HomeMy WebLinkAbout16962 _1� _ �ITY OF DIAMOND BAR DEPART.�I�ITT OF COIvIMUNITY&DEVELOFIVIENT SERVICES � 21825 E.Copley Drive (909)�60-319�Fax(909)861-3117 PRESS BUI�.BING PERMIT APPLICATION FIRMLY o� JOBSITE ���(�'- `,� � DATECATION ����-�� NU BER 6 #/C ADORESS�' � ISSUE NPE OCC APN LOT'' TRACT DA7E CONST. GROUP °C OWNER wf`� � OO ADDRESS� � � ��9'��'��` ZON(NG SETBACKS z CITY f�� l��i`i ZIP TE . ..a.� � FRONT RW ❑ � APPLICANT I TEL. REAR p � SIDElSIDE STREET RW ❑ m CONTRACTQ� �a�/ �°��`--'t1�'�''� SIDE ❑ � �� " �- -- ' �n ADDRES .,�+ � PROPOSED USE -�I ���--����� 0 CITY . ZIP / TEL ' ' � � �, �r�,:� „��,� w ARCWENG! �"�"�� �� �°'- z DESIGNER NO.DWEL.���`�-�O� NO. w a ADDRESS UNITS STORIES BEDROOMS � ,CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION cr) p�. 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C�NSELP.W(CHAPTER9(COMMENCINGWITHSECiION�oDo}OFOIVI510N30FTHE6USWESSANDPRO- V' POOUSpa FESSIONSGO�E)ORTHAiHEOR HEISEXEMPiTHEREFROMANDTHE8ASI5FORTHEALLEGEOEXEMP- (� � �� TION.ANYVIOLATIONOFSECTION7031,5BYANYAPPLICANTFORAPEftMITSJBJECTSTHEAPPLICANTTO Z Re-Roof �';.,ACIVILPEN0.LTYOFNOTMOqET ANFNEHUNDRED�O.LARS(f500�,): ❑I,ASOWNEROF7HEPqOPERTY,OFMVEMFLOYEESWITN,WAGESASTHEIRSOLECOMPENSATION, p �, Commercial �WILL DO THE WORK,AND THE STRUCTUR�IS NOT INTENDED�R OFFERED FOR SALE(SEC.7o44,BUSI- J �NE9SAN0 PflOFESSIONS CODE:THE CONTP�ACTORS L10EM1'SE LAW�O[S NOiAPPLY TO AN OWNER OF �'.�'�PROPERTYWHOBUILDSORIMPROVESTNEREIXJ,ANDWHODOESSUCHWORKHIMSELFORHERSELFOR � ' �"' THROUGH HIS OP HER OWN EMPI,DYEES,PROVIDEO THATSUGH 1MPflOVEMENTS AftE NOT INiENDED OR � � Q,� .�OFFEREDFORSALE.IF,HOWEVER,iTHEBUILDIN�OqIMPRDVEMENTISSOLDWITHINONEYEAROFCOMPLE ' TION,7HE OWNER-BUIL�EA WILL HAVE THE 6URDEN OF PROVING THAi HE OR SHE DID N�T BUILO OR I, _�, .IMPROVEFORTHEPUFPOSEOF�ALE). ' "l ❑I,AS OWNEROF THE PROPER7Y,Ah1 EXCLUSiVELY CONTRACTINCi WITH LICENSEO CONTRAGTORS �"� �TO'CONSTRUCT THE PROJECT(SEC,7a4d,BUSINESS ANO PROFESSIONS CODE:YHE CONTRACTORS L'- ��01UetI0M1 ADJ.AREA W'. 'CENSELAWOOESNOTAPPLVTOANOWNEROFAVROPERTVWH09UILOSOFIMPROVESTHEREON,AN� F�.�'�„�WHOCONTRACTSFORSUCHPRO.�ECTSWIiHACONTRACTOR(S)LICENSEDPUfl3UANTiOTHECONTflAP QUANTITY DESCRIPTION FEE � Y",",TORS LICENSE LAW.). , �'�' ❑I AM'EXEMPT UN�ER SEC.'i B.&P.G.FOR iH15 REASON � '�i, � LL DATE � OWNEF E' - Z U w � LICENSED CONTRACTORS DECLARATION W ¢ CC' IHEREBYAFFIRMUNDERPENALTYiOFPERJURYiHATIAN.UCENSE�UNDERPROVI510NSOFCHAPTER � �, 9(COMMENCING WITH SECTION 7000)OF�IVISIIXJ 3 0F THE BUSINF.SS ANO PR�FESSIONS CO�E,AN� Z X. MY UCENSE IS IN FULI FORCE AND EFFECT. - m ltl � � UCENSE CLA55 � LIC.NO. a J ���. V! DATE �� CONTRACTOR LL W' �� WORKEpS'COMPENSATION DECLARATION Q �, I U �; IHEREBYAFFIRMUNDERPENALTY;OFPERJUflY�IJEOFTHEFOLLOWINGDECLARAiIONS: Z O''�, _I HAVEAN�WILLMAINTAINIACER7IFICATEOF CONSENTTO SELF�INSURE FOp WORKERS' $ Z� COMPENSATION,ASPROVI,OeOBVSECTION3�(100FTHEI.ABORCOOE,FORTHEPEflFOqMANCE U ¢�' OFTHE WOflK FOR WHICHITHIS PERMIT IS ISSUED. � � W.' `I HAVE AND WILL MAINiA1N WORKERS'COMPENSATION INSURANCE,AS REQt11RED BV SECTION �� Q'� 3700 OF THE LABOR CO�E,FOR THE PERFOqMANCE OF THE WOpK FOA WHICH THIS PERMiT IS ���„ � ISSUED.MV WORKERS'CO PENSATION INSIJRANCE CARRIER AN�POLICY NUMBER ARE: CONSTRUCTION o « ¢ . cnraaiea � � -�'�� PLAN REVIEW ? � POLICYNUMBER � °^�.�_.J� ELECTRIC Q' I / , Q (1FiI55ECf10NNEmNOT6EO�MPLETEDOFhIEPERM�TISWRIXJEHU�➢JRE�DJLLApS(51ao)ORLESS). PLUMBING W � Z ICERTIFVTHATINTHEPE�FORMANCEOFTHEWORKF�FlWHICHTHISPERMITISISSUE�,I MECHANICAL (�. SHAILNOTEMPLOYANYP RSONINANYNANNERSOASTOBECOMESUBJECTTOTHE � WORKERS'COMPENSA7101�LAWSOFCALIFORNIA,ANDAGREETHATIFISHOULD9ECOME INSPECTIONFEE SUBJECTTOTHEN'ORKERS COMPENSA710NAROVISIONSOFSECilON37ooOFTHEIABOR '�, ~' CO[JE.ISHALLFORTHWITHrCOMPLVWITHTHOSEPflOVI510N5. ISSUANCE �^�y p DATE: APIbLICANT. SMIP ° I � J'�' WARNING:FAIWRE70 SECURE WqRKERS'COMPENSA710N COVERAGE IS UNIAWFUL,AND SHALL BE ENERGY P/C �y�.��. SLIBJECTANEMPLDVEFTOCRIMM/LPFNALTIESAN�CIVILFINESUPTOONEHUNDREOTHOUSAN� ENERGYPERMIT � ''� �OLLAflS(51oo,Goo),INADDITIONTbTY,ECOSTOFCOMPENSATION,DAMA6E5ASPROVI�EDFORIN ------- — �---- �,i SECTION 37ae O�iHE LABOR CODE,I.YiEREST,AND ATTORNEV'S FEES. RETENTION FEE: ^�+�� ���� CON�,STFIUCTION LENDING AGENCY PRE-ALT FEE: O I d'�� I HERE9YAFFIRM UNDER PEYALNpF PEflJURYTHATTHERE IS ACONSTPUCTION LENOING AGENCY �^ �'� FOR7HE PERFORMANCE OFTHE WORK FOfl WHICH THIS PEPMIT IS ISSUEO(SEC.3o9"!,CN.C.). Z ' W ,. � LEN�ER'SNAME�_._. 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