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HomeMy WebLinkAbout10990 �_. i( � -�-- CITY OF DIAMOND BAR � � t � � COMMUNITY DEVELOPMENT DEPARTMENT � _,---'�'"`� Ia , -, 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS """' BUILDING PERMIT APPLICATION FIRMLY � JOBSITE y� y� '_'1 !� o ADDRESS ��7tW_4��1'��n� G""�� DATEICATION ^ p�,� NUMB R �/�� #`C J °T APN LOT �� TRACT ��I �!�i I DATE ✓ ONST. GROUP p OWNER ,L C o ADDRESS �'��ta T[SY'Y'LW, k' • ZONING SETBACKS z CITY"�6YV'L1M.1�� ZIP��"l� TEL.�i�S�i��Fll9 FRONT RW ❑ a APPUCANT TEL. REAR ❑ aSIDE/SIDESTREET RW C Q CONTRACTOR SIDE C ADDRESS � CIN ZIP cl]� TEL. ..�' PROPOSED USE � ARCH/ENG! e t - z DESIGNER ���,�^+ta�C.9`� 4' ��'i`�' I9� w �-c NO.DWEL. NO. Np, � ADDRESS a„�!L'S�t''T t9�r d'(uG-�- Z�,:ic� UNITS STORIES BEDROOMS � CITY ZIP TEI. cn u� DESCRIPTION SQ.FT: FACTOR PSF ADJ.AREANALUATION � OWNER-BI;ILDER DECLARATION Q SFWADDiREM / � I HEREBY AFFIPM UNDER PENALTY OF PERJURY 7HAT I AM EXEMPT FROM THE CONTRACTORS LI- Ga18Q0/C3f�J01'I W CENSELAWFOaTHEFOLLOWWGREASON(SEC.7031.58USINESSAN�PROFESSIONSCODE:ANYCINOR (n U COUNTYWHICHRE�UIRESAPERMITTOCONSTRUCT,AL�ER,IMPROVE,DEMOLISH,ORREPAIRANYSTRUC� w TUHE,PRIOR TO ITS ISSUANCE,ALSO REDUIP,ES THE APPLICANT FOR SUqi PERMIT TO FILE A SIGNED W Patio(DeCk � STATEMENT THAY HE OR SHE IS LICENSED Pl1RSUANT TO 7HE PROVISIONS OF THE CONTRAC70ftS LI� CENSELAW(CHAPTER9(CAMMENCINGWITHSECTION?000)OF�IVISION30FTHE6l1SINESSANDPRO. �'�' PoOUS(7d � FESSIONSCO�E)ORTHATHEORSHEISEXEM?ThIEREFROMANDTHEBA515FORTHEALLEGEDE%EMP- (!� U TION.ANYVIOLATIONOFSECTION7o31.5BVANVAPPLICANTPoFAPERMIT&UBJECTSTHEAPPLICANTTO Z Re-Roof ACIVIL PENALTV OF NOT MORE THAN FlVE HUNDRED DOLLA(iS(SSoO).�: � ❑I,ASOWNEROFTHEPiiOPERTY,ORMYEMPLOYEESWITHWA3ESASTHEIRSOLECOMPENSATION, � COrtIlflelCldi Z WILL DO THE WOAK.AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOfl SALE(SEC.7044,BU51- J � NESS AND PROFESSIONS CODE:THE CONTRACTORS LIGENSE LAW DOES NOT APPLYTO AN OWNEfi OF � PROPEK�Y NMO 6UIL�5 Ofl IMPROVESTHEREON,AND WHq DOES Sl1CH WORN HIMSEIFOR HERSELF OR � THROUGHHISOFHEROWNEMP�OVEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTEN�EDOR m W OFFEfiEDFORSALE.I�,HOWEVER,THEBUILDMGORIlAPROVEMENTISSOLDWITriINONEYEAROFCONPLE- � TION.THE OWNEa�BUILDER WILL HAVE THE BURDFN[]F PRnVMG THAT HE OR SHE DID NOT BUILD OR Z IMPROVEFOR7HEPURPOSEOFSALE), _ ❑I,ASOWNEROFTHEPROPERTV,AMEXCLUSI'JELVCONTRAC7INGWITHLICEM1SEDCONTRACTORS W [[ TO CONSTRVC'THE PROJECT(SEC.7044,BUSINESS AND Pf10FGS510NS CODE:THE CONTRACTORS LI- VdIU3S10(1 ADJ.AREA W CENSELAWWESNOTAPPLVTOANOWNEROFAPROPERiYWHOBUILDSORIMPROVESTHEfiEON,AND - � WHOCONTRACTSFOaSUCHPFOJECTSWITHACONTRACTOR(SJLICENSEDPURSUANTTOTHECONTaAC- QUANTITY DESCRIPTION FEE TORS LICENSE JtW.). � C I AM EXEMP7 UNOER SEC..___.____ B.8 P.C.FOR 7HIS RFASON Q � �QQ , .,��y �' � � 'S � � DATE OWNER H Z w �O `"��"QI � LICENSED CONTRACTORS DECLARAT�ON —i ¢ W n Z�J � I HEREBYAPFIRM U��DER PENA_TY OF PERJURV TF'AT IAM LICENSED UNDER PROVISIONS OF CHAPTER � � a _� d 9(COMMENCING WITH SEC710N 7oD0)OF DIVISION 3 OF THE BUSINESSAND PRO=ESSIONS CODE,AND X MY LICENSE IS IN FULL rORCE AND EFFECT. = � LICENSE CLA55 �`'4/ LIC.NQ_C-.!.�R'+l�-�-� __ j U DATE�� CONTRACTOR�.7 Lr�_ a � � � � W � WORKERS'COMPENSATION DECLARATION Q + � I HEREBV AFFIRM UNDER PENALTY OF PERJURY ONE OFTHE FOIIOWING DECLARATIONS: V �'-' Q D5 �'� ��.J � I HAVE ANO WIL�_MAMTAIN A CERTIFICATE OF CONSENTTO SELF�INSURE FOq WORKERS' _ ¢ COMPENSA710N,ASPROVIDEDBYSECTION37000FTHELABORCOOE.FOaTHEPERFORMANCF U Q OF TNE WORK FOR WHICH THIS PERMIT IS ISSUE�. � � �HAVE AND WILL MAINTAIN WORKER5'GOMPENSATION INSURANCE,AS REQU�RED BY SECTION Q 3"!OO OF THE 1A30R CODE,FOfl THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.MYWORKEFi'CO ENSATIONINS ANCECA IERANOPOLICYMJMBERARE� CONSTRUCTION J > cAARiER �'� � �y, �U�� PLANREVIEW POLICV NUMBER�z""'/� �I �� Z �—�- ELECTRIC � �j/,� 0 (iH4SSEGTIIXVNEmNOTBECUMPLETEDOFhiEPERMfiISWRIXJEFAJNOHE00IX.lARS�5100)ORLESS). PLUMBING _ W Z I CEFTIFYTNAT IN THE PF.FiFORMANCF OF'HE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL (3 SHALLNOTEMPLOYANYPERSONINANYMANNERSOASTOBECOMESUBJECTTOTHE (_q WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANOAGREETHATI�ISFO'JLD6ECOME INSPECTIONFEE = SUBJECTTOTH WORKERS'CON�PENSATIONPROVISIONSOFSECTION37COOfTHELABOR �.�p� CO�E, SHALI fiTHWITHCOMPLVWITHTHOSEPROVI510N5. ISSUANCE f �^CJ � � �_ _ �- p DATE: APPLIrqNT: �__ _,__� SMIP W J WARNING: AILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUI,AND SHALL BE ENERGY P/C J � SUBJECTAN EMPLOYER TO CRI�411NAL PENALTIES AND CIVIL FINES 11P TDONE HUNDFlED TNOUSAND ENERGY PERMIT DOlLARS(Et 00,00D).IN ADDITION 70 THE COST 0�CONPENSATION,DAMAGES AS PROYIDED FOR IN J SECTION 3�OB OF THE LABOR CODE,INTEREST,AND ATTCRNEY'S FEES. � � oC RETENTION FEE: OCONSTRUCTION LENDING AGENCY PftE-ALT FEE: . .Q� ___ � I HERLBVAFFIRM UN�ER?ENAITY OF PER.'UaY THAT THEPE IS ACONSTRUCTIDN LENDING AGENCY FORTHE PERFORMANCE OFTHE WORK FOF WHICH TNIS PERMIT IS ISSUED(SEC.309'!,CIV.C.). "— Z W ? LENDER'S NAME y F— LEN�ER'SADDRESS wICERTIFVTHAiIHAVEREADTHISAPPLICATIONANDSTATETHATTHEABOVEINfORMATIONISCORRECi. TOTAL FEES � '�� � I AGREE TO COMPLY YlITH AlL CITY AND COUNTV ORDINANCES AND�TATE LHWS RElA71NG TO BUILOING � CONSTRUCTION,FND HEPEBYAUTMORIZE REPRESENTAT!VES OF TFi15 COUNTY TO ENTER UPON THE Z ABOVE-MENTIONEDPROPERTVFORINSPEGTIONPUFPOSES. COMMENTS � � �:� ���9� � • • /__l_� . m PERMITT NAME(PRINT) ' Q �� � . . ...�.:. . � SI TU EOFVERMITTEE TE �� � :, ^ � RECPT.NO. PAID BY � VAUDATION �`'— WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanCs Copy � -� �� ..:. ,::.,,..........,- .�M.,.:(twvw�+•.,�:� � .i.�«,.�v r.atrr..,,- •m�.-.,,..%'n�i..,;eox,dg�.. T.. ... . , , ..�Yf^.._r. , . ., ,... �. ,�. . , .,e, .�,. .. _. . . .. .. . .......-.. .. . . �" .. � �. � � 6 ... , , _.._. ...._.... __ , . , . ' �� . . ... . .. � ' 1 . . . .... ' ' . .-..� .:::...... --..- � - k i � � � $... � �. ;. � � � � "'� � � � � � � . , , � � _. . a�. .�� �.� �� . � . S.' � ��.�t�l�.��I:�T , 5(~� r-�a gC �__j.__.__ _�._._ - _........___. 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