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HomeMy WebLinkAbout16168 (1110) L�`1,'�``/'_�-'`" /l �� CITY OF DIAMOND BAR l��j.3�'�� � A�:. ., - DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �'`�- W 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS � ��� BUILDING PERMIT APPLICATION FIRMLY . .. � : _, _. ,. . . .,. . p� JOBSITE �, f�� �� � •�� { APPUCATION � `�—�I NUMBER n a`J nP/C ADDRESS '7 .L„ �'i DATE r� ISSUE TYPE OCC APN LOT TRAC7 DATE CONST. GROUP p OWNER"�',��.�,J 'T d ADDRESS��.��"„� �,,��\�,^j�.��-yl� ZONING SETBACKS � CITY I��j, ZIP��_ TEL.�jt��_ REORT RW ❑ APPLICANT TEL. SIDE/SIDE STREET RW ❑ � CONTRACTOR , SIDE ❑ � ADpRESS ! � CITY ZIP4'1R�:3�. TEL.�,�"'�� PRpPOSEDUSE � ARCHlENG/ ,�',r�l �r/ Z DESIGNER '�`T�•Y � � ADDRESS NO.DWEL. NO. NO. UNITS STORIES BEOROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ApJ.AREANALUATION � OOWNER-BUILDER DECLARATION SFR/ADD/REM p I HEREBV�FFIRM UNDER PENAI.TY OF PERJURY THAT I AM EXEMPT FROM THE CAN7RAC1 OFS ll- � GBrage/Carport W CENSELAWFOR'iHEFOLLOW�N�REASON(SEC.7031.SBUSINESSANDPFOFESSIONSCODE:ANYCINOR C.� COUNT'MMICHPEOUIRESAPERMRTOCONSTRUCT,ALTER.IMPHOVE,OEMOLISH,ORiiEPAIRANYSTRUC- W patiolDeGk WTUA�PRIOR TO ITS ISSUANCE,ALSO REW IRES THE APOLICANT FOR SUCH PERMIT TO FILE A SIGNED W � STATEMEM TFiAT HE OR SHE 15 LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI� � CENSE UW(CHAPTEP 9(COMMENCINO WITH SECTION 7000)OF OIVISION 3 OF THE BUSINESS AND PRD- V' POOUSpd FESSIONS CODE�OR THAT HE OR SNE IS E1(EMPTTHEREFROM AND THE BASIS FOR THE ALlEOED EXEMP� TIDN.ANYYIOLATIONOFSECTION703/.58VANYAPPLICqNTFORAPERMITSl1&IECTSTHEAPPLICANTTO Z R2-ROOf r I�CMLPENALTY OF NOT MORE THAN FIVE HUNDRE�DOLLAflS(i5oo).): ^ pI.ASONMEROF7HEPRQPERTV,ORMYEMPLOYEE5WITNWAGESASTHEIR50lECOMPENSATiON, C� COmm8fCi81 L riILL DO THE WORK,AND THE STRUCTURE IS NOi IN7Ef+�ED OR OFFERED FOR SALE(SEC.7044,BU51- J NESS ANO 7ROFESSIONS COOE:THE CONTRACTOr75 LICENSE UW pOEs No7 RPPLY TO AN OWNER OF � PHOPEHTYIM�IOBUP�DSORIMPROVESTHEREON,ANOVMODOESSUCHWORKHIMSEIFORHERSELFOR � Q THROUCd1 HIS OR HEP OWN EMPLOYEES,PROVIDED THRT 5VCH IMPROVEMENTSARE NOT MTENDED Oq QOFFEREDFOHSALEIF,HOY/EVERTHEBUILDINOORIMPROVEMENTISSOIDWITHINONEVEAROFCOMPLE- � 710N,THE OWNER-BUILDER WILL HAYE THE BUFDEN OF PROYINO THA7 HE OR SHE DIO NPT BUILD OR � IMPROVE fOR THE PURPOSE OF SPLEj. w ❑I,ASONTlk�tOFTHEPROPE�I:AMEMCLUSNELVCANTMCTINaWI7HUCENSEDCONTRACTORS (r TO CpNSTRUCT TNE PRO.IECT(SEG.70M.BUSME55 AND PROFESSKKdS CO�E THE CONTPACTOqS LI� V21118110f1 ADJ.AREA W CENSEUWDOESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUILDSORIMPRWESTNE�iEON,AND - � WFiDCONTRACTSFORSUCMPROJECTSWITHACONTMCTOR(S)UCENSE�VURSUANTTOTHECANTRAG QLANTIIY DESCRIPTION FEE X TORSUCENSELAWJ. --- � ❑IAM EXEM7T UNDER SEC.�_ B.8 P.C.FOR THIS REASON � 3 � � DATE _ OWNER___- . U � W �.e[ LICENSED CONTRACTOflS�ECLARATION W � Lr IHEREBYAFFIRMUNDERPENALTYOFPERJURYTNATIAMLICENSEDUhDEflPPOVISIONSOFCHAPTER U, (j� 9(COMMENCINOWITHSEC7!ON7o(IO�OFDIVISION30FTHEBUSINESSAN�PROFESSIOYSGODE,ANO � _ X MY UCENSE IS IN FULI FORCE ANO EFFECL m � IlJ � UCENSE CLASS� ur,.Na. � �� � V DATE � ,_ CONTFL1C70R a W � � WOftKERS'COMPENSATfON DECLARATION Q � t HERE6YAFFIRM UNOEN PENALTV OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: � fn Z Q � iNAVEANOWILLMAlNTAINA�EH?'!FICA7EaFCONoENTTOSELF-INSI:HEFORWORKERS' _ � COA!?ENBA710N,ASPROViDEABYS[CTION37ooOF7HEUGOHCC�E,FOFTHFPEHFORMANCE W . pFTNE'AIOtiK FORWHIC�1 T'r15 PFAMiT IS ISSUEQ. � � � 1 HAVEAND WiLLMAINTATI W6AKERS'COFAPENSATION INSURAkCE.AS PFOUIRED BY S[CT!ON ¢ 37�9 O�THE 4.ABUi�CCDE,FORTHE PER�(>RMANCE OF THE WONK FOR WNICH THIS PERMIT IS � IS5UFC.MY WORKERS'ODF.1S'ENShTiG4 INSURaNCE CARRIER AND P^LICV NUMBER ARE: GONSTRUCTION _ Q �i_...i,.. ��( ;y cnaaiEa_�_�ZL/S1� �`�,� ----__._..—_ PLAN REVIEW Z FOUGYNUMBER_,_��f�„�__�-�����C�.�-- ELECTRIC 4 � ` '� � (iHtSSECfIOnINEE�NO�BE�EtEUOF'n-'�FERRsrISfoROMEFKA�UREDDalnft51E1oo)ORLEssa PLUMBING ,.. •V `' W I CEfiTiFV TNA�IN THF FERFORMANCE OG THE bYOF�K FOfl WHICH TNIS PEflMIT IS ISSL'ED,I MECHANICAL Z (� StIALlNOTEMPLOVANYPER50NHJ1WVMANNERSOAST06ECOMESU2JECTTOTHE �j WONKEHS'CDN�PENSATIONlAW50iCAUF�RNIA,ANDAGFCETHA71FI5HOULDe[COME INSPECTIONFEE - S SURJECT70TNENK)RKE.RS'COMPENSATIONPROVISIONSOFSECTION37000FTHELABOR `_ \ C[JDE,!Sl1A4t FOH7MWITH CUMPLV W�TH THOgE PROVISIONS. ISSUANCE �y-. Q DATE: + .��_ APPLICAN7: �-) SMIP u _. � ENERGY P/G �'� �- �� � WAPNINO�FAILUR O SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE —""� — -' — �y SU&IE��EMPLOVERTOCRIMINALPENALTIESANOCIV!IFINESUPTOONEHUNDREOTNOUSAN� ENERGYPERMI rt9, . DOLLARS(510D.000�.IN AODITION TO THE COST OF COMPENS0.TION,DAMAGES AS PROVIDED FOR IN ��']--�8-�{}''7 1 � SECTION3'IDeOFTH6LABOPCODE,INTEREST,ANDATTORNEY'SFEES. RETENTIONFE ' � � �� '�`�°�v� pw._ CONSTRUCTION LENDING AGENCY pFGALT FEE: O 0. I HEREBY AFF�RM UNOEF PLNALTV OK PERJURV THAT THERE IS A CONSTRUCT�ON LEN�ING AGENCY FOR THE PERWRMANCE OF THE WORK FOR WHICM THIS PERMIT IS ISSUE�(SEC.3oe7.CIV.C.). w _' � �END�CR'SNAME _ F,_- LENOER'SADOHE55 �c\ wICEFTIFVTMATIHAVEREADTNISAPPLICATIONANDSTATETHATTHEFBOVEINFORMATpNISfAFRECT. TOTAL FEES � �`�� � I AGREE TO COMPLY WITH ALL CITY ANO CAUNTY ORDINANC[5 AND STATE LAWS REIATING TO BUILDING CDNSTRUCTION,AN01iERE8V AUiHORIZE REPRESENTATNES OF THIS COVNTYTO ENTER UPON THE ZAFtOVE-MENTIONED P�OPERTY FOR INSPFCTION PURPOSES, COMMENTS m ��G�-f� "�-- 4 PEHMITTEENAAAF(PFIPln __.. � � SIONP�7URE OF PERMITTEE A � RECPT.NO. PAID BV VALIDATION WHITE—DepartmenP Copy,YELLOW—Finence Copy,PWK—Assessor Copy.GOlOENROD—Fle Copy.GREEN—ApplicanPs Copy ����� �� ��m�������� �� 1 ����,"�� .�� ��� �`�� - � � ��; . � �., � � � � � � g�. 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