HomeMy WebLinkAbout05-379 �
__�� CITY OF DIAMOND BAR
DEPARTMENT OF COMMiJNITY&D�VELOPMENT SERVICFS �
: w _ 21825 Copley Drive,Diamond Bar,CA 91765
,,..: (909)839-7020 Fax(909)861-3117 Building Inspection Hotline(909)839-7027 PRESS
,.�... .
'9�' BLTII�DING PERMIT APPLICATION � � ' � F�RM�Y
"�' JOBSITE APPUCAT� d PERMIT P/C
o ADDRESS DATE_ �E � 0�� NUMBER #_��'��T�
a� ISSUE TYPE OCC
APN LO7 IIq TRACT DATE CONST. GROUP
p OWNER o�GItA Nn w�e-S
q ADDRESS JO�Ib Fjei St�1 St 9v�bG �qo 20NING SETBACKS
oCIN �oSt� Y1G4� ZIP TEI. ("Ita} 42�7-�56 FRONT RW ❑
APPLtCANT TEL REAR p
o SIDE/SIDE STREET RW ❑
z
� CONTRACTOR SIDE ❑
� ADDRESS PROPOSED U5E '�nJ �� • ' ,1
� CITY ZIP TE�.
w ARCHIENG! �O.G SI+G�c�.tf Ti�-W -
z DESIGNER �bPJGiL'� NS�7Ey J�RCNSTEGTS NO.DWEL. O. NO.
� ADDRESS 'ISRS �.A.�tk[ CG�,.jctn 5��tt a.ob
� � UNITS STORIES BEDROOMS
� CITY �Q,v___ �v.c. �C� ZIP 4�LIR TEL. �qe{g�bSS-IsJD
u� DESCRIPTION SQ.Ff: FACTOR PSF ADJ.AREANAIUATION
� OWNER-BUILDER DECLARATION SFWADDlREM �`p
O
[] I HEflEBY AFFIRM UNDER PENALN OF PERNIRV THAT 1 AM EXEMPT FROM THE CANTflACTORS LF Garage/Cerport
LU CENSEUWFORTHEFOLLOWIN6REASON(SEC.7031.6BUSINESSANDPROFESSIONSCODE:ANYCITYOR (n .
ZCOUNTYWHICHRE�UIRESAPERMITTOCONSTRUC7,ALTERIMPftOVE,DEMOLiSH,ORREPAIRANYS7RUC- W P8f10/DBCk
W NRE,PR1OR TO ITS ISSUANCE,AL50 RE�UIRES THE APPLICANT fOR SUCH PERMIT TO PIIE A SIGNED W
S7ATEMENT 7HAT HE OA SHE IS LICENSED PUqSUANT TO THE PROVISIONS OF THE CONTPACTORS LI-
� CENSE LAW(CHAPTER e�COMMENqNG WiTH SECTION 7000)OF OIVISION 30F iHE BUSINESSAND PRO• �'�' POOVSp2
FESSIONSWDE)OflTHATHEORSHEiSEXEMPTiHENEfROMANDTHEBASiSFORTHEALLEGEDEXEMP- (�
� TION.ANYVIOLATbNOFSECTION7031.59YANYAPPLICANTfORApEfiMITS118JECTSTHEAPPtICANTTO Z Re-Roof
� A CNiI PENALTY OF NOT MORE TtiAN FNE HUNORED DOLIARS(5500)J:
0 O),ASOWNFROFTHEPROPERTY,ORMYEMPLOYEESWiTH�WAGESASTHEIRSOLECOMPEN3AT10N, � COfDRI8tC181 -
Z WILL 00 THE WORK,AND THE STRUCNRE IS NOT INTENDED OR OFFERED FOR SALE(SEC.704t,BUSI- J
NESS AND PROfESS10N5 CODE:THE CONTRACTOPS IICENSE lAW DOES NOT APPLY TO AN OWNER OF
� PROPERNWF108U(LDSORIMPROVESTHEREON,ANDWHODOESSUCHWORKNtMSEtFOAHEASELfOA =
Lr THROUGHHISORHEROWNEMPLOYEES,PROVIbEDiNATSUCHiMPROVEMENTSARENOTiNTENOEDOR m ,
0 OFFEqEDFOASAi.E1F,HOWEVER7FIEBUItDINGORIMPpOVEMENiISSOLbW1THINONEYEAROfCOMPLE-
Z TION,THE OWNEq-BUIIDER WILL HAVE THE BURDEN OF PROVIN(3 THAT HE Op SHE DID NOT BUIID Oq
� IMPROVEFORTHEPURPOSEOFSAI.�.
❑i,AS OWNER OF THE PftOPEFtTY,Mf EXClU51VEtY COMRACT7N6 WITH LICEMSED CONTRACTOAS
� TO CONSTRUCT TME PROJECT(SEC.)044,BUSINESS AND PROFESSIONS CODE:THE GOMRACTORS LI- V81U8�10l1 ADJ.AREA
W CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUILOSORIMPROVESTHEREON,AND
� WHOCONlRACTSFORSUCHPROJECTSWITHACONTRAC70q�5)LICENSEDPURSUANTTOTHECOMfiAC- QUANTITY DESCFiIPTtON FEE
Y TORSIJCENSELAW.).
� O 1 AM EXEMPT UNDER SEC. B,L P.C.FOR THIS NEASON U
�
lL �.�-.
DATE OWNER U
W
� LICENSED CONTRACTORS DECLARATION �j
� I HEREBY AFFIRM UNOER PENALTY OF PERJURY THAT IAM LICENSEO UNDER PpOVISIONS OF CHAPTER �
� e(COMMENGM�Wt7H5ECT10N700ojOFDIVISiON30FTHEBUSINESSANDPROFESSIONSCODE,AND Z
�� AIY LICENSE IS IN NLl FORCEqND EPFECT. m
� LICENSECLASS ! 3�_ ���.No._ �Oa3?.`8 . _ �
�-
V DATE ��I�710.'S� CON7RACTOR i3�iC3a�rtsa� ��v�C' �
W
� WORKERS'COMPENSATION DEClARATION Q
N I HEREBYAFFlAM UNDEA PEMALTY OF PERJURY ONE OFTHE FOLLOWING DEClARA710N5: U
� Z
Q
z _I HAVEAND WILL MAINTAIN ACERTIFICATE OF CONSENTTO SEIF-INSURE fOp WORKEflS' 2
COMPENSATION,AS PROVIDED BY SECTION 370o OFTHE LABOR CODE,FOH TNE PEHFOFlMNlCE U
¢ OFTHE WORK KOR WHICH THIS PERMIT IS ISSUED. �
O
W �IHAVEANDWILLMAINTAINWORKERS'COMPENSATIONINSURANCE,ASREOUIREDBYSECTION
Q 37o00FTNELABOACODE,FORTHEPERFORMANCEOFTHEWORKf-0RWHICHTHISPERMITIS
ISSUED.MY WORKERS'COMPENSATION INSURANCE CARflIER AND POIiCY NUMBERARE: CONSTFUCTION
J
� CARHIER PLAN AEVIEW
Z POLICYNUMBER EIECTRIC
Q
� �nssECTpnt��taoTaEoa.+aFrEooFn€pEarxr�swrtavEHuwnEooaunns(ftro)oRiEss} PLUMBING
z 1 CERTIFY THAT IN THE PERFOPMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 MECHANICAL
(,�} SHALlMOTEMPLOYANYPEASONINANYMANNERSOASTOBECAMESUBJECTTOTHE
� WORKERS'COMPENSATION LAWS OF CAIIFORNI0.AND AaREETHAT IF I SHOUID BECOME tNSPECTtON FEE
SU&IECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE 1A80R
� CODE,1 SHALL FORTHWITH CAMPLY WITH TNOSE PROVISbNS. ISSUANCE
� SMIP
p DATE: APPLICAM: . .
� ENERGY P/C
J WAANING:fAILURE TO SECURE WORKERS'CAMPENSATION CAVERAOE IS UNtAWFUL,ANO SHALL BE
� SUBJECTANEMPLOYERTOCRIMINAIPENALTIESANDCMLF�NESUPTOONEHUNOREDTHOUSANO ENERGYPERMIT
DOILARS(5100.000).IN ADDITION TO THE COST OP CQMPENSATION,DAMAGES AS PROVIDED FOR IN �
.}-i SECTION37080FTHEtABORCODE,tN7ERE5T.MlDAROANEPSFEES. flETENTIONFEE:
�
� CONSTAUCTION LENDING AGENCY PRE-ALT FEE:
� INEREBYAFFIRMUNDERPENALTYOFPERJURYTHATTHEFEISACONS7RUCT10NLEN�INOAGENCY
FOR THE PERFORMANCE OF THE WOHIC FOR WH(CH THIS PEfiMiT IS ISSUED(3EC.3097,CIV,C.j.
Z
W
Z LENDER'S NAlAE �
�
F_ LENDER'SAOOflESS
w iCERTIFYTNRTtHAVEAEADTNISAPPUCATiONAMD57ATETHATTHEA80VEINFORMATIONISCORRECL TOTAL FEES ������� � � �����
� IAGqEETOCAMPLVW7THAl.LC17YANOCOUNTYORDINANCESANDSTATEUWSPEUTMGTO8U1lDIN�
CANSTRUCTION,ANOHEREBYAUTHOR2EPEPRESENTATNESOFTHISCOUNTYTOENTERUPONTHE +� �� �� �,y� ��� ��
Z ABOVEMEMIONED PqOPERTY FOR INSPECTION PURPOSES. COMMENTS �� °� �C=�C�'CU� YZ-"�`i'���G��✓�S
� ��'k 'PI� -�'�ee� L�i c� �' ►"�'IG�CeS- �"1`P- ��+o
�
m PERMtiTEENAME(PRINp .
Q
�
� SI6NANREOFPEtiMlTTEE OATE ����� ,.
z RECPT.NO. PAID BY VAIIDATION
~ WHITE—Department Copy,YELIOW—Ffnance Copy,PINK—Assassor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy