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HomeMy WebLinkAbout13695 �� CITY OF DIAMOND BAR � -� DEPARTMENT OF COMMUNITY&DEVELOPM�NT SERVICES 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS ���A�°� BUILDIIVG PERMIT APPLICATION FIR�IILY ,... .. . . . . .... :..... ....._......:.,�,_..,.,,...�..�. .x,.... QJOBSlTE ��L ��,��� �� DATE CATION f f NUMBER #/C ¢ ADDRESS �i7 lNT �� L' �� $ APN LOT TRACT DA EE � CONST. GROUP p OWNER �' � o ADD, �S ' ZONING SETBACKS Z CITY ' = ZIP TE , - l � FRONT. RW � g APPLICANT TEL. REAR ;� � SIDE/SICE STREET RW C CONTRACTOR SIDE C O ADDRESS � � PROPOSED USE� " CITY ZIP�f TEL. r- 7 � o ARCFUENGI � • u - z DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BED OOMS �G� � CI7Y ZIP_ TEL. � DESCR�PTION Sd.FT. FACTOR PSF J.AREANALUATION � OWNEfl-BUILDER DECLARATION SFRlADD/AEM � O Q I HEREBY AFFIRM WDER PENALTY OF PEPJUNV THAT 1 AAA EXEIAPT FROM i HE CONTRACTORS LI� � G3fdJe/C8fF70f} W CENSELAWFORTNEFOLLOWINOREASON(SEC.7D31.SB115ME5SANDPROFESSIONSCO�E:ANYCITVOR U COUNTYW!i(CHREOUIflESAPERMRTOCONSTflVCT,P.LTeR,IM7RWE,0EMOL�SH,ORREPAIHANYSTqUC� W PgtlO/�BCk w NRE,PRIOR TO ITS ISSUANCE,AL50 REOUIRES THE APPLICANi FOR SUCH PERMIT TO FILE A SIGNE� w � STATEMENT THAT HE OR SHE IS LICENSED PURSUANT 70 THE PROVISIONS OF THE CONTRpCTOP.9 LI� � CENSE LAW(CNAGTER 9(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE B1151NE55 FN�PPO- V" POOI/Spa FESSIONS OODE7 OR THAT HE OR SHE IS EXEMPT THEREFROPI AN01HE BASIS rOR THE ALLEGED EXEMD- V TpN.ANYVIOUTIONOFSECT10N7091.5BYANYAPPIICANTFORAPERMITSU&lECTSTMEAPPLICANTTD Z Re-Roaf F ACIVILPENALTYOFNOTMORETHANFtVEFIUNDREDDOLLAR5�S5DD).): � ❑�,ASOWNEROFTHEPROVEfiTI;ORMYEMPLOYEESWITHWAGESAST-�EiRSOLECOMPENSATION, O Gommercial WI4L DO THE WOFiK.AN�THE STRI:CTURE IS NOT IN7EN�E0 OR OFFERED FOR SALE(SEC.7044,BU51- J NESS AND PROFESSIONS CODE:THE CANTRACTCRS LICENSE LAW DOES NOT APPLV TO AN OWNER OF � PROPERTYNMOBUILDSOA�MPROYESTHFAEON,ANDWHODOESSUCHWORKNIMSELFORHERSELFOR � � THFIOUGHHISORNERONMEMPLOYEES.PROVIDEDTHATSUCH�MPRWEMENTSARENOTINTENOE�OR m � OFFEREDFOR541E.IF,HOWEVER7NEBUIIDINGORIAiPROVEMENTI550L➢WRHINONEVEAROFCOMPLE- __ � TION,7HE OWNER-BUILDER VALL HAVE 7ME BURDEN OF PROVINO THAT HE Ofl SNE�ID NOT 81111A OR � IMFROVEFORTHE?URPOSEOFSALE). ^I,ASOWNEROFTHEPROPERNN.f EXCLU5IVELYCANTRACTING WI7HLICBJSE�CONTRACTOFS ('WL TO CONSTAUC7 THE PROJECT(SEC.7oN,BUSIMESS AfYD PflOFE5510N5 CODE�THE GONTRACTORS U- V81J89�� _ _ ADJ.AREA 111 CENSELAWDOESNOTAPPLYTOANOWNEROFAPHOVE0.NWN09UILDSOHIMPROVESTHEREON,AND � WFfOCONTMCTSFORSUCHPR0.1ECT3WfTHACONTRqCTOA(S)LICENSEDPUP.SUANTTOTNECONTMG � QUANTITY DESCRIPTlON FEE Y TORS UCENSE UW.;. Q �I MA EXEMPT UtiDEH SEC.,____�- B 8 P.0 FOR TNIS AEASON � Q � ` ` U � �' D�iE � oWNEq__'_ __ � �" I Z W Q LICENSED CONTRACTQRS DECLaAATION ✓ � I � 1 HERESYqFFIRIF UNDER PENA:N OF PERJURY THAT I AM LICE�SEO UNDER PROVIS:CNS OF CHAP7�F# �yi d Y(CONAIENCINO K7TH SEC7bN 7u"00)OF C!VISION 3 0F 1H[BUS:NESS FND?RO�ESSIONS CODE.R�SQ�, � X MYUCENSE�S:N FULI FORCE AND EFFECT. °.(� �j �/�.6 f � - � LIGENSECLASS_C..� _IC,NO.�,�^J..! ��� �`' J J V DATE " �ONTFACTOF�A/ f���-+••f� a G� �r�� WORKERS'COMPENSATIOM DECLARA71�Ii C .Q � I HEREBYAFFIFN!U�FR PENNTYOF PERJURY OkE OFTHc FOLLOWIYG DECih��c�i���/ �� � � C/3 Q 0 I INAVEN.I�WiLLAeAINTP.INACEATI�ICAiEO�CONSENT705.LFINSUR=WRWORKERS' Z '�Qv- CCMAf•Ek5AT10N,AS aROYI�ED BY SECTIOM 3�00 GF TNE LABOR CbDE,FUR THE PER�-0RMANCE �U _____ OFTHE 4YONK FOR 1NHICH TWS PERld1T IS ISSUE�. O �-�— — `I HAVE MJU WILL MAINTAIN IYORKERS'COMpENSATION INSUftANCE,AS REO:;IR.EO 6Y SECTION d 370oOSTFIELABORCWE,�ORTHEPEflFORMMCEOFIMEWORKFORWH',CHTHISPERMITIS ���� ` z�-� � ISSUEO MY W/Oe�R!(ERS'COMPEPlS/A�TION iNSI:RANCE CFPRIER ANO�OI.iCY NUMSER ARE: � CONSTRUCTION __ _____ ��� � CARR!ER,�{/,��� � PLAN REVIEW � _' � poucvNUMaEn���!"�_�'����—__� ELECTRIC ____ ¢ 3 � �;,�.�;': � �r.ass��avN-�rareemuasrmoFn+kvew�rrs�tavEuur.oa:nm!�l�ool '�+°�5a" PLUMBING ------ �� W � rl MECHANICAL Z I CEA""iV THAT IN THE aF.AFORNANCE OF 71�1'c Ni00.%FOR'NHICM THiS PFRMIT IS I55'3ED.I ----- — (.j" SMRLL NOT EMPLOY F,NY�EHSON iN AI:V MANNER SO AS'O BECON.E SUBJECTTfJ iHE �, � WOAKERS'COFAP'NCATIONLAWSOFCAI.IFO:inIA,0.NDAGFEETHNTIFISHOULDBECOME � I INSPECTIONFEE ________._ 3U9JECTT07HEWORKERS'C07APENSATIONPROVISIONSOFSECTION3]COOL;HFLABOR ';�� '1 /, 4:^�x. ^` F= � ISSUANCE u E�:�� +4.�'r.`:�1 �"ll i, � G^OF.,:SHq11F R.HWITiCOMPL`.'WITiTNOSEPROVIS�O�15. � — -}�— ;-y,�' � _,�r���f� SMIP �yY�'�;r�,,... roCi� p DA7E:Q��� APPI.iCANT. __---'��t3 . fi � `� -�--^-- ENEflGY P/C - - . . J WARNINC F ILURE T SEGIRE WOFiKERS'GOMPEN3ATION COVEMCE IS UNUWFUL AN�SHN.L 6E- '— , �y SUBJECTANEMPLOVeRTOCRIMINALPENALTIESAN[7CIVILFINESUPTOONEHUNOAEDTHOUSANO ENERGYPERMIT DOLLRRS�5100,OW).IN AO��TION TO TN[COST CF COMPENSATION,DMIAGES AS PRQV!DEO FOR IN --' sSECTION370BOFTHEIABORCO�E,IN7EREST,ANPhTTORNEY5FEE5. — RETENTIONFEE: _____ d CONSTRUCTIONLENOINGAGENCY PRE-ALTFEE: _____.. �— O � IHEREBYAFFIRMUN�ERPENALNOFPERJURI'THATTHERF.ISACONSTRUCTION_ENDINGAGENCY � _______, FOR 1NE FERFORMANCE OFTHE WORK FOR WHI^H THiS PERMIT IS ISSUED ISEC.3087,CIY.G). � LF.kDER'S NRME �y��'�./__���/�__���/ � _____ H- LEN�ER'SA�ORESS����L��L! �T aCY�[(��F��Jr'�L wI CERT�FY tNAT I HAVE READ YHIS APPLICATION AN�STATE THAi TME A50YE INFOFMATKKi i5 COPREGT. TOTAL FE ES � IAGflEETOCAMPIVWITHALLCT'ANDCOUYTYOFDINANCESANDSTATELAWSRELATING708UILDING CONSTF0.ICTION,pNDHEREBYAUTHORIZEkEPRESENTATIYESOFTHISCOUNr'?O TEF N7HE� Z ABOVE�MENTIONE�PROPERTYFORINSPEC?IONPUR� POSES. � 6'�bE- ��''��' COMMENTS _._ � � C� %l i r�P -' 5�^��c<y--/ — m � : _ R_����-C ¢ PERMITTEE N E(PflINT) � � � �� � -- --�_� SIGNATUR'c oF PERMITi E '� E ' ^ 1 i = PECPT NO. ._ r __PAID BY � VALIDAT�ON ~ WHITE—Department Copy,YELLOW—Finance Copy.PINK—Assessor Copy. OLDENHOD--File Copy.GREEN—Applicant's Copy � .. ' ' s� ,. '� ., . . �� , .... �!; . >(. ` ;F,3 r„', - ,.�. ':i���:.. ?i5f . . � : . ,. � . ..,.,;... ., rf'' ''. "r�"...,'.'.•- - ; "sj .�, . - - . I'.�.'; k, :�:�'i' :a `a.z<< � *� , . s � �°S �•.'s:a.;' �y� { �3 t ' s�`!•" .� "� � r: �: V 4. d , ;y- '.� ,Y , . . . . . . . � „ . . , ,_.�.e :r-'! r .,. . . . . .., ., . �. �.z , .». .. . , . . ..._ .. . ., -„ . . .........., .. : ""' . ' ' , _ . . , .. . . . , .1 . . . �" ' "'F"': .. . �< '.. . _. . , .'. . ' . . . 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