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HomeMy WebLinkAbout05-378 1 �� CTTY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES ; 21825 Copley Drive,Diamond Bar,CA 91765 w . (909)839-7020 Fax(909)861-3117 Building Inspection Hotline(909)839-7027 PRESS "��� BUILDING PERMIT APPLICATION FIRM�.Y � 9t1'� `�'i�.,� � JOBSITE` APPIICATION / PEpMIT P/C Q ADDRESS DATE ! i ! � NUMBER # �� ' ��� �o ISSUE TYPE OCC APN LOT� TRACT DATE CONST, GROtJP p OWNER ,�Bnb��eJ� ��d�e.S � ADDRESS 3v 7b SQ�StoI St . S.�ikG. Zb0 ZONING SETBACKS oCITY .�eS� e�IrSo— ZIP�abaf TEL.t"IlL� 4a"7-�$(� REART RW p q APPLICANT TEL. SIDE/SIDE STREET RW C7 ¢ CONTRACTOR SIDE O � ADDRESS PROPOSEDUSE +�u" � ��w11�iI R ` � CI1Y ZIP TEL. w ARCH/ENG/ �o•'L Si�t�G.i it. �aw�aS t�� * z DESIGNER E2'f 5 EY ���NS'��eCS NO.DWEL.� NO. O. oW.. ADDRESS 'S$5 T.Q.�'�.t GLw�L�Q. �C Suite �ov UNITS � �� � STORIES BEDROOMS � CITY SiLv,v.� (.w! ZtP�' Ift TEL. �9'i4� diSS-ISS� � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER-BUILDER DECLARATION SFR/A�D/REM �, p i HEREBY AFPIRM UNDER PENALTY OF PERNIRY THAT I AM EXEMPT FROM THE CONTRACTORS L4 � Garage/CerpoA � 'm W CENSEUWFORTHEFOILOWINGREASON(SEC.70.71.6BUSINESSANDPflOFESSIONSCODE:ANVCINOR ZCIX1NiYWHICHRE�UIRESAP@RMIT7000NSTRUCT,ALTER,IMPROVE,DEMO(JSH,ORREPAIRANVSTRUG LLI patfo/Deck W NRE,PRIOH TO ITS ISSUANCE,AL50 REQUIRES THE APPIiCANT FOH SUCH PERMIT TO FItE A SIGNED W � STATEMENT THA7 NE OA SHE IS LICENSED VUA5UANT TO TNE PROVISIONS OF THE CONTpACTORS L6 � CENSELAW(CHAPTERB(COMMENCINGWITNSECTION70o0)OFDIVISION30FTHEBUSINESSANDPRO• � POOVSPB FESSIONSCODE)OHTHATHEORSHEISEXEMPTTHEREFROMAND7HEBASISFORTHEALLE6EDEXEMP• (�} � TION.ANYVIOUTIONOFSECTION7031.5BYANYAPPItCpNTfORAPERMtTStJ&IEC7STHEAPPLICANT70 Z Re-Root � ACM�PENALTYOFNOTMOflET}1MIFIVEHUNDREDDOLLAFiS(SSoo).): Q Ol,ASOWNEAOFTHEPAOPEATY,OAMYEMPLOYEESWITHY/AGESASTHEIRSOIECOMPENSATION, � Commercfal - Z WILL DO TNE WOqK,ANO THE STRUCNRE IS NOT INTENDED OR OFFERED FOR SALE(SECJO41,BUSI- J NESS AND PROFESSIONS CODE:TNE CANTRACTORS LICENSE LAW OOES NOTAPPLYTO AN OWNER OF � PROPERTYWl108UILDSOflIMPROVES'fHEFiEON,ANOWHODOESSUCHIVORKHIMSELFOAHERSELFOA = � THFtOUGHHISORHEROWNEMPLOYEES,PflOVIbEDTHATSUCHIMPROVEMENTSARENOTINTENDEDOR m QOFFEAEOFORSALEIF,HOWEVER,THEBUII,DINGORIMPROVEMENTISSOLDWRHINONEYEAROFCOMPIE- Z TION,THE OWNER-BUILOER WILL HAVE TNE BURDEN OF PROVIN6 THAT HE Oq SHE DID NOT BUILD OR � IMPROVE FORTHE PURPOSE OF SAI.�. w OI,ASOWNEROfTHEPROPERTY,AMEXCtt15NELYCOMAACTINGWITH!lCENSEDCOMAAC70AS (',� TO CANSTRUCT THE PRQIECT(SEC.7044,BUSINE55 AND PROFESSIONS COOE:THE COMRACTORS IJ- V8IU01I0(1 ADJ.AREA W CENSELAWDOESNOTAPVLY70ANOWN&FiOFAPROPERNWNOBUIIDSORIMPROVESTHEREON,AND � WFfOCONTRACTSFORSUCHPRQIECTSWITNACONTMCTOR{S)LICENSEDPUPSU/WTTOTHECOMRAC� QUANTITY DESCRIPTION FEE Y TONSUCENSELAW.). � ❑1 AM E%EMPT UNDER SEC. B,d P.C.FORTHIS REASON U � � � DATE OWNER U W � LICENSED CONTRACTORS DECLARATION �j � 1 HEREBYAPFIRM UNDER PENALTV Of PERJURY THAT IAM LICENSED UNDEH PROVISIONS OF CHAPTER � d 9 jCOMMENClNG WITN SECTlON 700D)OF DIY)SION 3 OP 7HE BUSMESS AND PROFESSIONS CODE,AND Z X MY LICENSE IS IN PULL FORCE AND EFPECL m � LICENSE ctASS�_LIC.NO. ��0�3`.�U � � . � . .. ...� �^ n �. � V DATE IO O:� CON7RACTOR��Z[�SiC��E�f7i �S?"'u�� d W � WORKERS'COMPENSATION DECLAflATlON Q � U � I HEREBYAFRFM UNDER PENALTY OF PER)UAY ONE OFTH6 FOLIOWiNG DECI.ARATbNS: C� Q � IHAVEANDWILLMAMTAINACERTIFICATEOFCONSENTTOSELF-INSUflEPORWORKERS' 2 � COMPENSATION,ASPROVIDEDBYSECTION37000FTHELABORCODE,FORTHEPEflFBFiMNJCE U ¢ OFTHE WORK KOR WH�CH THIS PERMIT IS ISSUED. � � W _I NAVEAND WILLMA�MAIN WORKERS'COMPENSATION INSURANCE,AS REQUIREO BY SECTION Q a70oOFT}iEl.ABOACODE,FORTHEPERFOPMANCEOFTNEWORKFORWHICHTNISPERMITIS ISSUED.MY WOpKEPS'COMPENSATION INSURANCE CARRIER ANO POIICY NUMBEflAPE: CONSTFUCTION J j CARRIER PLAN AEVIEW Z POLICYNUMBER ELECTRIC ¢ (ftflSSECTpNNE�NOTBE00MRETEDOFl1-EPERMttISFORUVEMR,DRED0011/RS(5100)ORLESS} PIUMBING � Z 1 CERTIFV THAT INTHE PERFORMANCE OF THE WORK POq WHICHTHIS PEPMIT IS ISSUED,1 -MECNANICAL� ... . (� SHALtNO7EMPLOYANYPEfl50NlNANYMANNEASOAS708ECOMESU&IECTTOTHE ������ �������� ������� � WORKERS'COMPENSATIONLAWSOFCAL�fORN10.ANDA6REETHATiFiSHOUIDBECAME INSPECTIONFEE SUBJECT TO THE WORKERS'COMPENSA710N PROVISIONS OF SECTION 3700 OF THE UBOR � CODE,I SHALL FORTHWITN COMPIY WITHTHOSE PROVIStONS. ISSUANCE O SMIP p OATE: APPLICANY. . . � ENERGY P/C WAANING:FNLURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNIAWFUL,AND SHAIL BE � SUBJECTANEMPLOYER70CRIMINALPENALT�ESAtJDCIVILFINESUPTOONEHUNDREDTHWSANO ENERGYPERMIT DOILApS(S10o.00D).IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN � SECTION37080FTHELABOROODE,INTEFiEST,ANDARORNEY'SFEES. RETENTIONFEE: . a CONSTAUCTlON LENDING AGENCY PPE-ALT FEE: � IHEREBYAFFIHMUNDERPENALTYOFPERJURYTHATTHEfiEISACANSTHUCTIONLENDINGAGENCY 0- FORTHE PERFORMANCE OFTHE WORK FOR WHICHTHIS PEfiM17iS ISSUED(SEC.3097,CIV.Q). . . Z W � LENDER'S NAME 1_ LENDEFYSAD�RESS s iCERTIFYTHATiHAVEREADTHISAPALICATIONANDS7ATETHATTHEA80VEINFORMATIONISCARRECT. TOTAL FEES �� �`}�!�'`+�� � ��py,`,,�'�y� � IA(iREETOCOMPLYWITHAILCITYANDCOUNTYORbINANCESANOSTATEUWSREiATIN6TOBUILDING � :��1� ��'�� �' �f`�"��/ CANSTRUCTION,ANDHEREBYAUTHORIXEREPRESENTATIVESOFTHISCOUNTYTOENTERUPONTHE G7 � :g{� � Z ABOVEMENTIONEDPROPERTYFORINSPECTIONPUpPOSES. . COMMENTS �` K��✓���nC��L�-\ 'K_'�'G� �.�Q�'LJ�i� J �y���9�"Y�� . `��GP' � . � � O�i" � ... .. '��� ��..: m PEflMiTTEE NAME(PRINn � _��`� �✓�.�-�'��I � Y'�c'= �C3 4�I� Q � � SIGNATUREOFPERM(TTEE UATE � � � � � = RECPT.NO. PAID BY VALIDATION ~ WHITE—Department Copy,YELLOW—Ffnance Copy,PfNK—Assassor Copy,GOLDENROD—File Copy,GREEtJ—Applfcant's Copy