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HomeMy WebLinkAbout17243 CITY OF DIAMOND BAR - � - DEPARI'MENT OF COh�Ilv1UNITY&DEVELOPMENT SERVICES � � . ��,; 21825 E.Copley Drive � (909)860-3195 Fax(909)861-3117 PRESS %HN�� BUILDING PERMIT APPLICATION FIRMLY � JOBSITE 2 �_ /��� ���/� DATE ` NUMBER # / APPLICATION !1 1 � � PERMIT �"I � P/C � ADDRESS!_���' 1 �> � r� �1/ L � ISSUE TYPE OCC APN LOT TRACT DATE '� �� � CONST. GROUP p OWNER o ADDRES ZONING SETBACKS z CITY ZIP TEL� FRONT Ry�l ❑ � APPLICANT TEL. REAR � z SIDEISIDE STREET RW ❑ Q CONTRACTO�j �' � � .r SIDE ❑ � ADDRES�S �' o CITY ZI TEL. � '? �+OP/�O• r �" o ARCH/ENG/ a DESIGNER w N0.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS F = CITY ZIP TEL. m �n DESCRIPTION SQ.Fi. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLAFiATION SFR/ADD/REM O p I HEREBV AFFlI7M UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LI� GffIdJB/C8fP01I W CENSELAWFORTHEFOLLOWINGREASON(SEC.7C31.SBUS�NESSANDPROFESS�ONSCOOE:ANYCITYOfl (n U COUNTYWHICNPE�UIRESAPERMITTOCO!JSTRUGT,ALT_R,IMPROVE,DEMOLISH,ORREPAIRANVSTqUC� W TURE.PRIOF TO ITS ISSUANCE,AL50 REQUIqES TNE APPUCANT FOR 51!CH PERMIT TO FILE A SIGNcO W Patio/Oeck � STAiEMENT THAT HE OR SHE i5�ICENSED PURSUANT TO THE PROV510NS OF THE CONTRACTORS LI� � � CENSE LAW(CHAPTER 9(COMMENCING WI7H SECTION 7000)OF DIVISION 3 Of THE BUSINESS AND PRO- POOVSpO 0 FESSIONSCO�EI�THATHEORSHEISEXEMPTTHEREFFOMAN�THEBASISFORhIEALLEGE�E%EMP� (� V TION.ANYVIOLATIONOFSECTION7031.58YANYAPPLICANTFORAP'cRMITSUBJECTSiHEAPGLICANTTO Z Re-Roof ACIVIL PENALTV OF NOT MORE THAN FIVE HUNDREO�OLLARS(SSaa).): p ❑I,ASOWNEROFTHEPFOPEFiTY,ORMVEMPLOYELSWITMWAGESASTHEIRSOIECOMPENSATION, � COfi1fI18fCIdI Z WILL DO THE WORK,AN�THE STRUCTUaE IS NOT INTENDED OR OFFEREO FOR SALE(SEC.7044,BUSI� J � NE55AND PROFESSIONS CODE:TME GOfJTRACTOFS LICENSE lAW DOES NOT APP�V TO qN OWNER OF � PROPERTY WHO BUILDS OR�MPROVES THEREON,AN�WHO DOES SUCN WOflK HIMSELF OR HERSEL%OR Q THROUGH HIS OR HER OWN EMPLOVEES,PROVI�ED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR m � OFFEREDFORSALEIF,HOWEVER,THEBUILDINGORIldPROVEMEN71S50LOWITHINONEVEAROFCOMPLE- Z TION,THE OWNERAUILDER WILL HAVE'HE BURDEN OF PROVING?HAT HE OR SHE�IO NOT Bl11LD OR � IMPROVEFORTHEPUPPOSEOFSALE). w ❑I,ASOWNEqOFTHEPROPERTY,AMEXCIUSIVELVCONTPACTINGWITHLICENSE�CONTF7ACTORS � TO CONSTRUCT THE PROJECT(SEC.70a4,BUSINL55 AND PROFESSIONS CO�E'.THE CONTRACTORS LI� V8IU8 ADJ.AREA W CENSELAWDOESNOTAPPLYTOANOriTJEROFAPROaERNWHOBUILDSORINPROVE3THEREON,AND -- � WHOCONTRACTSfORSUCHPROJECTSWI7HACONTRACTOR(S)LICENSEOPURSU.4NTTOTHECONTRAC� Q�JANTI DESCRIPTION FEE Y TORSLICENSELAW.). p ❑I AM EXEMPT UN�ER SEC. B.6 P.C.FOR THIS REASON Q � U lL � DATE OWNER F— Z W � LICENSED CONTRACTORS DECLARATION W ¢ � I MEREBYAFFIRM UNDER PENPLTV OF PEFJUFY THAT IAM LICENSEO UNDER PROVISIONS OF CHAPTER � � 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND z X MY LICENSE IS IN FULL FORCE AND EFFECT. � UGENSE CLASS UC.NO. _��7/�r�l] � V DATEc�r�^'�,} CONTRACTO ' � a W � WORKERS'COMPENSATION DECLAFATION ¢ � IHEREBVAFFIRMUNDERPENALTYOFPERJURYONEOFTHEFOLLAWINGDECLARA710N5: Z � _IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFOAWORKERS' ¢ 2 4 COMPENSATION,ASPPOVIDEOBYSEC710N37o00FTHELABORCODE,FORTHEPERFORMANCE U OF THE WORK FOR WHICH 7HI5 PERMIT IS ISSUEO. W � � W _1 HAVE AND WIIL MqINTAIN WORK[RS'COMPENSATION INSl1MNCE,AS flE0U1RED BY SECTION /� Q 3�0o OF THE:.ABOfl CODE,FOR THE PERFORMANCE OF THE WORK FOR VJHICH THIS PERMIT IS / � ISSUE�.!AY WOPK ENSATION INSUPAN C IER AND POLICY NUMBER ARE: CONSTRUCTION � •� \/ ¢ �� ^ � CAftflIER d V J PLAN REVIEW z POLICY NUMBEil � ���'3,�� ELECTR�C Q � (fiiISSECTICNJNEmNOTBECOMPLE?EDOFhiEPEWJ�ITISFOFQYEHUNDREDCOLIARS(5100)ORLESS} PLUMBING Z 1 CEFTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WH':CH THIS PERMIT IS�SSUED,I MECHANICAL C•} SHALLNOTEMPLOVANVPERSONINANYMANNERSOASTOBECOMESUBJECTTOTHE � WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGREF.THATIFISHOlJL�BECOME INSPECTIONFEE = SUBJECTTOTHEWORKERS'COMCENSATION7ROVISIONSOFSECTION37000FTHEL480R CADE,I SHALL FORTHWITH COMPLY WITH TNOSE PROVISIONS. �SSUANCE � SMIP � p DATE: APPLICANT. J J WARNING:FAILURETOSECUREWORKERS'COSIPENSATIONCOVERAGEISI)NLAWFUL,ANDSHALLBE ENEflGYP/C �y SU&IECTANEMPLqVERTOCRIMINALPENA�71E5AN�CIVILFINEStl7TOONEHUNDREDTHOUSAND ENERGYPERMIT DOLLARS($1 o0,oao�,IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PPOVIDED FOR IN J SECTION 3700 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. p� RETENTION FEE: � � CONSTRUCTION LENOINC�AGENCY pqEALT FEE: O � I HEREBVAFFIRM 11NDER PENALTV OF PERJURV TH�TiHERE IS ACONSTR:ICTION LENDING AGENCV FOR THE PERFORMAVCE OFTHE WORK FOp WHICH THIS PERMIT IS ISSUED�SEC.3091,CIV.C.). Z W � LENDER'S NAME H LEN�ER'SADORE55 � ICERTIFVTHATIHAVEREADTHISAPPUCATIONANDSTATETHATTHEABOVEINF00.MATIONISCORRECT. TOTAL FEES � ��.� /`� w I RGR[E TO CAMPIY W':TH ALL CITY AND COUNTV OFlDINANCES AN�STATE UWS RELATMG TO BUILDINO G/ �.l J � CONSTRl1CTION,ANOHEREBVAUTHORIZEREPRESENTATIVE50FTHISCOUNTYTOENTEFVPONTHE � ABOVE�MENTIONED PROPERTY FOR INSPECTION POSES. z COMMENTS 0 � � m PERMITTEE NAM PftINT) ¢ �_�-°��-----��_-�rz--��- � � SIGNATUREOFPERMITTE ❑A E = RECPT.NO. 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