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HomeMy WebLinkAbout12092 _..,_.�...___._ ,,,,R.,�..,,�,,.�.�..�..,,_,�..r .�_._,_,. ...�.... � �� CITY OF DIAMOND BAR � ��� �'��� � DEPARTMENT OF COMMLINITY&DEVELOPMENT SERVICES 21660 E.Copley Drive Suite 190 �; (909)860-3195 Fax(909)861-3117 PRESS A� BUILDING PERMIT APPLICATTON ._. FIRMLY . . ...... ., : . . ., ... ,., ,., . .., . � JOBSITE �`� � i� APPLICATION p��,���.l PERMIT r/z6!�n P/C ¢ ADDRESS �' DATE d ,�f NUMBER 1 �L, # � APN LOT TRACT DATE����/ / L7 CONST. GROUP p OWNER �Y �C ��. � �,� �— ADDRESS ZONING SETBACKS � CITY ZIP TEL. REART RW ❑ APPLICANT TEL. SIDE/SIDE STREET RW ❑ � CONTfiACTOR �' L/"" �`1� SIDE ❑ � ADDRESS PROPOSED USE 1 I/L iL1 1'� 1 1 /' 'i'7 ► /' o cirr �� ��a nC� ziP .�,. TEL. - .t --p r�_�v_—�f_-���r-r7�-� o ARCWENG/ z DESIGNER NO.DWEL. NO. NO. '�L' ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF AW.AREANALUATION � Q OWNER-BUILDER DEC4ARATION SPR/ADD/HEM O p I HEREBV AFFlRM UNDER PENALTY OF PERIURV THAT I AM EXEMPT FROM 7ME CONTRAC70flS ll� G8I890/C8R.10R W CENSEUWFORTHEFOLLOWINGREASON(SEC.7o37.5BUSINESSANDPROFESSIONSCODEANVCITVOR (� U COiINTVWHICHREIXlIR6APERMff7000N5TRUCT.ALTER.IMVROVE,OEMOLISH,ORREPAIRANYSTHUG LJ.i petiD/DeCk WTURE,PRIOR TO ITS ISSUANCE,ALSO REOUIRES TME APPLICANT FOR SUCH PERMIT TO FILE A SIONED W � STATEMENT h1FT ME OR SHE IS IJCENSED PURSUMIr TO THE PROVISIONS OF THE WhffRACTORS U� CENSE UW(CNAPTER 9(COMMENCINO WI7H SEC710N 7000)OF DNISION 30F 7HE BUSMESS AND PRU � Pool/Spa FESSIONS CODE7 OR THAT HE OR SHE IS EXEMP7 THEREfROM AND THE BASIS FOR THE ALLEOED E7fEMP• TION.ANVVKKATIONOFSECTION7o31.56VANVAPPL�CAMFORAPEqMITSU&lECTSTHEAPPLICANTTO Z qa-Roo1 � ACMLPENALTYOFNOTMORETHANFNEHUN�REDDOI.LARS({5o0).): ^ ❑I,ASOWNEROFTHEPqOPERTY.OHMVEMPIOVEESWITHWAGESASTHEIRSOLECOMPENSATION, 0 COI71R18fCi81 � j WILL DO TNE WORK,AND THE STRUGNRE IS NOT INTENDED�R OFFERED FOR SALE(SEC.704a,BUSI� J NESS MD PROFESSIONS CODE:THE CONTPACTOPS UCENSE LAW OOES NOT APPLV TO AN OWNEP OF � PpOPERTYYVFIOBUILD50RIMPROVESTHEREON,MIDWHO00ESSUCHWOflKHIMSELFORHERSELFOR m Q TNRdJGNHISORHERONMEAAPLOVEES,PROVI�ED7HATSLICHIMPROVEMENTSARENOTINTENDE�OR QOFFEREDFORSILEIF,HOWEVERTMEBU1lDINOORIMPROVEMENTISSOIDWITHINONEYEAROFCOMPIE Z TION,THE OWNER$11110E�7 M�ILL HAVE 7HE B1JR�EN OF PROVING iHA7 HE OR SME DID NOT BUILD OR = IMPROVE FOR 7HE PURPOSE OF SALE). C 4 AS OWNER OF TNE PROPERTY,AM EXQUSIVELY COIVTRACTING WITM LICENSED CONTMCTORS Q TO CONSTRUGT THE PRQIECT(SEC.70.1{,9USINESS AND PPOFESSIONS C�DE:THE CONTRACTORS LI- V81U8110n ADJ.AREA � CENSEUWDOESNOTAPPLVTOANOWNEflOFAPROPER7YWHOBUILD50RIMPROVESTHEREON,AND WHOCONTMCTSFOqSUCHPR0.IECTSWITHACONTRACTOR(5)LICENSEDPURSUANTTOTHECdNTRAG aunNriTv DESCRIPTION FEE TIXiS UCENSE UW.). O ❑IAM DfEMPT UNOER SEC. B.&P.C.fOR THIS REASON U ' rG�YJ ^�t �i � � � � O u" �pTE OWNER V / W ` E3Ey G . � UCENSED CONTRACTORS�ECIARATION W � � 1 NEREBV AFFlRM UNUER PENAL7Y OF PERJURY TNAT I AM LICENSED UNDER PROVISIDNS OF CHAPTER � (L B(COMMENCIN(3WITHSECTION7000)OFOIYISION30FTHEBUSINESSANDPROFESSIONSCODE,P1�1� Z }� MYLICENSE I6 M NLIFORCEAND EFFEC7. � � LICENSE�C^LASS G�/ � LIC.ND. � V ppTE !� '�L� •�•• .�� CONTRAC70R *' d- W � WORKERS'COMPENSATION DECLARATION —� Q � I HEREBYAFFlRM UNDER PENALTY pF PERJURY ONE Of TME FOLLOWMG�ECLARATIONS: U � Z a 0 �IHAVEAtAWILIMAINTAINACERTIFICATEDFCONSENTTOSELF-�NSUNEFOqWORNERS' 2 � COMPENSA710N,A9PHOVIDEDBYSEC710N37a00FTHELABORCODE,FOR7HEPERFORMANCE �U OF7HE WORK FOR WHICH THIS PF.RMIT IS ISSUE�. � 0 W __I HAVE AND Wlll MAIMAIN WORKERS COMPENSATION INSURANCE,AS REOUIRED BY SECT�ON Q 37000FTHELABORCODE,FORTHEPERWRMANCEOFTHEWOPKFORWNICHhi15PERMITIS ISSUED.MYWORKEPS'COMPENSATIONINSURANCECARRIERANDPOUCVNUMBERAPE: GONSTRUCTION J j CARRIER PLAN REVIEW Z POLICYNUMBER ELECTRIC ���� Q � (fHI55ECT10NNE�NOTBECa.PLEfEDOFhIEPERMiISFORCTIEHUI�DFIEDD01.lARS(E1ao)ORLESS) PLUMBING w ICEfl11FYTHATINTHEPERFORMANCEOF7HEWORKFOqWHICNTHIS7ERMITISI55UED.� MECHANIGAL Z (,�} SHALL NOT EMPLOYANY PERSON IN ANY MANNER SOAS TO BECAME SUBJECTTO THE � WORNERS'COMPENSATIONIAWSOFCA(.IFORNIA,ANDAGREETNATIFISH0�ILDBEC(NAE INSPECTIONFEE SU&IECTTO7HEN'OFKERS'COMPENSATKKJPROV�S�ONSOFSECTION370DOFTHEUBOR �$SUANCE I� CAOE.�SHAILFORTHWITHCOMPLYWITNTH EPROVISIONS. p DATE:��rC=�� APPLICANT:� _ SMIP W ENERGY P/C J WARNINGFPILVRETOSECUREV/ORKERS'COMPENSATIONCOVf.HAGEi$U UWFUL,AN�6HALLBE � SU&IECTANEMPLOVERTOCRIMINALPENALTIESANOCIVIIFMESUPTObRIEMl1NDFEOTHOUSANO ENERGYPERMIT DOILAflS(5700,000).IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR�N J SECTION3�oeOF1HElA00HCO0E,INTEREST,ANOATfORNEV'SFEES. RETENTIONFEE: � a CONSTRUCTION LENDING AGENCY pFE-ALT FEE: O � INEREBYAFFlAMUNDEfiPENALNOFPERJl1RV7F�ATTHEREISACONSTRUCTIONLENpINGAGENCY FOR THE PERWRMANCE�FTHE WORK FOR WHIGH THIS PERMIT IS ISSUED�SEC.909],CIV C.�. Z W � LENOER5NAME F— LENDERSADDHE55 ,� � ' - W I CEPTIfYTHAT 1 HAVE REPD THIS APPLICATION AN�STATE TNATTH'e ABOVE INFORMATION�5 COHRECi TOTAL FEES � p �r � �l � IAGREETOCOMPLYWITHALICITYANDCOUMYORDINANCESANDSTATELAWSREUTINGTOBUILDING CONSTqUC710N,AND HEREBV AUTHOFiIZE REPRESENTATNES OF THIS COUNTY TO ENTEfl UPON THE �,�� Z q80VE-MENTKKvEDPROPERTYFORINSPECTIONPUHPOSES. 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