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HomeMy WebLinkAbout12517 �� CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SBRVICES 21b6Q E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS �'9^'� � BUQ.DING PERMTT APPLICATION FIRMLY o� JOBSITE � („ � � . APPLICATION tU-1 _� PERMIT���� P/C ADDRESS ll� DATE NUMBE # c� ISSUE TYPE OCC .- APN�iOT��ACT DATE_ CONST. GROUP °C OWNER �w P V! � ADDRESS�- ���1'''� � ZONING SETBACKS � CITY �"Z"� ZIP L -'����� REAORT_ � G APPLICANT TEL. SIDE/SIDE STREET RW ❑ � CONTRACTOR .r' �1. , �� SIDE ❑ Q ADDRESS 8 � � � � PROPOSED USE � CITY � V� i'�M ZIP \ '7EL.���% •- Cs_� -- o ARCH/ENGI ;g�%c:2 iz DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. -- � DESCRIPTION SQ.FT. FACTOR PSF ADJ_AREANALUATION Q OWNER-BUILDER DECLARATION SFR/ADD/F1EM O � I HEREBY AFFlqM UNOER VENALTY OF PE0.)URY THAT I AM E%EMGT FFOM THE CONTRACTORS LI- � Garage/Carport W CENSEUWFORTHEFOILAWiNGREASON(SEC.�03t.58USINESSANDVP.OFESSIONSCODE:/WVCITVOR C� COUN7YWHICHREIXIIRESAPERMITTOCONSTRl1CT,ALTER.IMPROVE,�EMOLISH,ORREPAIRANYSTiiUG W PatiolDeck Z IURE,PRqR TO 1T9 IS9UANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMiT TO FlLE A SIGNED W STATEMENT THAT ME OR SHE IS tJCENSED PURSUANT TO THE PROVISIONS OF THE CONiRACTORS LI• � � CENSEUIW(CHAV�ER9(COMMENCIN(dWITMSECTION7W0)OFOIVISION3OFTr/EBUSINESSANOPR6 � PooUSpa S FESSIONSCOOEIORTHATHEORSHEISExEMPTTHEREFROMANDTHEBASISFORhIEALLEGEDEXEM?- V TKKJ.ANYVIOUTIONOFSECTION7031.SBYANVAPPLICANTFORAPERA�ITSUBJECTSTHEAPPLICAMTO Z pe-RDo1 � A CINL PENALTV OF NOT AIORE THAN FIVE HUkDRED DOLtARS�f5oo)_�: � ❑I.ASOVMEROFTHEPROPERT',ORAIYEAIPLOVEESWITHWAGESASTHE!RSOLECOMPENSATION, � �O�I1ff10fCIdI ' MALL DO THE WORK,AND THE STRUC7URE IS NOT INTENDED OR OFFEREO F00.SALE(SEC.704A,9USI- J � NESS AND PROFESSIONS CODE:THE CONiRACTOF3 UCENSE LAW DOES tJOT APPLV TO AN OWNER OF � PFiOPEHTY VRIO BUILOS OR IMPROVES THEREON,!WO YMO DOES SUGH WORK HIMSELF OR HERSELF OR Q iMROUGHHISOHHERONMEMPLOYEES,PROVIDE�THATSUCHIMPFOVEMENTSARENOTIMENOE�OR m QOFFEREDFOHSl�LE.IF,HOWEVERIHEBUIl01NGORMPROVEMENTI550L�WITHINONEVEAROFCOMPLE- Z TION.THE OWNER-BUILDEF WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BU:LD OP � IMPROVE FOR THE PURPOSE OF SALE} W GI,ASONTlEROFTHEPROPE{iTV.AMEXCWSIVELYCONTRACTINGYATHLICE45EDCONTRACTORS � TO CONSTRUCT THE PRWECT(SEC.�0/0.BUSINE55 AND PROFESSIONS CODE:THE CONTRACTORS LI- VdIU0tI0fl ADJ.AREA W CENSELAWDOESNOTAPPLYTCANOWNEROFAPROPERTYWH00UILDSORIMPROVESTNEREON,AND — -- � NRIOCONTRACTSFORSUCMPROJECT5IMTNACONTRAGTOR�S)LICENSEDPUqSUANTTOTYECONTRAG qUANTITY OESCRIPTION FEE Y 1DRS LICBISE uW.J. � J ` � ❑IAM EXFAiPT UNDER SEC. B.&P.C.FOR TH!S REASON Q _ � �C�'� Y � � ��- ' � � � DATE DWNER'_'_""'______ U z u, o LICENSED CONTRACTORS DECLARATIDN W ,� � � IHEREBYAFFIRMUN�EHPENAL'YOFPERJUHVTHATIAMLICcNSEDUN�LHPFOVISIONSOFCHAP'.ER �I � 9(COMMENCINO WITH SECTION 7000)OF DIViSION 3 OF THF BUSINE55 AI�L7 PROFESSIONS COD'e.ANJ Z� YY LICENSE IS IN FULL FORCE AND EFFECT. m � LICENSE CLASS'S1y"L!_�•� LIC.NQ `_ �� j V DATE V ` CONTRACTO '�r . W � WORKERS'COMPEN5ATION DE . /� ��I Q � I HEREBY AFFIRM t1NDER PENqLTY OF PERIURY ONE OF TY.E FOLLOWIN6 OECI.ARA'IOHS U C� Q � IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTiOSELF-INSUREFORWORKeRS' 2 � CAIJPENSATION.AS PROV�OED BY SECTION 37CA OF TNE LA80R CO�E,FOR THE PERFOR�AANCF W _ OF THE WORN FOR WHICH 7HIS PF.RMIT 7S ISSUED. � 0 W __IHAVEANDWILLMAINTAINWORKERS'CAMPENSATIOYINSURANCE.ASREqUIREDBYSEC710N Q 370o OFTHE LABOR CO�E,FORTHE PERFORIAANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSVED.MY WORi(ERS'(bMPENSATION INSURANCE CARRIEF AND POL'�.CY NUM6ER ARE: CONSTRUCTION _.___..__,__._ J jc�ARIER_ _ — PLAN REVIEW ___ ' �/L.,C� /� ZPOucvNUMBEn __"'__—'—"""_"'-- ELECT _"__ _ '�"� � Q Q (THLSSECTqNN`c�NOT8EC761PLEf�OFTY.EPEFUMISFnRONEHUM1D!iEODOL'eAR515mior��Ess7. PL.UMBING � MECHANICAL z I CEflTIFY THAT IN TME PERFORMANCE OF THE WORK FOR WHICH i!i!5 PEFMIT IS:SSUED,I _—_____________.._.____ ___. (,r} SHP.LLNOTEMPLOYANYPERSOYINANVMRNNERSOA5T08ECOMESU9JECTT07HE (J) WOFNEfiS'COMPENSF7IIXJLAWSOFC.OUFCRNIA.AN�AGREETHAiIF15HOULDBECOM[ INSPECTIONFEE ______._____` {q�p, �.,.'r�'') � SUBJECT TO THE WORNERS'COMPENSATION P IB1BN6�CF..�CTIOY 3700 Of THE IA90P �SSUANCE �R�E■ / U � CODE, SHALLF RTHWITHCOMPLYWI E28�`$IONS. — - . — � d`' C SMIF p DATE:J v • . •APPLIC T: _ ---- — W ENERGY P/C —� WARNING FAILUflE TO SECURE WORKER - ATION COVERAGE IS UNLAWFUL,AND SHAiL BE —' "---'—' J SU&IECT AN EMPLOVEH TO CRIMINAL PENAITIES ANO CIVIL FINES UP TO ONE HUNORED THOUSAND � ENERGY PERMIT ___.��_ ���_., DOILARS(f1 aO.00D).IN ADDITION TO THE COST OF C�MPENSATION,DAMAGES AS PROVIDED FOR IN —�--- J SECTION 3]08 OFTHE LABOR CODE,9JTEREST,AND ATTOFNEV'S FEES. RETENTION FEE: ¢ —...__'_""_"'""_'_ �AD � CONSTRUCTION LENDING AGENCY PRE-ALT FEE: �yr TY��FTDIA7M�}�O�N�aD_.�u� � �HEREBYAFFIqM UNDEi7 PEtiALN OF PcRJURV THAT THERE IS ACONSTRU(:TION LEN�ING AGENCV _ I']l T�.Df 1 V�,A 1 V!J I�TY FOR TME PERFORMANCE OF THE W05N FOR WHICH THIS PERAl1T IS ISSUED(SEG 308'i,CIV.C.�. ' Z W — -- � LENOER'S NAME ._ '_'__--__""_ ____ F— LENDER'SADDRE55 ._ __. _._... �._.__._..____ ,. � ICEfiTIFYhIATIHAVEREAD7HISAPPUCATIONANDSTATETHATTHEABOVEINFORMAT!ONISCORRECT. TOTAL FEES � � I AGREE 70 CAN.PLY WITH ALl CIiV AND COUNTY ORDINANCESAND STATE LAWS AELATING TO BU�LD:NG CONSTqULTION,AND MEREBY AUTHORIZE REPRESENTATIYES OF THIS CWNN TO ENTER UPON THE ZA � FfTIONED PROPEF'(Y Ofl INSPeCT10N PURPOSE CO�+IMENTS ____________ � � � � __ _— m PEHMITT /}, _ � �'^.�� ��� o _ � SIG URE OF PEflM 0 E � = 0 F!ECPT.NO. 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