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HomeMy WebLinkAbout16132 (224) j 1�� CITY OF DIAMOND BAR 't � DEPARTMENT OF COMMUNITY 6�DEVELOPMENT SERVICES � , 21660 E.Copley Drive Suite I90 PRESS ���H��� BUII.DING PERMIT APPLICATION FI LY JOBSITE ] �-7 �,j APPLICATION �9 PERMIT � P o ADDRESS /� (� (j�7����� L��� DATE � '�� �f NUMBER .�� ` � ISSUE TYPE OCC � APN LOT TRACT �---- DATE_ � ~� CONST. GROUP p OWNER __�L ,�IC'_.c� !i'��fJ � LL ADDRESS_�A7"7��� �"" ' c�' ZONING SET9ACSCS �w CITY� ZIP TEL. � "' " REART= RW ❑ APPLICANT�— (C_�� TEL. �"��'��"�',� SIDE/SI�E STREET_ RW G a� CONTRACT �'1,� D P-6�� l/� ' SIDE ❑ � ADDRES � PROPOSED USE ��� � ( �� � CITY � ZIP TEL �� . � � �� w ARCH/ENG/ � � --- � W DESIGNER NO.DWEL. ���' NO. NO. Q ADDRESS UNITS STORIES BEDROOMS � CITY ZIP _ TEL.__ � DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION � OOWNER-BUILDER DEC'.ARATION SFR/ADD/REM � 1 HEREBV AFFlRM UNDER PEhALN OF PEfiJURV THAT 1 AM EkEA1PT FRUM THE CONTRACTORS LI� GdBC]0/CdfPOft W CENSEUWFORiHEFOLLOWIN6REASON�5EC.70.3�.58U5ME5SANDPROFES5IONSCADE:ANVCIT'Ofl (n � COUNTYWHIGHFEOUIHESAPERMITTOCONSTRUGT.ALTER,IMPROVE.DEMOUSH,ORAEPAIHANYSTRUC� W PetlO/DBCk W NRE,Pq10R TO ITS ISSUPNCE,ILLSO REOUIRES 1TiE APPLICANT FOR SUGH PERMIT TO FILE A SIGNED w � STATEMENT TFU1T NE OR SHE IS LICENSED PJHSU/WT TO THE PROVISIONS OF THE CONTRACTORS LI� � CENSE LAW(CHAPTER 9(COMMENCINO YJITH SECTION 70oa)OF DIVISION 3 OF THE BUSINESS AND PRO� � PooVSpa FESSIONSCOOE)oRTNATHEORSHEISE%EMPT7HEREFFOMANOTHEBASISFORTHEALLEGEDE%EMP� (� V TION.ANVVIOLATIONOFSECTION7WI.SBYANYAPPLICANTFORAPERMiTSU&IECTSTNEAPPLICANTTO Z Re-Roaf � ACIVILPF.NALN OF NOT MORE THAN FIVE HUNDREG DOLLARS(f5D0)J: � ❑I.ASOWNEROFTHEPqOAERTY,ORMVEMPIOYEESWITHN'AGESASTHEIRSCLECOMPENSATION, � Lommercial VALL DO THE WORK�ND THE STRUCNRE I�NOT INTENDED OR OFiERED FOR SALE(SEC.704a,6U5!� J NESS AND PROFESSIONS GODE:THE CONTfiAC?ORS LICENSE L0.W OOES NOT APPLY TO AN OWNEH OF � PROPERNNRiOBUILDSORIMPROVESTHEREON,ANDNhiODOE55UCHW�RKHIMSELFORHERSELFOR � � THROUGH HIS OR HER OWN EMPLOVEES.PROVIDED THATSUCN iMPROYEMEh:S ARE NOT INTENDED OR �i — LLI OFFEHEDFORSALE.IF,HOWEVERTMEBUILDINGOHIMPROVEMENTI550'J'WITHINONEYEAROFCOMPLc� ZTION,THE OWNER�BUILAER WILL HAVE THE BUA.DEN OF PROYING THAT HE OR SHE DID NO?Bl1M OR = IMPiqVEFORTHEPURPOS`cOFSALE�. W CI.ASOWNEROFTHEPFOPER'iY,AIAEXCLUSIVELYCONTRACTING:N:THLICENSEtlCONTRACTORS �.y�y � TO CONSTRUCT THE PR0.IECT{SEC.704/.BUSINE55 AND PROFESSIONS CODE�,THE CONTRACTOFS L:� V0111dL'O� _ [-�_, � ADJ.AFEA____ W CENSEUWUOESNOTAPPLYTOANOWIvcROFATROPEFTYWHOBUILDSOR7MPROVES"HEflC-ON,AN� � WHOCONTRACTSFOqSUCH�HOJECTSWfTHACANTRAC�R!5?LICC-NSE�PURSUANTTOTHECOMRAG QUANTITY DESCRIPTION FEE Y 70RSLICENSELAW.). � J O ❑i AM E%EfAPTUNDER SEC. __.._._�a P.C.FOR'H�5 REASON � __ � — — —_ 2 LL DA7E OWNER__, F Z ---- _—_---' w i o LICENSED CONTRACTORS 4ECLARATION �j�- � I NEREBYAFFIFiM UI�EP PENALiY O�PE0.IURYTHAT IAM LICENSED 11NUER ARQVI510�5 OF CHAPTER � � 7 � B(COMMENCINO WITH SECTION TOOO)OF DIViSION J OF iHE BU5;NE5S AN0?�OPESSIONS CCDE,NJD Z �8 ��� MV UCENSE IS iN FULL FORCEAYD EFFECT. m � LICENSE CLASS�� LiC_NO.__���� � H V DATE _ __ CONTRACTOR���I.C�_.__ a W — —__ a� WOFKERS'COMPE�S,4TION DECLARATION Q I � U - � 1 HEHE9Y AFFIRA!UNDEN PENALTY OF PEFiJURY ONE CF TME FOLLOritYG CECLANATIONS: � Q —"_ 0 _IVIAtlEANCW!L161AI�TAIWACERTIFlCATcOFC04SEATiOSELF•INSUFEFqRWORKERS' _ � COh/PENSATKKd.AS PROVIOED BY SECTIOT;3'l0o OG THE LAEOR CODE,FOR'HE PER�aR1AAnCE �U _ OF TME WOflN FOH WHICH 7HI5 PERMIT 73:SSUfD. � O W _I HAVE ANO Y1iLL MAINTAIN WOPo(EfiS'COMPFtdSAT:Oh INSL'FlANCE,h5 REC;IIREI)BY SECTIDtl '� � Qa7ooOFTHELABORCJUE,FORTkEPEPF09MANCEOFiHEWOPo(FORWH:CHTHISPE�MITIS 4,,. — �� �' � ISSl1EC.MY WOR#ERS COM?ENSATION!NSJRNJCE CARR:ER AND PO!ICV�UMBER AR'e' I �nNSTRUCTION i� {,�� �• j C4RRIER__��•�_�---'_ PLAN REVIEW _.__"__'__ _ � �icrNUMeeR____ _ _ ______..____-_ ELECTRIC _ _ ¢ 0 �rwssEcroruNE�NoraEa�.w_�e�an-�afawr¢roFlFlorieHuwHE�'�:auis•xioai.Ess1 Pl'JMBING ____ ___________ ZI CEflilr TNAT IN TME PERFORMANCE OP T.+E�+VORY.FOR WHICH THIS��ERMIT IS ISSUE�,I MECHAMCAL � (�j SHA..LN07EMPLOYANYPERSO�INANYMANNERSOASTOBECAAlES'J9JECTTOTNE � YdORKERS'COMPENSATIONLAWSCFCALIFOflNIA,AN�AGREETHATIFISHOULCBECOME INSPECTIONFEE ._,__ _ SUB!ECi 70'HE WCR%ERS'COMPENSA710N P50Vi510N5 OF SEC7104 37oC OF 7HE lABOR �11 � = COOE,I SNALI FORTH4NTH COMPLY WITHT40SE PRGVISIONS. ISSUANCE __`��� _ —� � �]� � SMIP t�� '� p DATE: APPLICANT. _�• j___�C.�..�._..'__ --- ' J � ENERGV%C __ WARNIYG�FAILUFiE TO SECURE WORKERS'CCMPENSATION COVERACaE:S UNUWFUI.AND SHALL 6E LL SV&IECTANEM7LOVERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHL1NDFiE�T.HOUSAN� ENERGYPERMI � _ DOLLARS�f1a0.000).IN ADDITION TO THE COST Of COMPENSATION.OAAAAGES AS PROVIDED FOFi IN � SECTIDN9�08OFTHEU90flCO�E,MTEREST�—AhDATTOR�EYSFEES. RETENTIONFEE: ___ _ d CONSTRUCTION LENDING AGENCY pRE-ALT FEE: ___._ ___ —._ O � 1 HEREBYAF�IRM UN�ER PENAL�V OF PERJVRV 7HAi h1EaE:S A CDhSTRUCTION 1EN01NG AGENCY ____________ .___ FOR'HE PERFOHMANCE OF TNE WORR FOR WV{ICH THIS PEFMIT IS ISSUEO(SEC.309],CIV.C.). Z --- _' W � LENDEri'S�AME _.._"--'_'--"" ---'"--'—__ F- :ENDER'SAD�RE55 __— — --- � ^ � � � 1 wIGERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATE'HATTHEABOVEINFORM0.TIONISCORRECT. 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