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HomeMy WebLinkAbout14456 �•:� . .. �� _ CITY OF DIAMOND BAR - ' DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES "� 21660 E.Copley Drive Suite 190 � (909)860-3195 Fa7c(909)861-3117 PRESS ���%%�°�� BUII,DING PERMTT APPLICATION FIRMLY � J08SITE , p1 � / APPLICATION � '� �� PERMIT �Y � P/C o ADDRESS ��Is 6 ��nlT�f� WO'P�� DAT'E NUMBER # c� ISSUE NPE OCC � APN LOT TRACT DATE CONST. GROUP p OWNER �f�(����jV ADDRESS i ZONING SETBACKS � CITY7! �,�yn�Qj, '� ZIP9/7(� TEL. !- // FRONT RW C APPLICANT TEI. REAR r' Z SIDEJSICE STREET RW C � CONTRACTOR s�n,l�-�//nis �,?Fa-�j�[�-- SIDE __ C ¢ ADDRESS l ' � PAOPOSED USE " o ciTv`D��,.,o�QQ}.��o,. ziPqt�TEL. D i- 7 dtpw�.dC�1- L . w ARCH/ENG/ ���.C1�` �� w DESIGNER NO.DWEL. NO. NO. . a ADDRESS UNITS STaRIES BEDROOMS � CITY ZIP TEL. _ y DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADDlFlEM O 0 I HEREBY AFFIRM UNDER PENALTY OF FER.NRY TNAT 1 A61 EXEMPT FROM THE CONTRACTOHS�I� Gdf3JBlCdfpOrt W CENSEUWWRTHEFIX.LOWINGREASON(SEC.7031.SBUSINESSANOPROFESSIONSCADE:ANVCIT/OR (n __ U COUNTYWHICHREWIRESAPERMfTTOCON57RUCT,ALTER,IMPROVE,OEMOLISH,ORflEPAIRANYSTRUC- W patio/Oeck W TURE,PHIOR TO ITS ISSUANCE,AL50 REWIRES THE APPLICANT FOR 3UCH PEHMIT TO PILE A SIGNEO W � STNTEMEM THRT ME OR SHE IS LICENSm VUflSUANT TO THE PROVISIONS OF hiE CONTRACYORS LI� � CENSE LAW(CHAPTER B(WMMENCING WITH SEC710N 7000)OF DIVISION 30F THE BUSINES5�tiND'PHO- � PoOUSpd FESSqNS CODE]OR THAT HE OR SHE IS E%EMPT TMEREFROM AND 7HE BASIS FOH THE ALLEGED EXEMP• TION.ANYVIOIATIONOFSECTION7o9t.58YANVAPPLICANTFONAPERMITSU&IECTSTHEAPPLICANTTO Z RB-ROOf � � ACIVILPENALTVOFNOTMORETHANFNEHUNDREDUOLURS(SSoo)J: � OI.A60WNEROFTHEPROPERTY,ORMYEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSAiION, � Commercial - NALL DO THE WORN,AND THE STRUCTURE IS NOT IMENDED OR OFFEREO FOR SALE(SEC.7046,BUSI- J � NES£A.YD Pf�FE5510N5 CODE'THE CONTMCTORS LICENSE LAW OOES NOT pPPLY TO AN OWNER OF = PqOPEF7�Y MhlO 9UL05 OR IMPRDVES hIEREON.AND YMO�OES SUCH YVORK HIIASELF OR HERSELF OR � THRWOHHISORHEROWNEMPLDYEES,vqOVIDE�7HAT5UCHIMPROVEMEN75ARENOTINTENDEDOR m QOFFEHEDFORSALE.IFHOWEVER7HEBUIIDINGORIMPROVEMENTISSOLDW!TMNONEYEAROFCOMPLE- Z T10N,THE ONMEF�UILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DIO NOT BUILO OR � IMPROVE FORTHE PURPOSE OF SALE). ❑I,AS ONMEROF THE PROPERTY,AM EXCLUSIVELV CAMRACTING WITH UCENSED CAMTRMTORS � TO CONSTRUCT lHE PRQIECT(SEC.70M,BUSMESS AND PROFESSIONS CODE:THE CONTRACTORS LI- VdIUBfIOn _ ADJ.AREA W CENSELAWDOESNOTAPPIYTOANONMEROFAPROPERTVWHOBUtlD50RIMPROYESTHEREON,AND � YYFpCONTRACTSFORSUCHPROJECiSWITMqCONTRACTOR(5)UCENSEDPURSUANT70TNECONTRAG QUAN DESCRIPTION FEE � TORS LJCENSE tAW.�. � ❑I AM EXEMPT UNDER SEC. 9.8 P.C,FOR TH�S qEA50N U 3. _ —_'__ _-'_ � � � LL �ATE OWNER_ � Z U W — �Q LICENSED CON7RACTORS DECLARATION �j 2 I HEREBV AFFIRY UN�ER PENALTY OF PERJURY 7HA71 AM IICcNSED UNJER PROVISi0N5OF CNAPiER � � 9(COMMENCINO WITH SECTION 70m�OF DIVISION 3OFTHE BUSINESS AND PROFESSIONS CODE,AN�J z !C' MY LICENSE IS IN FULL FORCE AND EFFECT, m 0 UCENSE CU/1SS LIC.N0._ _/L���� � J �1 � ~ DATE�1�loY�'�.PPTS� CONTRACTOR��, J U a w � WORKERS'CDMPENSATION OECLARA?ION Q � � IHEREBVAFFIRMUNDEFiPENALTYOFPERIURYONEOFTHEFOLLOWINGDECLARATIONS. U � Z Q — � IHAVEAPDIMLLMNNTAINACERTIFICATEOFCANSENTTOSELF-INSUFEFORWORKe'RS' _ � COMPENSATION,AS PROVI�ED BYSECTION 37000F THE LABOR COOE.FOR THE PERFOFMANCE W _ OF TNE WORI(FOR WHICH THIS PF.RMIT IS ISSUED. � � W I HAVE AND WILL 1AAIN7qIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BY SEC'IDN /� !,� C nl Q 37o00F YHE LA90q CODE,FOR 7HE PERFORMANCE OF iNE WORK FOR WHICN THIS PERMIT IS --- (� >(J ISSUE�.MV WOR/K�ERS'COMPENSATION INSURANCE CARRIER AND POLICV NUMBER ARc CONSTRUCTION � CARRIEA .��� � __ PLAN REVIEW ____ y� � POLICYNUMBER ELECTRIC �■■ Q � — Q (iHISSECf%7NNE�NDTBEOOMPLEfEDOF1HEPFPMiISPDROPIENL'AOFiF.D�LIARS(5'�0)ORLE551. PLUMBING ___._.-. __ Z 1 CERi1FY lNAT IN THE PERFORMMIGE Of THE WORK FOR WFIICH 7HIS PEfiMR f5 ISSUEO,I MECHANICAL ___ f (,'j SHALL NOT EMPLDY ANY PERSON W ANY MANNER SO AS TO BELOME SUBJECT TOTHE g/� � WORKERS'COMPENSATIONLAriSOFCAUFOFYIA,AN�AGREETNATIFISHOULD9ECOlAE INSPECTIONFEE __mJi"a� =� SUBJECTTO THE WOFKERS'COMPENSATION PROVISIONS OF SECTION 37a0 OF 7HE U190R � CODE,ISNA.I.LFORTNWITHCOMPLVWRHTHOSEPROVISIONS. ISSUANCE Pti _ - '`— 1. jy � O `p �ATE:���APPLIGANT: _ SMIP �a sv:� � �i L � ENERGY P/C �,��'���}�����"'� J WARNINGFAIWRETOSECUREWORI(ERS'COMPENSATiOhCOVERAGEISUNAWFUL,ANDSHALL.BE --- . --"--'"'---- " �y SUBJECTAN EMPLOYER TO CRIMINAL PENALTIES AN�CIVIL FINES UP TOONE HUNDRED THOUSAhO ENERGV PERMIT DOLI.ARS(5100,OooI�INADDiT10NTOTHECOSTOFCOMPEN5AT10N,00.MAGESASVROVIDEDFORIN --- -'------'--'----- — � SECTION37000FTFIELABORCODE,iNTEREST,ANDATTORNEV'SFEES. RETENTIONFEE: ,_,__ __ pW_, CONSTRUCTION LENDING AGENCY PRE-ALT FEE: ___ _ O � 1 HERE9V AFFIqM UN�ER PENA�TY OF PERIURY THAT'HERE I$A CONSTRUCTION LEN�:NG AGENCV __ ____ � FOR THE PERFOHMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED�SEC 3097,CIV G), -- �� ' ' Z _ W . . . , . . ... . . � LENOEfi'SNPME__ ,. � nN.' -- F= LEN�ER5AODRE55� )1L/L��l47lS�X��.�'� � /-//� �� � � WICERTIFYTHA7IHAVEflEADTHISAPPUCATIONANDSTATETNATTHEABOVEINFOqMAT10NISCOFRECT. T`JTAL FEES �7(/}- �� � I AGREE TD COMPLY WITH ALL GRV AND COUNTY ORDINANCES PHD STATE LAWS RELATING TO BUIL�ING Y� CONSTRUCTION,AND HEREBY AUTHORIZE REPiiESENTATIYES OF THIS COUNTV TO EMER UPON h1E Z A80VE-MENTIONED PROPERTY FORINSPECTION PUFiPOSES. COMMENTS __ Q . .. ..... ,,. 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