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HomeMy WebLinkAbout15656 (20) ��1 �� _ CITY OF DIAMOND BAR `� DEPARTMENT OF COMMUNITY 8c DEVELOPMENT SERVICES � _� 21660 E.Copley Drive Suite 190 PRE$$ (909)860-3195 Fax(909)861-3117 �'9N'�� BUILDING PERMIT APPLICATION FIRMLY T JOBSITE �� • /�'d����` ,� APPLICATIO FEFtMR � #/C/� (� � ADDRESS• ��` �1C1..1 DATE - •4� � NUM��R���? `-/� ` ��-• � APN OT TRACT___ �SSUE � NPE OCC DATE � � CONST. GROUP p OWNEq��d /1 /�� � �L��_�fMFr/L/J',� LL ADDRESS � � �,]�ICY C��AC .f ZONING SETBACKS w ���, l FRONT RW fl__ �/ f �LZIP TEL.s� � '��/...5 zZ REAR ❑._ � � APPLICANT( ' 6 v�+.-�--�7e� J TE�. �y� i a i� SIDE/SiDE STREET RW ❑ a . � CONTRACTOR tn.7 -�(�L S _' ►2- __ SIDE i=7 Q ADDRESS c"�i�j�7 S ✓� C � CITY f.�.�C�h�itiJ�'_ ZIP � TEL. ' ` '1 L 1 '- PROPOSED USE�Vl.j'��J . � � f�.. � ARCH/ENG! DESIGNER � �y , NO.DWEL. NO. NO. ; p., ADDRESS I / C�` y - UNITS _ STORIES ___.__ BEDROOMS � y CITY �'A^�s�l+�r✓y�, ZIP�, TEL. ` -�'✓ G3 ,'g en DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � p� OWNER-BUILDERDECLARATION SFWADD/REM � Q I HEREBY AfFIRM UNDER PENPLTY OF PEHJUNY THAT I AAS EXEMPT FROM THE CONTRAC70RS LI- G8�8QB/CBfpOR W CENSELAWWRTHEFOLLOWINCFEASON(SEC.7o3f.6BU51NE5SANOPpOFES510N5CODE:ANYCITVOR (n C.) CWNTYWHIGIiREOUIRE3APEflMRTOfqNSTRUGT,ALTER.IM?ROVE,Dc'MO.ISH,ORFiEPAIRANY5TRUG W Patio/Deck '� W NHE,PRIOR TO ITS ISuUANCE,AL50 REQUIRE&THE APPLICANT FOR SUCH PEFAIIT TO FILE A SIGNEU W � STATEAIENT THA7 HE OR 3HE IS LICENSED PURSUANT TO THE PqOVISIONS OF THE CONTRqCTORS LI- � CENSE UW(CHAPTER 9(CO�.iMENCINO WITH SECTiON 70D0)OF DIVI910N 90F THE BUSINESS AND PRO� LL POOUSPB � FE5310NSCODE)OHTHATHEORSHEISEXEMPTTMEHEFflOMAVOTHEBASISFONTHEALLEGEDE%EMP- (�J V TION.ANVVIOL0.TIONOFSECTION7o31.58YANYAPPLICANTFORAPENMITSU&IECTSTHEAPPLICANTTO Z Re-Roof � ApMLPENALTVOFNOTMORETHqNFIVEHUN�REDDOLLqRS�S50D).): � ❑I,ASOWNEROFTHEPROPEHN,ORMVEMPIOYEESWITMWAGE5A5THEIRSOLECOMPENSATIDN, � Comme�cial � � WILLDO THE WORK,AND THE STRUCTURE IS NOT INTENDEO Oq OFFERED FOR SALE(SEC.704d,6USI- J .� NESS AND PflOFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APP�V TO AN OWNER OF j PROPER7Y W}10 BUILOSOR MIPROVES7MEREON.ANO WHODOF.S SUGH WOqK HIMSELF OR MEHSELFOfl � CL 7HflIX1GHHI50FlHEROWNEMGLOYEES,PROVIDE07HATSUCHIMPRDVEMENTSARENOTINTENDEDOH m � Q OFFERE�FORSALEIF,H04VEVERTHEBUILDINGORIMPPOVEMEtJTISSOIDWITHiNOYEVEAflOFCOMPLE- M]PI,THE OWNEH�Bt/1LDEH N7LL HnVE THE BUfiDeN oF PROVING 7HAf ME OR SHE DiD NOl'BUIL�OR ( J ��r j IMPFDVE FDR THE PURPOSE OF SALEJ. �,F� 9 F � t:l l,AS OVMEROF THE PROPERT;AM EXCIUSNELV CONTRACTING WITH I.ICENSED COMRACTORS '�'g- � TO CONSTflUCT THE PRQIEC7(SEC.7oda,BUSINF.S3 AND PHGFESSIONS CADE:THE CONTRACTOFS LI- V81118110f1 __�� _, �__],��_ ___A[1J./�flEA W CENSEUWDOESNOiAPPLYTOANOWNERUFAPpOPER7VWHOBUILD50RIMPFOVE57HEREON.AND - _ -'-' F VMOCONTRACTSFOHSUCHPR0.IECTSWITHACONTRACTOR�S1LICENSEDPUFSUANT70THECONTR.4G pUANTITY DESCRIPTION FEE TORS LICENSE LAW.). �' J � _ f.]I,UIEXEAIPTUNDEfiSEC.,_=___,_______,_,__...___B.80GFORTHISREASUN Q U � ------ -----------�------�'-------��— � e..� �ATE 01YNER U � W -- � LICENSEp GONTRACTOFS DECLARATiOtV W �, IHEREBYAFFIRMUNDERPENALTYOFPERJUPYTHATIAMLICEN9EDUNDERPROVISIDNSOFCHAPTER � 9(CaMMENCINGWITHSECTION7000)OFDIVISION30FTHEBUSINESSANDPROFESSIONSCACF,AND z � X MYLICENSE IS IN FULL FORCEAND EFFECT. m LLI {� p J s ' o UCENSE CLASS�`��✓ LIC.NO. ` ` ,�` �- ) F- .� J t V DATE���I�f9� GONTRAGTOR._L�f_1f1� _ _ w. i � � �, WOFKERS'COMPENSATIONDECLAfiATION �/'�' � — � >> U � I HEREBY AFFIRM UNDER PENALTV OF PERIURV ONE OF TNE WLLOWING DECLAR � - •�y P� IHAVEANOWILLMAINiAiNACERTI1lCAiEOFCONSL'N7TOSEl.F-INSUFF RWORKERS' � COMPENSATIOM,AS PflOVIDED BY SECTION 3Tn00F 7N[LRkI!)R COU[,FOR . CNC W /�,pF THE WOqK FOfl WHICH THIS PEflMIT IS ISSUFU. � W �/ �,I HAVEAND W!LL MAIK(AIN YlORKEP.S'COMPF.NSATI�N INSURANCE,NS HEQUiflED 6Y SEGTION i i "" Q 37000FTHELA80RCODEFORTHEPEFFORMANCEOFTHEWpHKFOflWHICVi74115PEPMIT � � ,� FSSUED.MYWORKERS'CO EfiSATIONINSUflANCLCARq1ERhN0�0ICYNUM �RARC� CONSTRUCTION ,______,._,__.._._ t � CAHRIER - __ _ ' `PLAIG'�EW ..."__'—"'_ __ � PaLICY NUMBER_.._ �' � �� LECTf�IC �----_- —_ --�_���— Q �� �. 1� W (iWSSECIK:NNE��TBEOCAfP O iEP� R FVJNDfiED[70Ul�fiS 0o1(J�L�SS IjC,1f]MBfNCa __... _.....__-__"- �n . 1,,,! ' lO � � Z �CEHTIFY7HATINiHEPERFORMANCEOFTHEWORKFOflWfilChiTliiSPERMITI515VE0,1 ECH�1NI __..__.,__._,, ,_.___.____ � � �('j� SHALLi10T 4MPLOYANY PF.P.SON IN ANY MANNEft SO AS TO BECOME SU9JECT TO E - � y WURKC-RS'COMPENSATIONLAWSOFCALIFORNIA,AN�AGRF[THATIFISHOUL�AL INSP EE _____ � SU&IECT TO THE WORKERS'COMPENSATION PFOVISIONS OF SECTION 3'Ioo OF TH[LABOR CO�E,ISHALLFORTHWITHCOMPL�WITHTHOSEPROVISIONS. ISSUANCE _________.____ .7 =�� vy�,,,,p � -__ ^� .� ,� -'� .� 1-Ii�C[iT� p DATE:_._"_____ APPLICANT: _. . 5MIP � 4NlJU �. -----...--�------.'._..---------- ENERGY P/C ����SF r)i A PVId� — WAFUJING:fAIWRE TO SECUflE WOFNERS'COMPF.NSATION COVERAGE IS UNLAWFI/l,AND SHALL BL SUBJECTANEMPLUYEfiTOCflIMINALPENALTIESANDQVILFINFSUPTOON[HUNDREDTHOUSAND ti � � DOLLARS(5100.0OO�.INAD�ITIONTOTHECOSTOFCOAIPENSATION,OAMAGESASPROVIDEDFORIN ENERGYPERMIT _ .�I.T�T.�d"lYT\7S. J1AIT'l C � SECTqN37080FiHELA90RCADE,IN1[R[ST,ANDATTORNEY'SFEES. <� �� RETENTION FEE: _.�_..-- � CONS7RUCTION LENDING AGENCY PRE-ALT FEE: ,j `.� � ' � � �-. � —`-----' - � IHEP[BYAFFIRMUNDERPENALTYOFPERJURVTHp77HF:RFISACOYSTRUCTIONLENDINGAGENCY � �17 FORTHE PERFORMANCE OF THE WORK FOR WHICH TNIS PERMIT IS IS5UED(SEC.3097,CIY.CJ. �/�'�` -`� � '-"-"-------""- . Z � _ - ' �� '_'...""_'___"_'_-'___"_'.__""_""--_"� � LENDER'S NAME'"'_...__' __"_-__"'_____'_- � � -I � LENDER'SAD�HESS ^ �. . �' � ICERTIFYTHATIHAVEHEADTHISAPPLICATIONAN�STATETHATTHEABOVEINFORM�TIONISCOfiRECT. TOTAL FEES�,/_ �' �� � I AGREETO COMPLY WITHALL CITV AN�COl1NTV ORDINnNCESANO STATE LAWS RELATING TO 6UILDING � GONSTflUCT1UN,AND HEflEBY AUTHORIZE REPRESLNTATIV[S OF THIS COUMV TO ENT[fl UVON THE �'j � Z A[jnvc.MENT1oNEOPROPERTYFORINSPECTIONPURPOSES. COMMENTS ��`�' �__' � � �� Q 'e -�___-_ �� �+ J � -__���S..L� - -�_-_- ______'__ "_ � - � PERAII E I ¢ �,� �V.-���-� o�-� ------ ' � - � y 51 E OpTE = RECPT.NO._. PAID BY VALI�ATION ~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy.GOLDENROD--FIIe Copy,GHEEN—AppllcanCs Copy . _..... � I ,i i i I ?`�r { t ,� E j -� "- G i. >���. " ' � i �� " i r ` r Y, _ ` I ( '' . . 1 � �.. � � k.�� . ' - � i . ; " ' . . ' .r i � k : �. I ' ' . . ' � ' - t � 4 . � .� � - ; ' �1 ,) � � � " ' . � � + '�. I : - r . ' i � � . I�... 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