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HomeMy WebLinkAbout10611 (5) �i '�` — CITY OF DIAMOND BAR � COMMUNITY DEVELOPMENT DEPARTMENT 21660 E.Copley Drive Suite 190 � .PRES•S � (909)860-3195 Fax(909)$61•3117 t�'�"'� BUILDINGPERMITAPPLICATION FIRMLY y J�OBSITE � � APPUCATION PERMIT P/C 0 ADDF?ESS �� �� �`'';��ti' � �°rr' � ��• DATE NUMBER_7�� � � � ISSUE TYPE OCC' APN LOT TRACT DATE CONST. OROUP p OWNER �1� V.ti���$�7�"7?(1 �r��/�a P�;/�S��.� �— W ADDRESS� C vd � � .� i�r :%� ZONWG SETBACKS w � ' ��-� � FRONT RW ❑, z CITY ��r a��r iS��� Z P Cr '!;. TEL`i�i��G'-u d 1 � � APPLICANT C� .� .n'I 7�1.�!^<1 y Y wd��o'r, REAR p Z % � SIDE/SIDE STREET RW ❑ � m CONTRACTOR Uv"a�I r�.�' ���I c% :� _ SIDE � � � ❑ � ¢ ADDRESS �a ?_f� I�,e��,> �.n.�.� •. � CITY " .c �alwa ti7c,> ' '-'r`` `� �� . ' PROPOSEDUSE ' o , ��ZIP 1 i�i.6 TEL�' �J r��il�`S�y� I o ARC 'ENG/ ' �z DESIGNER NO.DWEL. NO. NO; � ADDRESS UNITS STORIES BED,ROOMS � CITY ZIP TEL. � � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION pC OWNER•BL'ILDER�ECLARATION SFRlADD/REM O I HEREBY AFFIflM UNDEH PENALTY OF PERJURY THAT I AM EXEMPT FAOM THE CONTRACTOR6 LI- G8f298/CBf�101t CENSEUWFORTHEFOLLOWNI�+REASON(SEC.7031.59L151NESSANUPHOFESSIONSCODE:ANYCITYOR (f� C.) COUNTYWHIR1REOl11RE5APERMI7TOCON3TRUCT,AITER,IMPROVE,DEMOLiSH.OFREPAIRANY37RUG W P0ti0/DeCk � � � - Z 7URE.PRIOR 70 ITS iSSUANCE, O''�RE�UIRES 7HE APPLICANT fOR SUtli PERMI7 TO FILE A SIGNED ' ' ' W STATEMEN7 THAY HE Ofi 5HE IS LICENSEO Pl1H5UANT TO THE PROVISIONS OF THE CONTRACTORS LI• w � I � CENSE LAW(CHARTER 9�COIAMENCMG WITH SECTION 7�0J OF DIVISION 3 OF THE BUSINESS AND PRO- u' POOI/Sp8 �. ' . � 0 FESSIONSCADE)OR7FIATHEO SHEI$EXEMPTTHEREFROMpNDTHE8ASI5FORTHEALLEGEDEXEMP• (� , . � V TION.ANVVIOI.ATIONOFSECTIO�d7o31'.5BVAN�APPUCANTFORAGERMITSU&IECTSiHEAPPLICAN7T0 Z Re-Raof � �, � '.A CIVIL PENALTV OF NOT MOFiE i,HAN FIVE HUNDRED DOLLARS�55W).): ' 0 pI,ASOWNEROFTHEPRORER'fY,ORMYEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATON, O Commercial � � �. Z �WILL DO THE WORK,ANO THE STRUCTURE IS NOT WTENDED OR OFFERW FOR SALE(SEC.7044,BU51• J NESS AND PROFESSIONS CAOE ITHE CONTRACTORS LICENSE LAW DOES NOr APPLYTO AN OWNER OF � '. � PROPERTYWN06UILDSORIMPFIOVES�THEflEON,ANDWHO�0E55UCHWORKHIMSELFOHHERSELFOR = � � THROUGHHISORHEROWNEMPLOVEES,PROVIOEDTHATSUCHIMPROVEMENTSARENOTINTENDEDOR m W OFFENEOWRSALE.IFHOWEVER,hIEBUILDINGORIMPFOVEMENTIS50lDWITHINONEYEAROFCOMPLE � Z �TION,THE OWNER�BUILOER WILL HAVE THE BUi1DEN OF PROVING THAT HE OR 6HE DID NOT BUIIL OR - �. � 'IMPFlOVE f-0R THE PURPOSE OF�SALE1. . w , ❑I,AS OWNEROFTHE PRO�ER-AM IXQIUSIVELY CANiRACiP1G WITH LICENSEOCDNTRACTORS �, _ �: TO CONSTHUCT THE PROJECT(SEC. Oda,BUSINESS ANO PRDFE53Y NS CA�E:THE CONTRACTORS LI- V8�U8ji0I1 ADJ.AREA '�' � W G9JSE UW DOES NOTAPPLY TOAN O ER OF APROPEflN WHO BUIL 30R IMPflOVES THEREON.M1D �."�WHOCONTR4CTSFOFSUCHPRqJEG7�'H.7yCONT CTOR(5)LI NS�PURSLIANT70THECANTRAG QUANTITY � �ESCRIPTION '� � FEE '� � TORS LICENSE LAW.j. �/,,�/�r'" . ' R,SE� /'� /��� --��'� � B.&P.C.FORTMS RFASON Q � �'�� �. t/'�'/," ! � .�`�'�7' � V ' . . ' .� �- -"- - � � . . , OATE _ -- .. ' -OWNER � �' U � ' Z. . 1 . W . . , , o UCEN�ED CONTRACTOflS DECLARATION W Q 1 HEREBV AFFIRM 11N�ER PENALTM DF PERJURYTHAT I AM LICENSED UNDER PROVISIONS OF CHAPTEH � �. d � 9(COMMENCING WITH SEC710N 7DOo)Of DIVISION 30F THE BUSINESS AND PROFES510NS CADE,AND Z �X MV LICENSE IS IN FULL FOFCE ANb EFFECT, m � � � LICENSE CU15S � LIC.NO. j , � J V DATE CONTRACTOR a �, W � WORKERS'COMPENSATION DECLARATION Q _ .. . � I HEREB�4.FFIRM UN�ER PENALN OF P,ERJURV ONEOFTHE FOLLOWMG DECLARATIONS: Z ' � _�IHAVEANDWILLMAINTAIWACE�tTIFIGATEOFCONSENTTO5ELf•INSUREFORWOflKER3' _ ' � COMPENSATION,AS PpOyIDED BV SECTION 37a00F THE LABOR CO�E.FOR TNE PERFORMANCE U OFTHE WORK FDR WHiCH iHIS�,pEHMIT I5155UED. � . ''i�i � , � �I HAVE AND WILL MAMTAIN WORKEHS'COMPENSAiION INSUqANCE,AS REQUIRED 8Y SECTON �y , � j QQ 37000F THE LA60R COD�,FOR�HE PERFORMANCE OF THE WORK f-0R WHICHTHIS PERMR IS � {r�� -� �'i - ' / �- ISSUED.MV WOFKER5'COMPE SATION MSURANGE CARRIEP AND POUCV NUMBERARE: CONSTAUCTION � � E'Ci' � I � �� �• Q � � ��¢"'�'. > CARRIER PLAN REVIEW �. POLICYNUMBER ' ELECTRIC Q Q, (IHSSECiIONNE�WTBE'CONP(ETEDOFiHEPERlMISFORONEhUMHm00LLARS�5100)ORLESSA PLUMBING Z I CERTIFVTHAT IN THE PERFORldANCE OFTHE WORK Wfl WHICH THIS PEHNIT IS ISSUED,I MECHANIGA� - ' . (•j, SHALL NOT EMPLOY ANY d`E'R.50N IN ANY MANNER 50 AS TO BECOME SUBJECT TO THE ' �. WORKER&'COMPENSATIOryLAWSOFCALIFORNIA,AN�AGREETHATIFISHOUL�BECOME INSPECTIONFEE _' SU&IECTTOTHEWOflKERS'GOMPENSATIONPROVISIONSOFSECTION37000FTHEUBOR CODE,I SHALL FORiHWITFI COMP�Y W�TH THOSE PHOVISIONS. ISSUANCE "D� � SMIP p. DATE: ., ARPLICANT. . J' WARNING.FAIIURE 705ECURE WORKEI�S'CAMPENSATIDN COVERAGE IS UNIAWFUL,AND SHALL BE ENERGY P/C � SU&IEC:'rANEMPLOYERTOCRIMINALP�NALTIESANDCNILFINESUPTOONEHUNDREDTHOU5AN0 ENERGYPERMIT DOLLApS(5100,000�.IN ADOITION�p THE'COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN J SECTION 37090FTHE UBOR CADE,iNTEREST,ANDATTOHNEY'S FEES. � . . p� i RETENTION FEE: OCOt�5TF1I�ICTION LENDING AGENCY pRE-ALT FEE: � �, _, � 1 HERE6V AFFIRM UNDER PENALTY�iDF PERJURV THAT THERE IS A CANSTRUCTION LENOINO AOENCY ' FORTHE PERFORMANCE OF THE WOFiK FOR WHtCH THIS PEFMIT IS ISSUED(SEC.30W,CIV.CJ. , W � LENDER'S NAME i '� .. ' � F— LENDEF'SADDiiE55 ' w �'T TOTAL FEES � � I CERTIFY THAT I MAVE qE NIS APPI:I ATIDN AND STATE THAi iNE ABOVE INFORMAiION IS CORRECi � I AGREETO COMPLY WITi-[ALICITVIANO�OUNT1'-OHDINANCESANO STATE IAWS RELA7PlG TO BUILDING � - � �� CONSTpUCTION.AND MENE9YAUT�IOHIZ�REPRESENTA'[IVES OF THIS CDUNTY TO ENTER UPON THE ^ � p ,(''e Q ABOVE-MENTIONEO PROPEFtn'FOH INSPiECTION GURPOSE&. 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