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HomeMy WebLinkAbout05-314(4) I ^ _�,,!` CITY OF DIAMOND BAR DEPARTNI�NT OF COMMUIVITY&DEVELOPMENT SERVICES _ 21825 Copley Drive,Diamond Bar,CA 91765 ,.._�........ (909)839-7020 Fax(909)861-3117 Building Inspection Hotline(909)839-7027 PRESS '9N' BUILDING PERMIT APPLICATION FIRMLY Q� JOBSlTE APPLICATIOJ,J PERMIT P/C ADDf�ESS DATE SO ��rtC, QS NUMBER #�� ' �)� i`�� � ISSUE TYPE OCC APN LOT � 7RACT p OWNER �¢, ' DATE CQNST. lI'N'2 . GROUP Q'1 V' p ADDRESS 3D(v �'2��'`01 C►� Svite- a-vb ZONING SETBACKS��� ��� �`'""Dµ �FK Jfl� S��'� Z CITY CoSEc. d'it5t,. ZIP �lo2G TELC'llu� y2�-��� FRONT P�`^�Sutij_P���,,.a;�W 1��(Qc.S d� B� N _ � APPUCANT TEI. REAR ❑ Q SIDE/SIDE STREET RW ❑ z ¢ CONTRACTOR SIDE ❑ � ADDRESS PROPOSED U5E PS� e �`� , 1Ulv -t� '� �� ` � CtN ZIP TEL. w ` I t�' �+ t��� MS w ARCH/ENG/ — z DESIGNER Z f� QO�G� � CS w . NO.DWEL. NO. N . n. ADDRESS 1 1 �l t1NtTS t D STORIES a O�Q DROOMS��_ � cmr 1¢���z ziP9�1.'Z TEI.�I�I-'�`1-�t o0 u� DESCRIPTION SQ,FT, FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDERDECLARATION S�R/ADD/REM E� ��� O Q I HEHEBV AFFlpM UNDER PENJJ.TY OF PERtt1RY 7HAT I AM EXEMPT FflOM THE CONTRACTOHS L6 G8f8g0/C8lp011 W CENSELAWKORTIiEFOLLOWIN6REA50N(SEC.7031.5BUSINESSANDPROFESSIONSCODE:ANYCITVOR (n � U COUNTYNTiICHREWIRESAPERM1T7000N5TRUCT,ALTEfl,IMPROVE,OEMOLISH.ORpEPAIRANY3TRUG � W NRE,PRIOR TO ITS ISSUAltCE,qLSO REQUtRES THE APPtICANT FOR StJCH PERMlTTO F7LEA SIGNED W Patio/Deck � STATEMENT THAT HE OR SHE IS LICENSEO PURSUANT TO TNE PROVISIONS OF THE CONTRACTORS LI- � � CEN56 LAW(CHAPTER B(COMMENCING WITH SECTION 7000)OF DIVISWN 3 OF 7HE BUSINESSAND PRO- POOUSp2 � FESSIONSCOD�OpTHqTHEORSHEISEXEMPTTHEREFROMAND'fHEBASISFORTHEALLE(3EDEXEMP• (� �r 710N.ANYVIOLATIONOFSECTION7037.SBYANYAPPLICMRFOflAPERMi75U&IECTSTHEAPPLICANTTO Z Re-Roo1 i��� . A CML PEtJALTV OF NOT MORE TttAN FNE Ht1NDRED DOLl.ARS(5500).): d ❑I,ASOWNEROPTHEPROPERTV,ORMYEMPLOYEESWITHN/AGESASTHEIRSOIECOMPENSATION, � Commercial - z WILL 00 THE WORK,AND THE STRUCNRE IS NOT INTENDED OR OFFERED FOR SALE�SEC.704d,BU51• J � NESS AND PROFESSIONS CODE:THE CONTMCTORS LICENSE LAW�OES NOTAPPIY TO AN OWNER OF � PROPERTY WFiO BUILOS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HEflSELF Oq � THflOUQHHISORHEflOWNEMPLOYEES,PpOVlDEDTHATSUCHIMPAOYEMENTSAAENOTINTENDEDOA m 0 OFFEREDFORSALEIF,HOWEVER,THEBUILDINGORIMPROVEMENTISSOLDWRHINONEYEAROfCAMPLE- � TION,THE OWNER-BUILDER WILL HAVE 7HE BURDEN OF PROVIN(i THAT HE OR SHE DID NOT BUItD OR � IMPROVEFORTHEPURPOSEOFSAt,� w ❑I,ASOWNEROFTNEPqOPERTY,AMEXCIUSNE�YCAMRACTINGWfTHLICENSEDCONTflACTORS (r 70 CONSTAUC7 THE PRQIEC7(SEC,70M,BUS1NE55 AND PAOFESSIONS CODE:THE COMRACTORS LI- V81U2UOn ADJ.AREA W CENSEIAWDOESNOTAPPLYTOANONRJEROFAPROpER7YN7iOBUIlD50RiMPROVESTHEREON,AND � NRWCONTRACTSFORSUCHPRQIECTSWITHACONTHACTOR�S)UCENSEDPURSUANTTOTNECOMRAC- QUANTIN DESCRIPTfON FEE � Y TORS LICENSE LAW.). � ❑1 AM EXEMP7 UMDEA SEC. 8.6 P.C.FOR THIS REASON Q � U t� � DATE OWNER U 0 W Q LICENSED CONTRACTORS DECLARATION W [IC I HEqEBYAFFlBM UNOER PENNSY OF PERJURY THA7 tAM LICENSED UN�Efl AROVISIONS OF CHAPTEA � [,L 9(COMMENGNGWIiHSECTiON70W)OFOIVISIONaOFTHE8U51NESSANDPPOFESSIONSCODE,AND Z � MY LICENSE IS IN FULL fORCEANO EFFECT. ] � � UCENSE CLASS � LIC.NO. ��/'��� j ~ DATE G I�IIb 5 CONTRACTOR ��� d LUt.t � � WORKERS'COMPENSA710N DECLARATION Q � 1 HEREBV AFFIRM UN�ER PENALTY OF PERIURY ONE OFTHE FOLLOWIN4 DECLARATIONS: Z Z _IHAVEANbWILLMAINTAINACERTIFICATEOFCONSEMTOSEIf•INSUREFOqWOPKERS' _ COMPENSATION,ASPROVIDEDBYSEGTION37o00FTHELA80RCODE,FORTHEPEflFORMANCE U QOFTHEWORKFORWHICHTHISPERMITISISSUED. � � _IHAVEANDWILLMAINTAMWOAKERS'CAMPEMSATKNJlMSUAANCE,ASAEWlAEDBYSECTION Q 37000FTHELABORCODE,FORTHEPERFORMANCEOFTHEWOpKFOpWHICHTHISPERMITIS ISSUED.MY WORKERS'COMPENSATION INSURANCE CAHRIER AND POLICY NUMBERARE: CONSTRUCTION J � CARRIER PLAN REVIEW Z POIiCYNUMBER ELECTRIC ¢ (i}0.SSEGTpNNE�NOTBE00MPlETEDOFhEPERIXfiSFORONEFIIJt�DFiFDOq1M5K100)ORLESS� PLUMBING 0 z 1 CEqTIFY THAT M THE PEflFORMANCE Of THE WOAK FOR WN(CH TNIS PERAIIT IS ISSUED,t MECHANICAL C� SHALLNOT EMPLOY ANY PERSON IN ANY MANNEH SOAS TO BECAME SU&IECTTO THE �/j - WOqKEflS'COMPENSA710NLAWSOFCALIFORNIAANDAaREETHATiFISHOULDBECOME INSPECTION FEE � SUBJECTTOTHEWORKERS'COMPENSATIONPROVISIONSOFSECTION37o00FTHELA80R = CADE,I SHALL FOFITHWITHCOMPLY WITHTHOSE PHOVISIONS. ISSUANCE � SMIP p DATE: APPLICANi: J WAflNING:FAILURETO SECURE WOpKERS'COMPENSATION CAVERAGE IS UNLAWfUI,AND SHAILBE ENERC3Y P/C � SUBJECTANEMPIOVERTOCRIMINALPENALTiESANDCIVILKINESUPTOONEHUNUREDTHOUSAND ENERGYPERMIT DOLLARS(5100.Oo0),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDEb FOR IN � SECTION37080FTHElAeORCODE,INTEqEST,ANDATTORNEY'SFEES. RETENTIONFEE: a CONSTRUCTION LENDING AGENCY PRE-AlT FEE: O � IHEREBYAFFIRMUNDEftPENALTYOFPERJUFiYTHATTHEREISACONSTRUCTIONIENDINOAGENCY FOR THE PERFORMANCE OF THE WORK POR WNICH TNIS PERMIT IS ISSUED(SEC.3097,CIV.C.). . . .. . . Z W � LEN�ER'S NAME �� � � I— LEN�EWSADDRESS . w ICERTIfYTHATIHAVEqEADTHISMPLICATIONANDSTATETHATTHEABOVEINFORMATIONISCOqpECT. TOTAL FEES ��� ���' `� � ��. � IA6AEETOCOMPLYWITHALICIP/ANDCOUNTYORDINANCESANDSTATEUWSHELATINGTOBUILDING CONSTRUCTION,ANpHEPEBYAUTHORREflEPRESENTATN@SOPTNISCOUNTYTOEMERUPONTHE � �� �� Z ABOYE•MEMIONED PiIOPERTV FOq INSPECTION PURPOSES. COMMENTS � ���CSC���� �I�C�L._��C���"� g ''��P1� -�� ��c� -��PI� E�� �14-C�� 'OS �14�11� m PERMITTEE NA1AE(PRINn � - .. Q � , � SIGNATUFEOFPERMITTEE DATE �.���� � � � = RECPT.NO. PAID BY VALIDATION ~ WHITE—Deparlment Copy,YEILOW—Finence Copy,PINK—Assessor Copy,GOLDENFIOD--Ffle Copy,GREEN—ApplicanYs Copy