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HomeMy WebLinkAbout11876 CITY OF DIAMOND BAR 1 -- -��--- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICE� 21660 E.Copley I9rive Suite 190 !� (909)860-3195 Fax(909)861-3117 �� PRESS �����'��� BUII.DING PERMIT APPLICATION FIRMLY o DDRESS!-1`1-t �_�f��'1 L'F� ���3� � ��, 4�A� DATE � z� � � NUMBER I� # � � i � APPLICATION PERMIT P/C � ISSUE 1YPE OCC APN LOT TRACT DATE 2 � CONST. GROUP � OWNER J-�li'1�� i:(f�l�'� o ADDFESS_I�1i1� �VVI� i U� ZONING SETBACKS W CITY �r r'r'1 1'� �_ ZIP TEL. PRONT RW ❑ � APPUCAN��j,g'��P� TEL.�c�� 67ri� � REAR � � SIDEISIDE STREET RW ❑ aa CONTRACTOR � - SIDE � ADDRESS Sit "c'' « ` y� � " �� r' , ZIP��2 TEL.�7_�PI i"7�Z_ PROPOSED USE /C L�/��C�� o cirv �rwr�C�TC� S�� w ARCH/ENG/ z DESIGNER �A I 1/] a ADDRESS �� NO.DWEL. j NO. �Z NO. � � CITY ZIP TEL. UNITS ! STORIES BEDROOMS ^ cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � CWNER-BUILDER DECLARATION SFR/ADD/REM O I HEREBV AFFIRM UNDER PENALTY OF PEPJURY THAT;AM E%EMPT FROM TFIE CONTRACTORS LI- Gdf8Q0/CatpOR W CENSELAWPoRhIEFOILOWINGREASON(SEC.7031.SBUSMESSANDPROFESSpNSCODE:ANYCITYOR U GOUNTYWHICHqEOUIqESAPERMITTOCON3TRUCT,ALTER,IMPflOVE.DEMOUSN,ORREPAIRANYSTRUC� �f,J patt0/DBCI( W TURE,VRIOR TO ITS ISSUANCE,lLLSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNEO W STATEMENT THAT ME OH SHE IS LICENSED PUFlSUPNT TO THE PROVISIONS OF THE CONTRACTORS LI� � CENSE UW(CHMTER 9(COMMENCINO WITH SECTION 7000�OF DIVISION 3 OF THE BUSINESSA4D PRD� V' PaOVSpe FESSIONS OO�E)OR THAT HE OFl SHE IS EXEMPT THEREFROM AND THE BASIS FOfi THE ALLEGED EXEMP• TKKJ.ANVVIOLATqNOFSECTION7091.58YANVAPPLICANTFORAPERMITSU&IECTSTHEAPPLICAMTO Z Re-Roof ���' F ACIVILPENALTY OF NOT MORE THAN FNE HUNDREO OOLLAHS(SSoo).): � ❑I,ASONMER�THEPROPEflTY,ORMYEMP�OYEESWITHWAGESASTHEIRSOLECOMPENSATION, � COITIRIQfCl31 � N1LL DO THE WORK,AND TNE STR4CTURE IS NOT IMENDED DH OFFERED FOR SALE(SEC.7044,9U51� J y NESV AND PROFESSI�NS CODE:7HE CANTRACTOflS LICENSE LAW DOES NOT APPLY TO AN OWNER OF = PROPER7V WMO BUILDS OR IAiPROVESTHEREON,AND WHO OOES SUCH WORK HIMSELF OR HERSEIF OR � 7HIIOUGHHISORHEROWNEMPLOVEES,PRDVIDEDTHATSUCHIMPROVEMENTSAREhOTINTENDEDOR m QOFFEREOFORSALEIF,HOWEVERTMEBUILDINGORIMPFOVEMENTISSOlDWI7HINONEVEAROFCAMPLE� Z TION,THE OWNER�UItAER WILL HAVE THE BURDEN OF PROVING TNAT NE OR SHE DID NOT BUILD OR � IMPROVEFORTHEPURPOSEOFSALE� ❑I,AS OWNEq OF THE PROPEFlTV.AM E%CLUSIVELY CON�RACTING WITi LICENSED CAN7RACTORS f �^ � TO CONSTfiUCT T}1E PRO.IECT(SEC.7ola,&15INES3 AND PROFESSIONS GODE:THE GOMRAC70R5 LI� V81UHtI0t1 �/�G�U'_G°l.-�' ADJ.AREA � CENSEUWDOESNOTAPPIYTOANONMEROFAPROPERTYwHOBUILD50RIMPROVES7HEftEON,IW� - WVIOCONTFUCTSFORSUCHPR0.IECTSWITHACONTRAC70R�S�LICENSEDPl1RSUANT70THECONTRAG QUANTITV DESCRIPTION FEE Y TORSLICENSELAW.1. Q J Q G I AM E%EMPT UNDER SEC. B.8 P.C.FOR THiS REASON Q }� U W � OATE OWNER_ _ V Z W � LICENSED CONTRACTORS DEGLARATION W � IHEREBVAFFIRMUN�ERPENAl7YOFPERIURYTHATIAMLCE�5E0UN0ERPROVISIONSO�CHAPTER � d B(COMMENCINO NATH SfCTION 7oD0)OF OIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND Z X MY LICENSE IS M NLL FORCE AND EFFECT. m LLJ / Q � I � UCENSE C1UISS ����_ LIC.NO. k%�',e'"�� ��`�° r � j V �A7E�1��� CONTPACTOR�j� '��di'Ir�1,� d W � WORKERS'COMPENSATION DECLARATION � Q � IHEREBYAFFIRMUNDEAPENALNOFPERJURVONEOF7HEFOLLOWINGDECLANITIONS: Z � IHAVEIWDWILLMAINTAINACERfIFICATEDFCONSENTTOSELF.INSUREfORWORKERS' a Z — 2 CAMPEN3ATION,ASPROVIDE�9YSECTION37ooOFTHEU90RCODE,FOi1TNEPERFORM0.YCE U Q OFTHE WOPo(FOR VlHICH THIS PERMIT IS ISSUED. � � W _IHAVEANDWILL/AAINTAINWORKERS'CAMPENSATIONiNSURANCE.A5RE0U1RED9V5ECTION Q 370pOFTHELABORCODE.FORTHEPERWRMANCEOFTHEWOi1KFORWHICHTHIbPERM!TIS CI 4 /�I � iSSUED.MYw/p^p,K,E 5' PEN TION INSURANCE CAHqIERAN�POLICY NUMBERARE' CONSTRUCTION J ! r r j CARRIEfl. L:/l�. �G Li I7E`� � R PLAN REVIEW ---�- ---- 2 POLICY NUMBER.p�%4- I7°..`�, . ^�i ELECTRIC __ � (1}+sSEci�otuNE�NOTBEODMRE7EDOF7F1EaEm.aTlSwaoNEHLroRF.DoaU�RS;E70o)aiLEssF PLUMBING � Z I CERTIFY THAT IN iHE PERFORMANCE Or THE WORK FOfl WHICH THIS PEFMIT IS ISSUE�7,I MECHANICAL __ __ (7 SHALLNOTEMPLOYANVPERSONINANYMANNERSOASTOBECOMESUBJEC7TO7HE � WOFKERS'COMPENSATIONL/IWSOFCALIFORNIA,AN�AGaEETHATIFISHOULDBECO!dE INSPECTIONFEE _ � SUBJECTTOTHEWORKERS'COMPENSATIONPFOVISIONSOFSECTION370aOFTHEI_ABOR � CODE.ISHALLFORTHWITHCOMPLVWI7HTH05 FOVI10� ISSUANCE _ d/�b 0 ry � p DATE: �� � g APPLICANT: SMIP __ O � WARNING:FAILURE TO SECURE WORKENS'COMPENSATiON Q VERAGE IS VN:AWFUL,AND SHALL BE ENEFiGY P/C _____ __ � SV&IECTANEMPLDYERTOCRIMINAI,PENAlTIESANDCIVIL'rINESUPTOONEHUN�REDTHOUSAND ENERGYPEflMIT DOLLARS(f70o,00o),IN ADDITION 70THE COST OF COMPENSATION,�AAdAGES AS PROYIDE�FOR IN -- ----�— � SECTION 3708 OF hiE LABOR COOE,�NTEREST,ANDATTORNEYS FEES. RETENTION FEE: _,_. a CONSTRUCTION LENDING AGENCY PkE-ALT FEE: O -- � IHEREBYAFFIRMUNDERPENAITYOFPERJURYTHATTHEREISACONSTFUCTIONIENDINGaGENCY FOR THE PERFORMANGE OF THE WORK FOR WHiGH THIS PERMR IS ISSUED(SEC.3D87,CIV.C.�. Z W — � LENDER'S NAME _ _...__—_ � F_ LENDER'SADORE55 (� •�`/ � ICERTIFYiHATIHAYEREAOTH15APPlICATIONIWUSTAT£THATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES ��� ^" � ���� // � IAGflEE TO COMPLV WITHALL CITY ANO COUNTY ORDINFNCES AND STATE LAWS RELATING TO BUIL�ING t " � � COFISTRU�ION,AND HEREBV AUTHORIZE REPRESENTATIVES OF 7HIS COUNTYTO ENTER UPON THE (�77 ABOVE-MEM�ONEDPROPERTYFOiiINSPECTIONPURP0.SE5. fy, �y}l Y__CDr C]I��� �/ EI Q cr^ COMMENTS��/�v(,� �'�L�1ni{r�rrn�IP�3�� Lc�i . Y� �S,f� � / (�G�"1 --�'i%1p�-"Y�fC t?�!.'F-� G.i�-�l1 �:�u,r ,� ,,,cr . 4,fl ��. � ' � ���,,�G f6a�� ` � Q PERMI NAME PRI N v.{,,• � , � �� �f� � SIONA E ERMITTEE �DNTE = RECPT.NO. 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