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HomeMy WebLinkAbout10612 — CTTY OF DIAMOND BAR COMMUNITY DEVELOPMENT DEPARTIvIENT .;,,,w 21660 E.Capley 1Drive Suite 190 PRESS (909)860-3195 Fax(909)861-3117 "��° BUILDING PERMIT APPLICATION FIRMLY �! o AdDRESS �- �� I1~ 1��/� e DATECATiON NUMB R����#/C , / �� c� � ISSUE NPE OCC APN LOT TRACT DATE CONST. GROUP °C OWNER _ t�'1� 5��'i'2 , O - ' ADDRESS '? �=�� ��d � ��+�' G. ZONING SETBACKS W r � 7 ) ,�t' FRONT RW ❑ o CITY i��i�E9t1�i,) 'i r�,.r�LJ,�-ZIP % TEL{;7 �iarl:, / p' o APPLICANT I TEL. ( � '/� S DFJSIDE STREET RW ❑ � CONTRACTOR �%'1� vd t`�•- I_��-�� �/ SIDE O ' � ADDRESS 7.i���S` /E_'o�I c? :.-, ! �'.9' -� I i?r� TEL.�G � F d%" �'s � PROPOSED USE CITY j�•uR�:.t� �a'',7 ZIP � o ARC ENG/ �— z DESIGNER NO.DWEL. NO. NO. a ApDRESS II UNITS STORIES BEDROOMS _, CITY I ZIP TEL. �' DESCRIPTION SQ.Ff. FACTOR PSF ADd:AREAMALUATIOM � OWNER-BULDER DECLARATION SFR/ADD/REM O , 0 , I HEREeY AFfIRM LJNOER PENALTY OF PERJURY h1Ai I AM EKEMPT FROM THE CONTRACTOflS LI- � G8f890/Ca1P011 - � � " " ' ' �� W CENSELAWFORTHEFOLLOWINGREASON(SECJo97.50US�NESSANDPROFE5510NSCADE:ANVCITVOR U COUNIYWHICHRE�UIRESAPERMITTOCONSTRUCT,AL7ER.IMPROVE,�EMOLISH.ORRE7AIRANYSTRUC- W paIlO/D6Ck � w' TURE,PRIOR TO ITS ISSUANCE,ALSO'REQU�HES THE APPCICANT FDR SL1CH PERMIT TO FILE A SIGNED � '� ''' �. STATEMENT THAT ME Ofl SHE I�LICENSED PURSUANT i0 THE PROVISION3 OF THE CONTRACTORS LI- . , � CENSE LAW(CHAPTER e(COMMF�NCING WRN SECTION 7000)OF DMSION 30F THE BUSINESS AND Pfl0- V' POOUSPB , O FE6610N5CADE)ORTHATHEOqSHEISEREMPTTHEREFROMAN�THEBASISFORTHEALLEGEOE%EMP• (� , , . . V TION.ANVVIOLATIONOPSECTIoN�o91.5BYANYAPPLICANTFORAPERM175UBJECTSTHEAPP6ICANTTO z RERW( � � ' AGIVII.PENALNOFNOTMORE HANFIVEHUNDHEDDOLLAR5�35o0).�: , p OI,ASOWNEROFTHEPRO ERNORMVEMPLOVEESWITHWAGESASiHEIRSOLECbA1PENSATION, � �mmercial � , Z� �WILL DO THE WOHK,AND THE S�RUCTURE IS NOT INTENDEO OR OFFEF�FOR SALE(SEC,70as,BUSI- J � NESS ANO PROFESSIONS CADE:THE CONTRACTORS LICENSE LAW DDES NOT APPLY 70 AN OWNER OF j � � � � PROPERTYWHOBUILDSORIMP OVES:THEREON,AN�WHODOESSUCHWORKHIMSELFORHEPSELFOR � THflOUGHHISORHEROWNEMP VEES,PROVIDEDTVIATSUCHIMPROVEMENTSARENOiINTENOEDOR m , . QOFFEREDGORSALEIF,HDWEVE�7NEBUILOINGONIMPROVEMENTISSOLDWIiHINONEYEAROFCCVdPLE Z �'T1oN,TNE OWNER�BUILDER WILL,HAVE 7HE BUflDEN OF PROVIMG THAT HE OR SHE Dlp NO7 BUILD OR �IMPROVEFORTHEPURPOSEOF�SALE�. , W,; ' ❑I,ASOWNEROFTHEPRO��ERTY,AMEXCLUSIVELVCONTRACTINGWITHLICENSEOCONTMC70p5 . . . ., ' � .TO CANSTRUCT THE PflQIECT(EC,.1044 BUSINESS AND PfiOFESSIONS CODE:THE CANiRACTOR9 LI� V31110110f1 E W ��CENSELAWDOE9N07APPLYT6Af.OVYNEROFAPAOPEATY-WHOBUILD50RIMPROVE6THEREON.AND � "WFIOCONTRACT6F SUCHPR�ECTSWITHACONj�iACTOR(S�CICE�SEDPURSUANTTOTHECONTRAF QUANTITY DESCRIPTIO � '' FEE� � Y TOqS LICENSE LAW). � �� Q- ❑I EXEMP7 �SEC / � - � �� B.&P.C.FOR THIS REASON � � r—;�I � � .�: � � �� �f ' � °'"'" �, �— . y A7E -� OWNER �-- U , Z� w � � UCEN�ED CONTRACTORS DECLARATION �y I H BY AFFIRM UNOER PENALTIY OF PERJUR�THAT I PM UCENSEO UNDEq Pq0'11510NS OF CHAPTEq �� a, 9 CAMMENCINGWITHSECTION7U00)OFDIY�SIIXJ30FTHEBUSINESSANDPHOFESSIONSCODE.AND Z . I �X MY LiCENSE IS IN FULL FORCE A�D EFFECi m "' . � � LICENSE ClASS LIG.NO. � ��. � V DATE_ CONTRACTOR 'a W � WORK I RS'COMPENSATION DECLARA710N �U , � r I� � IHEREBYAFflRMUNDERPENALTVOFPER7URVONEOFTHEf-0LLOWMGDECLARATIONS: � C� ? f� ¢ ' O I HAVE AND WILLMAINTAI;[ACEATIFICATEOF CONSENT TO SELF-INSUHE FOp WORKEqS' �T � CAAAPENSATION,ASPRO}'tOEDeYSECTION37omOFTNELABORCODE,FORTHEPERFORMANCE U ¢ OF THE WORK FOR WHICW THIS�PERMIT IS ISSUED. � � � W _I HAYE ANO WILL MAINTAI I WORKER3'COMPENSATiON INSLIRANCE,AS REQUIREO BY SECTION Q37aoOF7HELABORCoO�j,FORTHEPEFFORMANCEOFTHbWORKFORWHICHTHISPERMiTIS J ISSUED.MY WORKERS'COMPEN&ATION INSUflANCE CARRIER AND POLICY NUMBER ARE: CONSTRUCTION j CAflRIER i � PLAN REVIEW � POLICYNUMBER � ELECTRIC Z Q 0 (IHISSECTIONNE�NOTBE�WMPLEfEDOFTNEPERiMISFORIXJEHUrARED00lL4R51570D)ORLpS} PLUMBING Z ICEflTIFYTHATINTHEPE FORAAANCEOFTHEWORKFORWHICHTNISPERMITISISSl1ED.1 MECHANIGAL �) SHALLNOTEMPLOYANY ERSONINANYMANNERSOASTOBECAMESUBJECTTOTHE �— Uj WORKERS'COMPENSAT�UWSOFGALIFOFNIA,ANDAGREE7HATIFISHOULDBECAME INSPECTIONfEE � SUBJECTTOTMEWOPoCE 5'COMPENSATIONPROVISIONSOFSECT�ON370DOFTHEUBOR � � CADE,I SHAIL FORTHWI COMPLV WITH THdSE PflOVI510NS. ISSUANCE � SMIP p DATE: A PLICANT: � ' � EI3ERGY PJC � J WAHNING FAILURE TO SECURE RKERS'COMPENSATION COVERAGE IS UNLAWFUI,AND SHALLBE � SU&IECTANEMPI.OYERTOCRIMI ALPENALTIESANOCIVILFINESUPTDONEHUNpPE�THOUSAND ENERGYPERMIT �' DOLIARS(5100,Uoa),INADDITION OTHECOSTOFCAMPENSATION,DAMAGESASPROVIDEOFORIN J SECTION 37ae OF THE LA90R COO�,INTEFESI;ANO ATTORNEV'S FEES. ' RETENTION FEE: d O CO�STRUCTION LENDING AGENCY PRE-ALT FEE: � � IHEREBYAFFIRMUNDERPENAL OFPERJURYTHATiHEREISACONSTPUCTIONLENDINaAOENCY FORTHE PERf-0flMANCE OFTHE IORK KOR WHICH TH�S PERMIT IS ISSUED(SEC.30B1,CtV.C.). W � LENOFA'S NAME F- LENOER'9 ADDRESS , � ICERT�FYTHATIHAVEREADTH�SAPPLICATIONANDSTATEh1ATTHEA80VE�NFORMATIONISCORRECT. TOTAL FEES ' - � � �� IAGREETOCOMPLVWRHALLCITVAN�COUNTVORDINANCESANDSTATELAWSPELATINGTOBUIL�ING . . . �. 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