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HomeMy WebLinkAbout05-377 _�� CITY OF DIAMOND BAR �- � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES w 21825 Copley Drive,Diamond Bar,CA 91765 ,,,.. (909)839-7020 Fax(909)861-3117 Building Inspection Hofline(909)839-702'7 PRESS 9�' BUILDING PERMIT APPLICATION � ;� FIRMLY i � JOBSITE ApPLfCAT ON ` PERMtT P/C o ADDRESS DATE. �`�-��� !�`� NUMBER #_E>-�� ' '��'] o� ISSUE TYPE OCC APN LOi" � � TRACT DATE CONST, GROUP p OWNER � , � �� �" � ta � "- ` - ZONING SETBACKS p ADDRESS �f) ita iSTf�` `i�. � •r�t�r "�:7�:J oCITY .�����.. i°^�e�4... ZIP C�:"� TEI. ��u1T vL;t� REART RW ❑ � z APPLtGANT TEL. StDEISiDE STREET RW C7 Q CONTRACTOR SIDE ❑ � ADDRESS PAOPOSED USE 1 ' G-- i ` O �w ARCWENG/ ZIP� T�EL_ S�if 7 nW, A DR SSR l�� ' e �� ���J�`� NO.DWEL ( { NO. NO. � CITY ZIP Q�bIR TEL. b .. UNI7S PI�F� 1 STORIES ^ BEDROOMS � T� � DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION � OWNER-6UILbER DECLARA710N SFRlAL1D/REM O p i HEREBY AFFIfiM UNDER PENAI.N OF PE0.NRY THAT i AM EXEMP7 FROM THE CONTRACTORS LI• G0I8g0/C0fP0(1 W CENSEUWFORTHEFOIIOWINGREA50N(SEQ7031.58USWESSANDPROPES310NSCODE:ANVCITYOR (n . ZCO(INTYWFIICHflEIXJiRESAPERMI7TOCONSTRUC7AtTER,IMPAOVE,DEMOLI5H,0AAEPAIAANYSTAUG W �8f10/DeCk w TURE,PRIOR TO ITS ISSUANCE,AlSO REOUIRES THE APPIICANT fOR Sl1CH PERMI7T0 FILE A SI6NED W � STATEMEM THAT HE Oq SHE IS LJCENSED PURSUANT TO TNE PROVISIONS OF iHE CONTRACTORS ll- � CENSE lAW(CHAPTER B(COMMENqNO WITH SECTION 7oD0)OF OIVISION a OF THE BUSINE55 AN�Pfl0- u' POOUSp2 � FESSIONSCOD�OqTHATHEOR5HEI5EXEMPTTHEREFROMANDTHEBAS�SFORTHEALIEGEDEXEMP• U 710N.ANYViOLATIONOFSECT10N7o3t.5BYAMYAPPIlCANTFOAAPERMITSUBJEC7STHEAPPLIC/.N7'70 Z Ae-Roof � A CML PENALTY OF NOT MORE TI1AN FIVE HUNDRED DOLLAflS(5500).): � ❑I,ASOWNEROFTHEPROPERTY,ORMYEMPLOYEESWITHN'AGESASTHEIRSOLECOMPENSAT�ON, � CORirtI8fCl21 - � Z Wlll DO THE WOAK,AND TNE STPUCNRE IS NOT INTENDEb OR OFFEPED FOR SALE(SEC.7041,BUSI- J NESS AND PROFESSIONS CODE:THE CANTRACTORS IICENSE LAW DOES NOT APPLY 70 AN OWNER OF � PHOPERTYWF108UIIDSORIMPROVESTHEAEOM,ANDWHODOESSUCHWOAKHIMSELFORHEpSELFOR � � THROUGHHISORHEROWNEMPLOYEES,PROVIOEDTHATSUCHIMPROVEMENTSARENOTIMENDEDOq m QOFfEqEDFORSALEIFHOWEVER,THEBUIIDINGORIMPROVEMENTISSOIDWRHINONEYEAROFCOMPLE- ,Z TION,THE OWNER-BUIIDER WILL HAVE T}1E BURDEN OF PROVfNa THAT HE OR SHE DID NOT BUttD OR � IMPROVEFORTHEPURPOSEOFSAIE). ❑1,AS OWNER OF THE PAOPEqTY,AM EXCLUSNELY COMflACTING WITH IICENSED CONTRACTORS � TO CONSTRUCTTHE PR0.IECT(SEC.7044,BUSINESS AND PROFE3510NS CODE:7HE CONTMCTORS LI- V81U8�IOf1 ADJ.AHEA LLI CENSEIAWDOESNOTAPPLVTOANOWNEROFAPROpERTYWHOBUIlD50RIMPROVESTHEREON,AND � WIiOCONTRACTSFOHSUCHPRWECTSWITHACONTflACTOR(S)LICENSEDPURSUAMTTOTHECONTRAG QunNriTv DESCRIPTlON FEE x TORS UCENSE LAW.j. � ❑I AM EXEMPT UNDEH SEC. B.6 P.C,FOR THIS REASON � � � � DATE OWNER V � LICENSED CONTRACTORS DECLARATION W 2 1 HEREBYAFFIRM UNDEfl PENALTY OF PERJURY THAT IAM UCENSED UNOER PROVISIONS OF CHAPTER � .� d, 9(COMMENCINQ WfiH SECTION 700D)OP DIVISION 30F THE BUSINESS AND PROFESSIONS CODE,AND Z X AIY LICENSE IS IN FUi1 FORC�pND EFFECT. m � LICENSE CLASS L LIC.NO. ���Z J !�!� � � H � V DA7E_S G O� CONTRAC70R �'�t;��G! ����Dilti.G� n- W � WOAKERS'COMPENSATION DECLARATION Q � IHEAEBYAPfIPMUNDERPENALTYOFPERJURVONEOFTHEFOLLOWINGDECLARATIONS: U � Z a O IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSEIF-INSUqEFOflWORKERS' _ C�MPENSATIOR,ASPftOVIDED6YSECTION3>OOOfTHELAeORCODE,FOR7HEPERFOAMANCE U ¢ OFTNE WOFiK KOR WHICH TNIS PERMIT IS ISSUED. � � W _i NAVEAND WILLMAINTA�N WORKERS'COMPENSATION INSURANCE,AS REOUIRED 9Y SECTION Q 370oOFTHELABORCADE,FORTHEPERWRMANCEOFTHEWORKFORWHICHTHISPEHMiT�S i55t1E0.MY WORKERS'COMPENSATION INSURANCE CAPRIER AND POIiCY NUMBEqARE: CONSTRUCTION J j caqRtea PLAN REVIEW Z POLICYNUMBER ELECTRIC ¢ (I}6SSECiIONNE�NDTBE00MPLETEDOFhEPEf1MfTISfOflGVEMR�OFiED00lLARSK100)OFI�ESS} PLUMBING � Z 1 CERTIFY THAT IN THE PERFOqMANCE OF THE WORK FOq WHICH THIS PERMIT IS ISSUED,I MECHANICAL (�} SHALLN07EMPLOYANYPERSONINANYMANNERSOAS708ECOtAESUBJECTTOTHE � WOPKERS'COMPENSATIONLAWSOFCAL�FOqNIAANDABREETHAT�F�SHWLDOECAME lNSPEC710NFEE SUBJECT TO THE WORKERS'COMPENSATION PfiOVISIONS OF SECTION 3700 OF THE UBOR � CAOE,ISHpLLFORTHWITHCOMPtYWITHTHOSEPROVISWMS. ISSUANCE � SMIP p OATE: APPUCANT: , . � ENERGY P!C WARNIN6:FA�LURE TO SECUpE WORKERS'COMPENSAT�ON CAVERAGE IS UNIAWPUL,AND SHALL BE � SUBJECTANEMPLOYERTOCRIMINALPENALTfESANOCIViIFMESUP700NEHUNDAEDTHOtISANO ENERGYPERMIT DOLLARS(Siao.000).�N ADDITION TO7HE C0.ST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN � SECTID7737oeOFTHELABORCODE,INTEREST,ANDATfORNEV'SFEES. RETENTIONFEE: Q CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O �j )� QI HEREBYAFFIRM UNDER PENALN OF PERJUHY THATTHERE IS ACANS7RUCTION LENDINO AGENCY �g g� -� a .��"� ��-T�°�� ��-��"�7���I� � FOR THE PEfi W fii.1ANCE OF TFIE WOFK FOR WHICN THIS PEAMIT 7S lSSUED(SEQ 3097,CIV.Q). � W �'f�: � � �.���$���i-:���1 �-'t�-"��c7'� �r��r��� lt' �� � LENDER'SNAME `•-�>,�°'�� '�. � +-� �'�f'e�'�{`���C9�-{�S F_- LENDE(YSADDAESS p � ICEHTlFYTHATIHAVEAEADTHISAPPLICATIONANDSTATETHAT7HEABOVEINFORMATIONISCORRECT. TOTAL FEES � ����� 1 �) �1�5� ��� � IACiREETOCOMPLYWiTHAILCITYANDCOUNTYORbINANCESANDSTATELAWSREUTIN6TO8VIL�ING � ..�• ��� �,��., G�,' ��C�.� .� CONSTiiUCTION,ANDHEREBYAUTHORI2EREPRESENTATNESOFTHISCWNTYTOENTERUPONTHE �' ( ZABOVEMENiIONED PROPERTV FOR INSPECTION Pt1RPOSES. COMMENTS � .�...t "� ��G- -���.. AC3t��� ••�r l�J��c�S� ��71- .3�p _� 4T1 PERMITTEENAMElPH1Nn � � .. Q � � SIONATUREOFPERMITfEE DATE ?�/'"j/���/J ���� �� = RECPT.NO. PAID BY �L��-�=�,�✓VALIDATION ~ WHITE—Departmenl Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD--FIIe Copy,GREEN—Applicant's Copy