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HomeMy WebLinkAbout05-314(3) ^ _!�` CITY OF DIAMOND BAR DEPARTM�NT OF COMMUNITY&DEVELOPMENT SERVICES : � , 21825 Copley Drive,Diamond Bar,CA 91765 (909)839-7020 Fa�e(909)861-3117 Building Inspection Hotline(909)839-7027 PRESS 9tid Y BUII.DING PERMIT APPLICATION fIRMLY � JOBSITE PERMIT P/C . � APPLIC tON o ADDRESS DATE�A ��v�,�. D5 NUMBER q_F��- �)1,.� �> � APN LOT I TRACT ISSUE TYPE OCC � DATE CONST. V'IJ�L GROUP ��� V�P p OWNER F��c�bH�i�1 �Mc-� ---�— p ADDRESS �qO ►vj 12iSTol ST� ���e �3Oo ZONING SETBACKS A�,l �`"� }�i�•�`+nw�(3v1�P V;(�,c� S�Gch {-t, Z CIN L�S�G d�l,cSa.. ZIP�.2��4 TEL.C�IN� t127~�.�ZL FRONT _ �Ik-+�s i S�y-�Ic,.,µ,•,,..�yy�i��� . � APPLICANT TEL. REAR z SIDElSIDE STREET RW O ¢ CONTRACTOR SIDE � ADDRESS A � CIN ZIP TEL. PROPOSED U5E S i CK i�a,� v 1 E-'. ��; �vti w ARCWENG/ /n z DESIGNER I�K A � �l l{•��L'. � G'�(fUQ7 w NO.DWEL. NO. NO. � ADDRESS 1 � '" Q v� UNITS I� STORIES � OVCQ B�.Y.w.•d�DROOMS o�-�o N CITY �U it+�G ZIP g�Z TEL.1��� g�l'�l�{� � DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION O OWNER-BUIIDERDECLARATION SFRlADD/REM Q� ��f� Q I HEREBY AFFIRM UNDER PENALTY OF pERJURY THAT 1 AM EXEMP7 FROM THE�CONTRqCTOpS ll- Gef898/CerpOd �' W CENSELAWf'ORTHEFd10WINGREASON(SEC.7037.6BUSINESSANDPROFESSIONSCODE:ANYCITYOR (n z COt1NTYWNlCNREQlItRESAPFAMIi7000M5TRUC7ALTEA,IMPAOVE.DEAfO115N,0AAEAAIAANY57AUG W P0�10/DBCk w 7URE,PR�OR TO ITS ISSUANGE,ALSO REQUIRES THE APPL�CANT FOR SUCH PERMIT TO FIIE A SIONED w �r STATEMENT THAT HE Oq SHE IS tICENSED PUHSVAN7 TO THE PROVISIONS OF THE CAMRACTOPS LI� _ � CENSE lAW(CHAPTER B(COMMENCiNG WITH SECTION 7000)OF DIVISION 30FTHE BUSINESSAND PR0. � PooVSpa (,+ FESSIONSCWE)OpTHATHEORSHEISEXEMPTTHEREFROMANOTHE8A51SFORTHEALIEGEDE%EMP- (� V TIOM.MfYV101ATKNJOFSEC710N7031.6BYANYAPPLICANTFOAAPERMITSU8JEC7STyEAPP!lCAN7T0 Z Re-Root ���'3, � ACNiI PENALTY OF NOT MORFTHAN FNE HUNORED DOLLARS(5500).): 0 ❑I,ASOWNEqOFTHEPHOPERTY,ORMYEMPLOYEESW17HyJqGESASTHEIRSOLECOMPENSATiON, � Commercial z WILL 00 TNE WORK,AND THE STRUCNRE IS NOT INTENDED OR OFFERED FOp SALE(SEC.70l4,BUSI- J ' � NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE UW DOE3 NOTAPPLYTO AN OWNER OF j AAOPEATY WHO BUILDS ORlMPAOYES THEAEON,AND WHO DOES SUCH WOAK HIMSELF OA HEHSELF Oq CC THROUGHHISORHEqOWNEMPLOYEES,PROVIDEDTHATSUCHiMPROVEMENTSAPENOTiNTENDEDOR m Q OFFEREDFORSALEIFHOWEVERTMEBUIlDIN60RIMPROVEMENTISSOLDWITHINONEYFAROFCOMPLE• 2 TION,THE OWNER-BUILDEfl WILL HqVE THE BUHOEN OF PROVING THAT HE Oq SHE DIO NOi OUILD OR � IMPROVEFOqTHEPURPOSEOFSAL�. � O l,AS OWNER OFTHE PROPERTY,AM EXq.USNELY CONTRACTM(3 WtTFi LICENSED COMRAC70RS (= TO CONSTRUCT THE PRQIECT(SEC.7041,BUSINESS AND PqOFES510NS CODE:THE COMFUCTORS LI• V81U811011 ADJ.ApEA S CENSELAWOOESNOTAPPLYTOANOWNEROFAPflOPEHTYWNO8U1LO50RIMPROVESTHEREON,AND � WF�tOCOMRACTSFORSUCHPRQIEC7SWiTHACONTRACTOR(SjUCENSEOPtIRSUANTTOTHECONTfiAG QUANTITY DESCRIPTION Y 7oAsucENSEUW.). FEE O ❑1 AM EXEMPT UNDEfl SEC. B.6 P.C.FOR THIS RFASON Q �y U � DATE OWNER F�— � U q LICENSED CONTRACTORS bECLARA710N W � I HEREBYAFFIPM UNDEfl PENALTY OF PERJURY 7HAT IAM IiCENSED UN�ER PROVISIONS OF CHAPTER � p,_ B(COMMENCINO WITH SECTION 7000)OF DIVISION 30F THE BUSINESS AND PROFESSIONS CADE,AND Z X MY IiCENSE IS IN FULL FORCE EPFECT. m d LICENSE ClASS ,,�f + UC.NO. ���VF C./ � U DA7E G 1:,�1fij�i .� CONTRACTOR �� A W � � WORKERS'COMPENSA710N DECUIRATION Q � 1 HEREBYAFFIRM UNDER PENALTY OF PERJURY ONE OFTHE FOLLOWING DECLARATIONS: Z Z _IHAVEANDWILLMAINTqiNACERTIFiCATEOPCONSENTTOSELF-INSUREFORWORKERS' _ ¢ COMPENSATION,pSPROVIDEDBYSECilON37000F7HELA80HCODE,FORTHEPERfURMANCE U Q OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED. � Fw... �IHAVEANDWILLMAINTAINWORKERS'COMPENSATIONINSURANCE,ASREOUIpEDBYSECTiON nQ 37000FTHELABORCODE,FORTHEPEflFORMANCEOFTHEWORKFORWNICHTHISPERMITIS ISSUED.MYWORKERS'COMPENSATIONINSURANCECARRIERANOPOLICYNUMBERAHE: CONSTRUCTION j CARRIER PLAN REVIEW � POIiCYNUMBER ELECTRIC Q a �ni+ssccravr�a>rioraEoo�,wEr�ooF-n��rvxrsrorioNEt+�wnEoaaians�5�ao�ofltEss} PLUMBING w � I CERTIFYT1iAT IN THE PERFOflMANCE OF THE WORK FOR WHICH THIS PERM171S ISSUED,1 MECHANICAL C�J SHALL NOT EMPI.OYANY PERSON INANY MANNER SOAS TO BECOME SU&IECTTOTHE � WOqKERS'COMPENSATION I,AWS Of CAIIFORNIA,AND AGREE7NAT IF 1 SNOULD BECOME INSPECTIOIV FEE � SUBJECTTOTHEWORKERS'COMPENSATIONPROVISIONSOFSECTION37000FTHEU80q � CODE,ISffALLfOR7}iWiTHCOAfPtYWITMTHOSEPROVlSWMS. ISSUANCE Q p DATE: APPUCANT: SMIP W J WARNIN6:FAIWRETOSECUREWORKERS'CAMPENSATIONCAVERAGEISUNLAWPUL,ANDSHALIBE ENERGYP/C � SU&IECTANEMPLOYERTOCqfMINALPENALTiESANUCIVILFINESUPTOONEHi1NOREDTHOUSANO ENERGYPERMIT DOLLARS(S7o0,000),IN ADDITION TO 7HE COST OF COMPENSATION,DAMAOES AS PROVIDED Pop IN � SEC7bN370BOF7HELABORCODE,INTEREST,ANDATTORNENSFEES. RETENTIONFEE: OCONSTRUCTION LENDING AGENCY PRE-AlT FEE: Q IHEREBVAfFIRMUNDERPENALTYOFPERJURYTHATTHEREiSACONSTqUCTIONIENDINOA6ENCY . FOA THE PERFOHMAMCE OF TNE WOAX FOR WNICk 7Hl5 PEAMR IS lSSUED(SEC.30.97,ClY.C.). Z W � LEt7DER'SNAkiE F— LENDEiYSADDAESS � ICER7IFYTHATINAVEflEADTHISAPPLICA710NANDSTATETNAT7HEABOVEiNFORMATIONISCORRECL TOTAL f EES � e'4�4� Q IAGREETOCOMPLYWJiHALLCiiYANDCAUNTYORDiNANCESANDSTATELAWSREUTIN6TOBUIIDING � CANSTPUCTION,ANDHEREBYAUTHOR2EREPRESENTATIVESOFTHISCOUNTVTOEMERUPONTHE ,y� �.: ..� y� Z ABOVEMEMKXJEDPROPERTYFOR7MSPECTlONPUHPOSES. COMMENTS �'K-'Ti ��C-.Y��� YC� � E�O�"�"� � � r�Gc. -� .�a�c.�� plc.3�cs���i�C�� �s �F�-L�� � � m PERMITiEE NAME(PRItJn ' Q � � SIGNATUREOFPEflMiTTEE DATE � � RECPT.NO. PAtD BY VAUDATION WHITE—DepaAmenf Copy,YELLOW—Ffnance Copy,PINK—Assessor Copy,GOLDENROD—Ftie Copy,GFEEN—AppllcanPs Copy