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HomeMy WebLinkAbout15800 (656) _...__ ._,_._,,,... _.._. �" / `Y�i ��_ CITY OF DIAMOND BAR �'('j/ ���,/ r DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �`�./ a 21660 E.Copley Drive Suite 190 9�,�.. (909)860-3195 Faa(909)861-3117 PRE$S BUII.D�TG PERMIT APPLICATION .. � ` , F'�I�hIILY, o� JOBSITE �7 ADDRESS���� G��C��.:J'/ZSri�, �/� DATE CATION � � �'�� �� NUMB R I � �� #`C � APN OT� TRACT��C�J C� DATE 61 I K.�� ���� CONST. GROUP p OWNER �C. p ADDR�/,� � �/ . ZONING SETBACKS � CITY /G%ZIZI'�A�../% ZIP� O� TEL:�ifd��.'�d 3lg'(9 REAFT RW ❑ APPLICANT TEL. 51DE/SIQE STREET RW ❑ � CONTRACTOR d�u �,� j2 ,r,4 ' SIDE � o ADDRESS ' �, � PROPOSED USE CITY ZIP 1i?l� TEL 4'�j(�'7�2,Z.� w ARCHJENG/ Z DESIGNER ADDRESS NO.DWEL. NO. NO. UNITS STORIES eEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER-BUILDER DECLARATION SFR/ADDlREM O p I HEREBY AFFlRM UNDER VENALTY OF PERIURV THA7 I AM E%EMP7 FROM iHE CANTRACTORS LI- G8�890/C81p01t W CENSELAWFORTHEFOLLOWINOREASON(SEC.7a37.58USINESSANOPROFESSIONSCODE:ANVCITVOR (n �.7 COUNTVNMICMREWIIRESAPERMtTTOCONSTRUCT,AL7ER,�MPROVE,DEMOlISH,ORREPAIHANYSTRUC• �Z NRE,PRIpR TO IT3 ISSUANCE,ALSO RERUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W PatiolDeck � STATEMENT THAT HE OR SHE IS UCENSED PURSUANT N THE PROVISIONS OF THE COMiPACTORS LI- � � CENSE UW(CHAPTER 8(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINE55 AND PRO- POOVSPe FESSqNSCOOE)OR7HA7HEORSHEISEXEMP77HEREFROMAND7HEBASISFONTHEALLEOEDE7fEMP- (� 710N.ANVVpLATIdJOFSECTION7031.6BVANVAPPLICANTPOHAPERMI7SUBJECTSTHEAPPLICANTTO Z Re-Roof r ACINL PEN�L7V OF NOT MORE THAN FIVE HUNDRED DOLLARS IS5001J: � ❑I.ASOWNEROFIHEPROPERTY,ORAdVEMF�DYEESWITHWAGESASTNEIR50LECOMPENS0.TION, O CommefClal - WILL DO THE WORK,ANO THE STRUC7URE IS NOT INTENDED Oii OFFEREO FOR SALE(SECJOa,9USI- J � NESS M1D PROFESSIONS CODE:7HE CONfRACTORS LICENSE LAW�OES NOT APPLV TO AN OWNER OF = PROPERTV WFIO BVIIAS OR IMPROVES THEREON,AN�WFiO DOES SUCH WORK HIMSELf OR HERSELFOR � TMFi0U6HHISOflNEROWNEMVLOYEES,PROVIOE�THATSUCHIMPROVEMENTSAREfS�TINTENDEDOR m OFFERED fORBALE IF,HOWEVER 7F�E BUILOING Ofl IMPROVEMENT IS SOLD WITMN ONE YEAR OFCAMPLE- Z TIqV,THE OWNER�BUILDER WILL HAVE TME BUROEN OF PROVING TNAT HE OR SME OIO NOT BUILD OR � IMPROVEWRTMEPURPOSEOFSILL£). W ❑I,ASONRiEROPTHEPROPERTY,MAEI(CWSIVEIYCONTRACTINGWITHUCENSEOCONTRACTORS � TO CONSTRUCT THE PRQIECT(SEC.9044,BUSINESS AND PROFESSIONS CODE:THE CONiRAC70RS LI- V81UdtiOfl ADJ.AREA W CENSELAWDOESNOTMPLYTOANOWNEROFAPROPERTYWHOBUIL�SORIMPqOVESTHEREON,AND WFIO CONTRACTS FOR SUCH PRQIECTS WITFi ACONTiIACTOF�S)LICENSEO PUFSUANTTO THE CONTRAG FEE TORSLICENSELAW.). QUANTITY DESGRIPTION � ❑I AM EKEMPT UNDER 3EC. B.8 P.C.FOR THIS REASOH Z u' DATE owNER '�u� � LICENSED CONTRACTORS OECLARATION � S ' s Q a��r ts i C� 1 HEREBYAFFIHM UNDER PENALTY OF PERfURY THAT I AM LICENSE�UN�ER PROVISIONS OF CHAP?ER � _�,.. � Y(COMMENqNQ WITH$ECTION 7oa1)OF DIVISION 3 0F THE BUSINESS AND PROFESSIONS CODE,AN� Z R S x MV LICENSE IS IN FULL FORCEAND EFFECT. o UCENSE CL45S C� ��G LIC.NO.� ! / � ,.� � D �, � V DATE CONTRACTOR,����� O- ��` � W � � WORKERS'COMPENSATION DECLARATION - • �,�s. � IMEREBYqFFIRMUNDERPENALTYOFPERJURYONEOFTHEFOLLOWINGDECIAMTIONS'� v' /5 � .�G:� � _IFUVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUR'cFORWORKERS' ,` � ,� COMPENSATION,AS PROVIDEO BY SECTION 370o OF THE LA60R CODE,FOq THE PERFORMANCE � L Q OFTHEWORKfORlVHICHTHISPERMIT191SSUE0. �� /,�r -^ � ( G/ _I MAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REW IRED BY SECTqN Q 37ooOFTHELABOHCOOE,FORTHEPERfORMANCEOFTHEWORKFORWHICHTHISVERMITIS "y� � ISSUED.MY WORKERS'COMPENS,A�T-ION INSII �1NCE CARRI AND POLICY NUMBERARE: CONSTRUCTION ��+ ��e^� jCMRIER��'_/j-.,�,Lz�lt.1�31�y PLAN REVIEW 0Z PIX.ICYNUMBER_,�� �✓�� �( "" � _ ELECTRIG Q p (I}USSECfK1NNE�NOTBE�LETmOF7HEPERMfTASFORONEFiUPARED00LLARS(E100)ORLESS�. PLUMBING Z 1 CEHTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PEftMiT IS ISSUED,I MECHANICAL (� SNALI.NOT EMPLOYANV PERSON IN ANY MANNER SOAS TO BECOME SUBJECTTO THE � WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AOREE THAT IF I SHOULD BECAME INSPECTION FEE SUBJECTTOTHEWOiiKERS'COMPENSATIONPROVISIONSOFSECTION3]o00FTNELABOR n _ _,.;� CODE SH FORTHWITH COMPLV W 7HTH0 PflOVI510NS. �SSUANCE � '� - S, �=--�•+•�' p DATEf _ �� APPIICAN'T���� ��-iy"Y SMIP .� J WARNI G:FAILURE TO SECURE WORKERS'COMPENSATION CAVERAGE IS UNLAWFUL.AND SHALL BE ENERGY P/C �` � SUBJECTANEMPIOVEFlTOCRIMINALPENALT7E5ANDCIVILfINESl1PTOONEHUNOREDTHOU3AN� � °� & )5� DOLLARS�S100,Oao),INAD�ITIONTOTHECOSTOFCOMPENSATION,DHMAGESASPROVIDEDFORIN ENERGYPERMIT z✓ /. .+. /_F�� J SECTION 37080f 1}1E LABOFi CO�E,INTEREST,ANDATTORNEY'S FEES. Y. p� RETENTION FEE:`�>'.r"a..r rt�,-a�e^.:,a ���e^;'�ejd'� y.'�N,�� a CONSTRUC710NLENDINGAGENCY 'Ja; �,� �3. ��.,�u . .5 . . . PREALT FEE: - . , O i�� �R. 5.,/k:'EL.S P'L+.'u�..r rx�a.r . . � IHEREBYAFFIRMUNOERPENALTYOFPERJUMTHATTHEREISACONSTRUCTIONLENDINOA6ENCY � fOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.C.). , Z W � LENDER'SNAME s�r�.3�' ' i— LENDER'SRDORESS � TOTAL FEES Opa�, 30 � I CERTIFY THAT I HAVE READ THISAPPUCATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT, � IAOREETOCOMPLVWITHALLCITYANDCAUNTVORDINANCESANDSTATEUWSRELATINGTOBUILDINO � CONSTFUGTION,PND HEREBY AUTFiORIZE REPRESENTA71YE5 OFTHIS GOUNTY TO ENTER UPON THE Z ABOVE-MENTIONEOPROPERTYFORINSPECTIONPURPOSES. COMMENTS � - 0 � � y s - m PERMITTEE (PRINT) � � l f 2 r� � SIO ATU EOFPERMITT D = RECPT.NO. PAID BY VALIDATION ~ WHITE-0e artment Co YELLOW�inance Co PINK—Assessor Co GOLDENFiOD--File Co GREEN— p py, py, py. py, ApplicanYs Copy � �: .,{,:: .., .. .e: _.. ..� -�1 .• ;`K' ' . .- ,.,e,.. �:: -. . . , ��> n,..�.:.. . r . .. .,� -,,. ,�'. ,:'�� ,�t, . . ... . , . 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