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HomeMy WebLinkAbout05-314(2) �� CITY OF DIAMOND BAR DEPARTM�NT OF COMNMUNITY&DEVELOPMENT 5ERVICES 21825 Copiey Drive,Diamond Bar,CA 91765 �� (909)839-7020 Fax(909)861-3117 Building Inspection Hotline(909)839-7027 PRESS ������ BUII.DING PERNIIT APPLICATION FIRMLY '�9tt> � JOBSITE APPLICATION PERMIT P/C , o ADDRESS DATE�`' O Tv�n G G�J NUMBER # �� " �I�- �) o ISSUE TYPE OCC °.° APN LOT ` o� TRACT DATE CONST. �'N� GROUP � �I�� p OWNER IJY�nI�F��Ir� p-IvvL���j , , � ADDRESS �i T l ZONING SETBACKS �� � � ��^Y``� v��t��- `SPe�'� P W otC� FRONT S✓b Pl�wa:� �.Q,E�� �-,3�� � , o CITY C S� �tl@.�e� ZIP� TEL �i 4 "1'(� (� APPLICANT TEL. REAR ❑ o SIDE/SIDE STREET RW ❑ ¢ CONTRACTOR SIDE p o ADDRESS PROPOSEDUSE Si ►�iG�I Nvl�i--1�r,.w.�t NW � CITY ZIP TE�. �� w ARCHlENG/ z DESIGNER �ZM�C �iRQ�i,�2S CPO�C.: �a� G��� NO.DWEL NO. NO. a ADDRESS I�l s.�l�,,,►oJ�1t1�A►� . Stl�e.- lcso UNITS STORIES BEDROOMS � CIN �!(L�l i N.G ZIP�� � TEL. q'{°�' (d� �=�/6G� � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANAIUATION OOWNER-BUILDER DECLARATION SFR/ADD/REM �� (�� p 1 HEREBY AFFIflM UNDER PENALN OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTOPS LI- GflfBge/CBIpOf( W CENSEUWFORTHEFOLLOWIN6REASON(SEC.703i.68USiNESSANDPflOFESSIONSCODE:ANYCITVOR (n , zCOUNTYWHICHRE�UIRESAPERMITTOCONSTRUCT,ALTEfl,IMPROVE.DEMOLISH,ORREPAIqANYSTRUG W Pg(10/DBCIC w TURE,PRIOfl TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO i1LE A SIGNED W � STATEAIENT THAT NE OR SHE IS LICENSEO PURSUANT 70 THE PROVISIONS OF THE CANTRACTORS LI- � CENSE IAW(CHAPTER 9(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO• LL' POOUSPB FESSIONS CODE)OR TNAT HE Ofl SHE IS EXEMPTTHEREFROM AND THE BASIS FOfl THE ALLEOED E%EMP- � TION.ANYYIOLATIONOFSECTION7031.5BYANYAPPLICANTFORAPERMITSUBJECTSTNEAPPLICANTTO Z Re-Roof ���� � ACML PENALTY OF NOT MORETHAN FNE HUNDRED DOlLAFlS(5500).): � ❑I,ASOWNEROFTHEPROPERTY,ORMYEMPIOYEESWIiH�YAGESA5THE1flSOlECOMPENSATION, � COfOffIBlCiel � Z WILL DO iHE WORK,AND THE STRUCNRE IS NOT MTENDED OR OFFERED FOfl SALE(SEC.�7041,BUSI- J NESS AND PROFESSIONS ODDE:THE CAMRACTORS IiCENSE LAW DOES NOT APPLY TO AN OWNER OF � PROPEflTYNRiOBUIlD50RIMPROVESTHEREON,ANDWHODOESSUCHWORKHIMSELFORHEp5E1.FOR � � THFiOUGHHiSORHEROWNEMPIOYEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTENOE00R m 0 OfFEflEOWflSPIEIF,HOWEVER,iHEBU1�DINGORiMPROVEMENiISSOtDWRHINONEYEAROFCOMPLE Z TION,THE OWNER-BUILDEfl WILL HAVE THE BURDEN OF PROVINO THAT HE Ofl SHE DID NOT BUItD OR � IMPROVEFORTHEPUpPOSEOFSAI�. ❑I,AS OWNER OF THE PROPERTY,AM EXCIUSIVEIY CONTRACTIN6 W(TH UCENSED CONTPACTORS � TO CONSTflUCi THE PROJECT(SEC.7044,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- V0IU81I0l1 ADJ.AREA W CENSEUWDOESNO7APPLYTOANOWNEHOFAPROPERNWHOBUILDSORIMPROVESTHEREON,AND � WIiOCONTRACTSFORSUCHPR0.IECTSWITHACONTRACTOR(S)IiCENSEDPUPSUANTTOTHECONTFiAG QUANTITY DESCRIPTION FEE Y 70RSlJCENSELAW.). � ❑IAM EXEMPT UNDER SEC. 0.8 P.C.FORTHIS PEASON � � � � DA7E OWNER V W � LICENSED CONTflACTORS DECLARATION �j �� � IHEREBYAFFIRMUNDERPENALNOFPERJURYTHATIAMLICENSEDUN�EflPROVISIONSOFCHAPTER � � e(COMMENCING W(TH SECTION 7000)OF DIVISION a OFTHE BUSINESSAND PROFESSIONS CODE,AND Z Y�.� IAY LICENSE IS IN NlL FORCE AND EPFECL m s 1 � � LICENSE CLASS LIC.NO. !�� .� J � � DATE � CONTRACTOR ` � �- W � WORKERS'COMPENSATION DECLARATION Q � U � IHEflEOVAFFIRMUNDERPENALTYOFPERJURYONEOFTHEFOLLOWINGDECLARATIONS: C!! Q � 1 HAVE AND WILLMAINTAIN A CERTIPICATE OF CANSEMTO SELFdNSURE FOR WORKERS' 2 � COMPENSATION,ASPROVIDEDBYSECTION37000FTHELABORCODE,FORTHEPERFOHMANCE U ¢ OFTHE WORK FOR WHICH TNIS PERMIT IS ISSUED. � 0 W _IHAVEANDWILLMAINTAINWORKERS'COMPENSA710NWSUWWCE,ASpE�UIREDBVSECTION Qs7000FTHELABORCODE,FORTHEPERFORMANCEOFiHEWORKWRWHICHTHiSPERMITIS J ISSUED.MY WORKEflS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBERARE: CONSTRUCTION � CARRIEA PLAN REVIEW Z POIICYNUMBER ELECTRIC ¢ (iMS5ECT1oNNE�NOTBECOMttE7EDOFTNEPERMRISfORaNEMR�DHED00LLARS(S1oo)ORLE55} PLUMBING 0 W MECHANICAL Z I CERTIFYTHAT IN THE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED,I � SHALLNOTEMPLOYANVPERSONINANYMANNERSOASTOBECOMESUBJECTTOTNE � WORKERS'COMPENSATIONIAWSOFCALIFORNIANIDAOREETHATIFISHOULUBECAME INSPECTIONFEE SUBJECT 70 THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR � CWE,ISHALLfORTHWITHCOMPlYW1iHTHOSEPROVI510NS. ISSUANCE 0 SMIP p DATE: APPLICAN7 , . � ENERGY P/C WARNINO:FAILURETO SECURE WORKEflS'COMPENSATION CAVERAGE IS UNLAWfU4 M1D SHALL BE � SUBJECTANEMPLOYERTOCRIMINALPENALTIESANDCIVIIFINESUPTOONEHUNDRE�THOUSAND ENERGYPERMIT DOLUflS(S10D.0o0),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOp IN � SECTION370BOFTHEI.ABORCODE,INTEPEST,ANDATTOflNEY'SFEES. RETENTIONFEE: . d CONSTRUCTION LENDING AGENCY PRE-AlT FEE: � INEREBYAFFIRMUNDEHPENAITYOFPERJURYTHATTHEflEISACONSTftUCT10NlENDINOAGENCY � � FOR THE PERFORMANCE OFTHE WORK FOR WHICH TNIS PERMIT IS ISSUED(SEC.3097,CIV.C.). Z W � LENDER'S NAME F— LENDER'SADDRESS � ICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETHATTHEABOVEINFOqMAT10NISCARRECT. TOTAL FEES ���� '`--��"'� ,� w IA6REETOCAMPLYWITHALICITYANOCOUNTYORDINANCESANDSTATEUWSflEUTINGTOBUIIDINO � CANSTRUCTION,ANDHEREBYAUTHORIZEPEPRESENTATNESOFTHISCOUNTYTOENTERUPONTHE .}�,� `� 3��� `. ZABOVE-MEMIONEDPROPERTYFORINSPECTIONPUPPOSES. COMMENTS �� TT �=��F-��`�� ���� � �`�"� � 's� �Ic- -�� ��c� •-�w- �1�'�o���l"d-L1�—�-�.��.1-001� � m PERMITTEENAME(PRIFfT) " Q l/� � SI4NATUREOFPEPMITTEE OATE �� = RECPT.NO. PA�D BY VAUDATION ~' WHITE—DepaAmenl Copy,YELLOW—Finence Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy