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HomeMy WebLinkAbout10167 CITY OF DIAMOND BAR ,�-` COMMUNITY DEVELOPMENT DEPARTMEfVT i .,,,e 21660 E Copley Drive Suite 190 PRESS (909)860-3195 Fax(909)861-3117 �'""' BU[LDING PERMIT APPLICATION FIRMLY JOBSITE 1- t t APPLICATION � (_+,�/ PERMIT f � ' � P/C o ADDRESS Z-S 2- W O Oa�Y'1� �� DATE � �f / NUMBER � # � APN LOT� TRACT ��K S I DA EE ONST. GROUP p OWNER TL� N On'1 E S " ADDRESS 34g 0 1 O hZR ANC� $1 U]�. �-�, ZONING SETBACKS gCITY '�O'I�.R►�1/JC..G ZIPqnS'� TEL.3�o �7�"s7'1't1 FRONT RW C APPLICANT TEL. REAR ❑ � SIDE/SIDE STREET RW p � CONTRACTOR ��t.Cr L SIDE ❑ � ADDRESS p . p PROPOSED USE CITY ZIP�I��� TEL. �lg D/S w ARCH/ENG/ W DESIGNEA NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDRO�MS � CITY ZIP TEL. N DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BI:ILDER DECLARATION SFR/ADO/REM O � 1 HEREBY AFRRM UNDER PENALTY OF PERJURV THAT I AM EXEMPT FROM THE CANTRACTORS U- Gflf9gB/C81POf[ W CENSELAWFONTHEFOLLOWMGREASON(SEC.7031.SBUSINESSANDVROFESSIONSCODE:ANYpTYOfl (n U CWNTYNMICHREOUIRESAPERMRTOCONSTRUCT,ALTER,IMPFOVE,DEMOLISH.ORpEPAIRANYSTRUC� W pat10IDBCk w TURE.PRpR TO ITS ISSUANGE,AL50 REOUIRES THE APPUCANT fOR SUpi PERMIT TO FILE A SIGNED w _ � STATEMENT THAT HE OR SkE IS IICENSED PURSUANT TO TlIE PROYSIONS OF THE CONTRACTOftS LI� � CENSE LAW(CHM7ER 9(COMMENbNO MATH SECTION 7Wo)OF DIVISION 3 DF THE BUS`IN'ESSAND�P{iD- LL POOUSp3 FESSIONS�E)OR 7HA7 HE OR SHE IS E%EMPT 7HEREfROM AND 7ME BASIS FOR THE ALlEOED E%EMP• � TION.ANVVIOLATIONOFSECTION7031.5BVMn'APPLICANTFORAPERMITSUBJECTSTHEAVPLICANTTO Z RB-ROO� A CNIL PENALT'OF NO7 MORE THAN FIVE HUNDRED DOLURS(S�)�): ❑L AS OMMEH OFTHE PROPEHiY,OR MV EMPLOYEES WITH WAGES AS 7HEiR SOLE COMPENSATION. O Z Commercial WILI DO iNE WORK,AND 7HE S7RUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7ott,BUSI� J NE55 AND PROFESSIONS COOE:THE CONTRi1CTORS LICENSE LAW DOES NOT APPLY N AN OWNER OF y PROPEHTVVhIOBUILDSOi11MPROVESIHERE�N,ANDWHDDOE5Sl1CHWORKHIMSELFORHERSELFOq � � THROUGNHI30RHEROVlNEMPL�'EE3.PFlOVIDEDTHA75UCHiMPROVEMEN7SAiiENOTINTENOEDOR m � OFFEREOWHSALE.IF,HOWEVERTNEBUILDMGORIMPROVEMENTISSOLDWITHINONEVEAROFCOMPLE� Z TION.THE OWNER-BUILDER N7lL HAVE THE BURDEN Oi PROVING 7HAT HE OH SHE DD NOT BUILD OR � IMPROYE FOH TNE PURPOSE OF SALE�. W OI,ASONMEROFTHEPROPERTY,AMEXCLUSIVELVCANTRACiINGWITHLICENSE�CANTRACTOflS � 70 CONSiRUCT THE PROJECT(SEC.701a,BUSMESS AN�PROFESSIONS CODE:THE CONTRACTCRS Lb V01U8ti0l1 ADJ.AREA W CENSEUWDOESNOTAPPLYTOANOYVNEROFAPppPERT'WHOB�ILOSORIMPROVESTHEqEGN�,AND F YMOfANTfl4CTSFORSUCHPRQIECTSNATHACONTRACTOR(5)L�CENSEDPURSUANTTOTHECONTRAC- Q�JANTITY DESCRIPTION FEE Y TORS LICENSE LAW.). 0 GIAAIEXEMPTUNDERSEC. 8.8P.C.FORTHISREASON Q LLQ KMY � 1 DA7E aWNER V Z W � LICENSED CONTRACTOFiS DECLAHATION w � I HEflEBYAFFlRM UNDER PENALTY OF PEflJURYTHAT IAM LICHJSED UNDER PROVISIONS OF CHAPTER � B(�MMENGING WITH SECTIDN 7DOOI OF DIVISION 3 0F 7HE BUSINESS 0.ND PpOFE5510N5 CODE.AND X MY LICENSE IS IN FULI FORCEAND EFFECT �w y�y 2z2_ UGENSE CLASS ��A� _LIC.NO. ��T-� WDATE��q 7 CONTRACTOR L..1�--�F ��� n� WORKERS'COMPENSATION DECLARATION � � � INEREBVAFFWMUNDERPENAI.NOFPERJUAVONEOFTHEFOLLAWINGDECLARA710NS: N � _INAVEANDWILLMAINTAINACERTIfICATEOFCONSENTTOSELFINSUREFOFWOHKENS' ¢ COMPENSATION.ASPflOVIDE�9Y5ECTION3T000FTHEUBONCODE,FORTHEPERFORMAHCE OF THE WOHK FOR WHiCH THIS vERMI7IS ISSUED. W �NAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIqED BV SECTION Q 37oa OF THE LA80R CODE.FOR THE PERFOR1.1pNCE OFTME WORK FOR WHICH7HIS PERMRIS ISSUED.MYWORKERS'COM7 NSATIONINSURANCE J¢ANRIERANDPOLIGVNUMBERARE� CONSTRUCTION a ��� �l,J V�V PLAN VIEW � CARRIER __— Z POLICV NUMBEP '�-�"'�, Q�«4 L� i`LECT � � .� a 0 ��ss[tnoarveIDrroree�t�ooF'n+everoarswAorae�oaurtis�s+oola��ss). PLUMBING Z 1 CEM�FY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PEflM1T IS ISSUED,I MECHANICAL (J SFIALL NOT EMPLAY ANY PERSON IN ANY MANNEH SOAS TO BECOME SUBJECT TO THE -� � WORKERS'COMPENSATIONlAW50FCALIFORNIA,ANOAGREETHATIFISHOULDBECOME INSPECTIONFEE F SU&tECT70THEWORKERS'COMPENSATIIXJPHOVISIONSOFSEC7iON37ovOFTHElA80Fl � � CODE,1 SN�V.L FORTHWITH CdAPLY W17HTHOSE PRONSIONS. (SSUANCE � SMfP p DATE: APPLICANT: — � ENERGY P/C WAqtJINO;FAILURE TO SEIXIHE WOPoCERS'COMPENSA710N COVERAGE IS UNUWFUI,MD SNALL BE tg�♦ �p� LL SU&lEC7ANEMPLOYEHTOCRIMINALPENALTIESANDCIVILFINE5UP700NENUNOHEDTMOUSAND ENERGYPERMI7 �)6V � �Y�i� ?, DOLUNS(i7aD,D0o),IN AD01710N TO THE COST OF COMPENSATION,�AMAGES AS PROVIOE�FOR IN �-j---Q-�� J� SECipN 37080FhiE LABOR CODE,INTEREST,AN�ATTORNEY'S FEES. RETENTION FEE: d CONSTRUCTION LENDING AGENCY PRE•ALT FEE: � 1 HEREBY AFFiRM UNDEH PENALTY OF PERJt1RY THATTHENE IS A CON3TRULTION LENDING A4ENCY � FOR7HEPERfORAIANCEOFhIEWORKFORWHICHTHISPERMITISISSUED(SEC.70W.CIV.C.�. Z W - � LENDEH'S NAME 1_ LENDEHSADOFE55 ¢ ICERTIFVTHATIHAVEREADTHISAPPLICATIONANDSTAiETHATTHEABOVEINFORMAiKNJISCARRECT. TOTAL FEES � � IAGREETOCOMPLVNATHAILCITlPNDCOUNtYOHDINANCESANDSTATEUWSRELATINGTOBULDING �' g� � CONSTRUCTION.AND HERE9YAUTNORRE REFRESENTATIVES OFTNIS CWNTV TO ENTER UOON THE Z ABOVE-MENTIONED PqOPERTY FOR INSPECTION PURPOSES. 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