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HomeMy WebLinkAbout11892 /,. � '� ,..�^ CITY OP DIAMOND BAR / � ���--��`-- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES J � � 21660 E.Copley Drive Suite 190 � � �����^�� BUILDING PE (RMIT APPLICA.TION FIRM Y y��, JOB5ITE ., -� , ' '' APPLICATION PERMIT , ,����/C � ADDRESS '+' � � �" DATE��q NUMBER��_ � ISSUE C/ TYPE OCC APN LOT _ _ TRACT DATE � � CONST. GROUP p OWNER ��,�� �'... . ADDRESS_,f��R�"'i�_ ��'���✓ ZONING SFT8ACK5 W CITY,�'r�!�'e!�s? ClZ1P � 7EL.�� FRONT RW fl � APPLICANT TEL_ REAR ❑ __ SIDE/SIDE STREEf_ RW I I__ � CONTRACTOR �•S'� 'r�--�--'�-.I6�•� ' d `� SIDE __ fl_____ ADDRESS aC. ' � a' ' .O � CITY� /'�nr�4 ZIP ' TE� ��'�, �"�'tj'� PROPOSED USE_ w ARCWENG/ f�/"�,�.'� %�f � DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS STORIES _ BEDROOMS � CITY ZIP TEL. N �ESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OOWNER-BUILOEH DECLARATION SFWAD�/REM p I HEflE9Y AFFlRM UNDER PENALTY OF PER,NRY THA1 I AM fXEMP?FROM THE CONTRFCTOAS U- G8f8Q0/C8(POI� LLJ CENSEUWFORYHEFOLLOWINGREASON�SEC.7031.S8USINESSANDPROFESSIONSCODE:ANYCITYOR (n Uz CIXINTYWHICHREQIlIpESAPERMRTOCONSTRUCT,ALTER.IMPROVF..DEMOLISM.ORREP/URANYSTflUC� W P3110/D6Ck W TUHE,PRIOR TO ITS ISSUANCE,ALSD REQUIRES iHE APPUCANT FOR SUCH PEAMIT TO FILE A SIGN[D W .� SiATEMEAIT THAT HE OR SHE IS LICENSE�PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI• � GENSE UW(GMAPTER e(COMMENCING WITH SLCTION 7Wa)OF�IVISION 3 OF THE BUSINESS AN�PRO- LL PooVSpa FESSION3 COOE)OR iHAT HE aR SHF IS F%EMPT THEREFHOM AND iHE BASIS FOR THE ALLEGEU E%EMV- V TION.ANYVIOLpTqNUF5EC710N7031.5BYANYAPP�ICANTFORAPFRMIiSU&IECTSTHEAPPUCANTTO Z pe-Rooi � ACMLPENALNOFNOTMORE7HANFIVFHUNDREDDOLLAH5(55W)): ❑4A.40WNEROFTHEPROPERTY.OHMYEMPLOYFESWRHWAGESASTHEIFSOLECOMPENSAYION, � COrt1RIBfCIBI WILI 00 7HE WORK SMD 7HE S7PUCTURE IS NOt INTENDEO oR OFFERED FOR SALE(SEC.7044,6USI- J NES£AND PHOFESSIONS CODE:THE CONTPACTORS LICENSE LAW OOES NOT APPLY TO AN OWNER OF N PROPEflTYVhiOBU1LD50RIMPROVESTHEREON,ANDWHDDOESSIICHWORKHIMSELFORHFRSELFOR � � iHROU(dHN150RHEROWNEMPLOYEES,PRDVI�EDTHAT5l1CHIMPROVEMENISARENOTINTEN�E�OR m � OFFERFDFORSALEIF,FIOWEVEf1,1HEBUILDINOORIMPROVEMENTI550lDWITHINONEYEAROFCOMPLE _ z 710N,TNE OWNER-BUILDER WILL HAVE THE BUFDEN OF PROVIYG THAS HE OR SHE 01�NOl 911IL�OR = IMPflOVEWRTHEPUHPOSEOFSfJ.E). ❑I,AS ONMEH OF THE PRDPfRTY,AM EXCLUSIVELY CONTRACTING WRH LICENSE�CONTRAC70F5 � TO CONSTRUCT THE PRQIECT(SEC.7016,9USINE55 AN�PROFFSSIONS CODE:7HE CONTRACTORS LI- V8IUa11W7 ADJ.AREA W CEN6EUWDOESNOTAPPLYTOANOWNEROFAPROPERTVWHOOUILOSORIMGROVESTHEREON,AND � Mh1000NTR4C7SFORSUCMPHOJECTSWITHAGONTRACTOR(5)LICENSEDPURSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FEE Y TOfiS LICENSE I.AW.). Of.]I AM EXEMPT UNDEfl SEQ_,___ B.8 P.Q FOR THIS REASCNJ � �_ _'__-_'_"'-- LL DATE '___OWNEFi____'"_--_' Z j o LICENSED CONTRACTORS DECLARHTION j � IY.EREBYAfFIRf.1UN0ERP[NPLTYOFPEPJURYTHqTIRR!UCENSEDUNOERPROVIuICtiSCFCHAPTCH � � (y e(WMMENCIN(iWITHSECTION7000)OFDIVISION30FTHE6USINESSAN�PROFESSIONSCODt,ANU �_ _ X MYLICEN5EISINNLLFORCEAN�EFFECT. � p ?,�/;,Z �_�,�'.� �.,���'""'`.t'� � UCENSE CLASS_� LIG.N0. � �+ [�,� /� a � V DATE `:_ �T"� CONTqACTOF�/`�-a� �'`fc-�� — .'_'."' "_--__—._._..._._...- � w � WORKERS'COMPENSA7IQN DECLAPATION a f ��� �, � �-] � � 1 HEqEBYAFFIRM IINDER PENALTV OF P60.JURV ONE OF THE FOLLOWING DECLAHATI043 Z ✓+,�^y�'�r f �F`7� �'i7D9r y � 2-y e� "/d T O ,IHAVEANDWILLMAINTAINACERTIflCA7EOFCON5F.N7iOSF.IL�INSUREFORWONK[FlS' S � COMPENSAYION,A6 PROVIDED BYSECTION 370o OF THE L480R CAUE,(�OR TNF PERFOFlMANCF W OF THE WORK FOR1A'HICH THIS PEflM1T IS ISSUED. � o , ,I NAVE AN�WILI MAINTAIN WORNE�S'CAMVENSATION INSUFiANCE,AS HE�UIPEO 6Y SFCTIDN Q3�0o OF TH6 LS9OR CODE,FOR"ME PERFOqFAANC[DF TN[WOfiK�OH WHIGH T1115 PERMIT 15 _ ISSUE�.MYWORKE.RS'COMPENSATIONINSURANCECARRIERANUVOLICYNUMBERARE: CONSTRUCTION _ _____ J '"'"- "__-_-_._.__..__ , � CARRIEH PLANREVIEW ---.-- _ --._...-"--'- —'---. ' Z POLICYNUMBER ELECTFIC ._..,_..____.___ __.___...._. Q � (n+�ss[cnor+NEm�uoraEoor.�ErfnoFn�vFcu�r�srorsonErnxs�ooav�asisiro)oR�Ess). PLUMBING .._..-----.- ------ ,,,, / . o 0 Z i CERTIFY THAT IN THE PERFOHMANCE OF THE WOFK FOR WHiCH TNIS PERMIT IS ISSUEO,I MECHANICAL _______.__ _____ (} NPLINOTEAIPLOVANYVEF50NINANYMANNEftSOASTOBEGOMESUBJECTTOTHE - � (n �WORKERS'COMPENSATIONLAWSOFCALIFOHNIA,ANDAGRE THATIFISHOUI.09CCOMF INSPEGTIONFEE _.._.._ � ���SU&IECTTOTHEWORKERS'COMVENSATIONPPOVISION SECT 7000FTHEUBOR �SSUANCE __,_____ �_ I�•00 CAUE.I SHALL FO Hyv�17H COMPIY WITH Pfl0 )N. p �I'... f� �O ���'�`�l�.r� SMIP 0 DATE: APPLICANT: _ ---- -"—...-'----"'— W ENERGY P/C �/�/� J WARNINFi.FAILUflE TO SECUPE WORKEflS'COMPENSATION COVERAGE IS UNLAWFUL,ANU SINLL96 '--- '�""�YRF�--"-""""-"`-- � Sll&IECTANEMPLOYERTOCRIMINALPENALTIESANDCIVIIFINESUPTOONEHUNDREDTFiOUSAND ENEFGYPERMIT y�� ____ r pOLIARS(51oo.alo),�N ADDITION TO THE COSTOFCOMPENSATpN,DAMAGES AS PROVI�ED FOR IN �MU7�77�..D .-__ "- J� SECTION37080FTH[LABORCADE,INTEREST,ANDATTORNEY'Srees RETENTIONFEE: _._._� A1�rt�i�� ,1'� OCONSTRUGTION LENDING AGENCY PpE-ALT FEE: ____.__„_ `�r�SAFI'+.� � IHEPEBVAFFIRMl1N0ER7ENALTYOFPLRJURVTHATTHF.REISACONSTfiL1CT1041.ENOMGAGENCY _ _. FOR THE PERFOALIANCE OF THE WORK FOP WHICH THI6 PERMIT IS ISSUE�(SEC.3oD7,CIV.C.). Z '__'_" _-'_' "'___ _ W � LENDER'SNAME '_'___'__ _'__'___ f- LENDEH'S.'1DDRE55_.__.____ ....____.--__ /� (� WICEflTIFYTHATIHAVEflEADTHISAPPLICATIONANDSTATETHATTHEABOVEINFORMAT10NI5CCHflECT. TOTP.L FEES �v • Ov � 1 pGflEE 70 COMPLY WITH ALL CITY AND COUNTV OROINANCES ANO STATE LAWS RELATING TO 6JIL�ING CONSTRl1CTION.ANO HEREBY AUTI/OHIZE REPRES[NTqT1YE5 OF 7HI5 GOUNTY TO ENTEF UPON THE ZAEIOVE-MENTIONEDPROPERTVFORINSPECTIONPURPOSES. COMMENTS_ .___ _-. __.__._ � �� .� ��-t`�+�C,•�'� _ ------ - � a � -^,T- / m PEFMITTEE��M2�iRIN � � � fS ' .fi '-- _"_' ¢ G•:./t,��� Cl C.� � _�`�- �---- ----�� _ Z-�- -- - [n S�GNATUHEOFPEHMITTEE DlTE � RECPT.NO. PAID BY ,___VALIDATION _ WHITE-Department Copy.YELLOW--Finance Copy,PINK-Assessor Copy,GOLDENROD--File Copy,GREEN-ApplicanYs Copy , � , .�...._ ..�, ..',_. ...,...-.r._ � . 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