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HomeMy WebLinkAbout10109 j ..�- , CITY OF DIAMOND BAR j� COMMUNITY DEVELOPMENT DEPARTMENT 7^'�- ,,.,W . 21660 E.Copley Drive Suite 190 � PRESS (909)86Q3195 Fax(909)861-3117 '�"�� BUILDING PERMIT APPLICATION FIRMLY o ADDRIESS S�w ������DOD DATE CATION/���� NUMBER�C? !� p�C �-! ISSUE / TYPE OCC � APN L�T TRACT DATE `("'I 7 `�� CONST. GROUP p �OWNER ���/�ZPt�L1 IuC�N �.ADDflESS /� C..�I ZONING SETBACKS gCITY�f,�i'�� IP TEL. b I � S FRONT RW �7 APPLICANT �NB w� TEL.B!$ 8/O6/3$ REAR ❑ Z SIDE/SIDE STREET RW ❑ ¢ CONTRACTO S SIDE ❑ p� ADDRESS Z G � CITY LU w/�/P�" ZIP Qf1� TEL. � �/OG/3� PROPOSED USE w ARCH/ENG/ W DESIGNER 5��� NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CI7Y ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BI:ILDER DECLARATION SFR/A�D/REM O W CENSELAWFORTHEFOlL01MNCaREA ON(SEC.�7 JRSBUSINESSAN�PPROFESSIIXdSCODE: �CITYOR GaragelCarport U COUNTVWHICHPEOl11RESAPERMITTOCONSTRUCT.ALTER.IMPROVE.DEMOLISH,ORREPAIRANYSTRUC- � wTURE,PRIOR TO 17S ISSUANCE.ALSO REOUIRES THE APGLICAM FOR SUCH PERMIT TO FILE A SIGNED W patio/Deck � STATEMENT THAY HE OR SHE IS UCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- � GENSE LAW(CHAPTER e(COMMEHCING WITH SECTION 70W)OF DIVISbTJ 3 OF THE BUSINESS AND PRO- u' PODIIS�]a 0 PESSIONSGODE)ORTHATHEORSHEISEXEMPTTHEREFROMANDiHEBA515FORTHEALLEGEDEXEMP- V TION.ANYVIOLATIONOFSECTION7031.58YANVAPPLICANTFOqAPERMITSU&IECTSTH�AOPLICANTTO Z Re�Raot _ � 0.CNIlPENAL7VOFNOTMORETHANFIVEHUN�REDDOLURS(SSW�.): ' ' ' � 7i.ASOWNEROFTHEPROPEHN,OfiNYEMPLOYEESWITHWAGESASTHEIRSOLECAMPENSATION, 0 COmmBlCial Z WILL DO THE WONYc,ANO 7HE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7066,BUSI- J � NESS AN�PROFESSIONS CADE�THE CONTRACTORS UCENSE LAW DOES NOT APPLV TO AN OWNER OF `s PROPERTYWHOBUILUSORINPROVESTHEREON,ANDWNODOESSUCHWORKHIMSELFORHERSELFOR = O �f� OD [t THRW6HHISORHEROWNEMPLOYEES,PROVIOEDTHATSUCHIMPROVEMENTSARENOTINTENDEDOR m w OFFEREDPDRSALE.IF,HOWEVER7NEBUILOMGORIMPiiOVEMENTISSOIDWITHINONEYEAROFCOMPLE� � TION.THE OWNER-BUILDEfl WIU.HAVE THE BUROEN OF PROVING THAT HE OR SNE DID NOT BUILD OR Z IMPROVE FOHTHE VURPOSEOF SALE). � ❑I.ASOWNEROFTHEPROPERTV,AMEXCLUSIVELYCON?RACTINGWITHLICETISEOCONTRACTORS � TO CONSTRUCT 7HE PFQIECT(SEC.)04�,BUSINE55 AND PROFESSIONS CODE:THE CONTRACTORS LI- VellJelion zC� ADJ.AREA W CENSEtAWDOESNOTAPPIYTOANOWNEHOFAPROPERTYWHOBUILD50RIMPROVESTHEREON.AND � WHOCONiRACTSFORSUCHPRQIECTSW17HACONTRACTOR(S�UCENSEOPURSUANTTOTHECONTR4C- QUANT�TY DESCRIPTION FEE Y TORS LICENSE LAW.). � �i AM E)(EMPT UNDER SEC &i P C.FOR TMIS HEASON U � ___ � u' DATE _OWNER _ U W � LICENSED CONTRACTORS DECl11RATION W � I HEREBY AFFIRM UNOER PENALTY OF PERJURY THAT I AM IICENSED UNOER PROVISIONS OF CHAPTEH � � e(COMMENCING WITH SECTION 700Dj OF DIVISION J OFTHE BUSINESS IWO PROFESSIONS CODE,AND Z AIY LICENSE IS IN FULL FORCE AND EFFEC7. m � LICENSE CLASS L�/�—� LIG NO. � �� j V DATE��—'7 7 CONTflAG70F �'�'-'• �- W � WORKERS'COMPENSATION DECLARATION a = U � I HEREBY 11FFIRM UNDER PENALTV OF PERIURV ONE OF THE FOLLOWING DECLARATIONS: � Z Q � IHAVEANDWILLMAINTAINACERTIFICATEOFCONSEN770SElF�INSUREFORMlORKEFis' 2 CAMPENSATION,AS PROVI�ED BY SEC710N 37oa OF THE LABOR CODE.FOR THE PERFORMANCE U Q OF THE WORK FOR WHICH THIS PEHMIT IS ISSUED. � � w _I HAVE AND NALI MAINTAIN WORKEHS'COMPENSATION INSURANCE,AS RE�UIRED BY SECTION Q 370o OF THE LABOF CO�E.FOR 7HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 �`J�� ISSUED.MY WORKERS'COMPENSA710N INSURANCE CARRIEH AND POLICY NUM6ER ARE: STRUCTI � ¢ P a i 3�.cu�/ � CAftFIEfi � POLICYNUMBEFl ELECTHIC _ 6 � (iH¢SEcr�an�NE�ra7BEC�MaLEfEDOF'rHEaEaMIiISwRon�EF►JrDFiEDDaIAfiS(StaoIORLESS}. PLUMBING w I CERTIFYTHAT IN THE PERFORMANCE OF TF1E WDRN FOR WHICH 7HIS PERMIT IS ISSUED,I MECHANICAL Z -- (,'} SHA1L NOT EMPLOY ANY PERSON IN PNV MANNER 50 AS TO BECOME SUBJECT TO THE � WORKERS'COMPENSATIONLAWSOFCALiFOqNIA, OAGflEETHATIFISHOULDBECOME - �NSPECTIONFEE _ SU&)ECT TO THE WORKERS'COMPENSATION PR SIONS OF SECTION 37000F THE LABOH ' �LPJ�y � CAD�i SHALL FORTHWI7H COMPLV WITH PRO SIONS. _� � U CE. _ � p DATE:���APPLICANT: _ - �� W ENERGY P/C ' � WARNING�FAILURE 70 SECUHE WORKERS'COMPENSA710N COVERAGE IS UNLAWFUL,M1D SNAIL BE � ��-�}r-- �y SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FM'eS UP i00NE NUNDRED iHOUSPND ENERGY PER IT DOLLARS�f100,U00).IN ADDITIONTO THE COST OF COMPENSATION.DAMACE5 AS PROVIDED FOR IN � SECTION 3�OB OFTHE U1BOR CODE,INTEREST.AND ATfOi1NEY5 FEES. RETENTION FEE: _ OCONSTRUCTION LENDING AGENCY PRE-ALT��� � �T_ � I HEREBYAFFIRM UNDER PENALT/OF PERJURV THpT THERE IS A CONSTRUCTION LENDING AGENCY �- FOR THE PERFORMANCE OF THE WORK�OR WHICH THIS PERMI7 iS ISSUED(SEC.3087,CIV.C.�. ' Z W ` � LENDER'S NAME ' 1— LENDER'SADORESS -- � ICERTIFYTHATINAYEREN07NISAPPLICATIONANDSTATETMATTHEA90VEINFOFMATIONISCORRECT. TOTAL FEES � ��-�/_` W IAGREETOCOMPLYWITHALLCITYANDCOUNTYORDiNANCES0.NDSTA7ElAw5FElATINO708U1LDING �r/ CONSTAUCTION.AND HEREBY AUTHORRE REPRESENTATNES OF 7HI5 COUNTY TO ENTER U70N 7HE ZABOVE�MENTIONEOVROD TYFORINSPECTIONPURPOSES, COMMENTS _ 0 _ _ — , . m PER E J/ - � � /��/ f/� —__A • SIGNA TT E � OATE -� � RECPT.NO. 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