t✓f� - m PERMITTEE N E PRINT) � e� J./�' .� / � SIO EOFPERMI DATE L _ \_. RECPT.NO. PAID 8Y �J VALIDATION ~ WHITE—De ahment Co YELLDW—Finance Co PINK—Assessar Co GOLDENpOD—File Co GREEN— IfcanPs Co P pY. PY. 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