HomeMy WebLinkAbout14-5042' CITY OF DIAMOND BAR
WDEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21810 Copley Dnve, Diamond Bar, CA 91765 PRESS
(909) 839.7020 Fax (909) 861.3117 Building Inspection Hotline (909) 839-7027 FIRMLY
BUILDING PERMIT APPLICATION
JOB SrrE ADDRESS [ Y
APN LOT T CT
OWNER Deli,,OI GJn
ADDRESS % x/Z S-
CITY�ZIPCY/76J=TEL 4rt S 14- 2
APPLICANT ErAala -1 J 7/i
TEL
CONTRACTOR /eJ C
ADDRESS y; -�r�r �taTC r•�--
CITY Mr/rNIr+6' I ZIP "t2j-A FEL yJ"1 6�B D7y6
ARCH/ENG/DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of penury that I eon exempt train me CarNpcM's State Uwms Law for the reasonls)
Indicated below by me checkmark(,) I have placed next to me applicable Ifemts) ISeCDon 70315, BWm and
Praleselom Coder My city a county tat requires a permit to construct, offer, Improve, demolish, a repair, my
structure, pdor to No tears, else mqulms Be applicant tar the permut to file a slgmtl statement that he by Ye
Is Mohamed pmsesrd to Be povdslons of The CoMactol Spite Deama Law (Chapter B) Co o ncing with Swdm
of Oaaton 3 of Be Business and Pmfmiam Code] or that he or Me Is exempt from hcensure and me basis far
the alleged exemption Any vul N Section 70315 by any applicant far a por it subject the applicant to a clod penalty
of not more Nan five hundred dollem (S500)
U 1, a owner N the property, or my employee with wages m their seta compensation, will do U 91 of or U pardons
N me work, and the structure Is not Intended or offend for sets (Section 7DAA, Bushes and Pro esslmal Code The
Cemmc4m' Stale Ucense Law doe not apply to an owner N property win, through employees' or personal chat bullds
or Impmms me property, crowded that the Improvements are not Intended or offered far ale If however, me pudding or
mmproement Is sold within one year N comple vin, me Owner Builder will have the burden of owing that N was not built
or Improved for the purpose of ale I
U I, m owner of me pmperry, am exclualolyconmong with flamed Cgnactem to construct me prgect (Section
7DAA, Busmen and Rolmom Cade The contractors' State Llcema Law don not apply to an owner of property Mfe
bullds or Impmres meraon and whocwm'ecbfir me pmlec o with a Bared CmIndcturpumu uft the Contractile' Sure,
License Law)
U I rum exempt Non Ilcensum under me Committers Store Liberal taw for me following imports)
By myslgafom below I acknowiedger that except for my parseW romessa In Mich I most here mdMd for at Lean one
yearpdwWmmpletmNmeImpm OMmveredbyrulep NIcamelIogaRyellastructuretatIeve Wlaasu
owner-belldwlf B tam rut berm cambuned In IpieM"by Named=ncfem I wtlerspind mnampy N meapplhable
law Sachem All N me Buirmem and Professional Cade N available upon request man they application is submitted or at
the followhq Web are htV~leglmo a gal/claw hod
DATE SIGN
LICENSED CONTRACTOR'S DECL R TION
I hembyeffirm under penalty N penury mat I eon homed under pmwiobm N Clonal B (commmmdng with Section 7000)
N Ommo 3 N me Business and! Normal Coe and! my Lane b in MI fire and affect.
LICENSE CLASS ��—'��C'- W'" UC NO y '�
DATE CONTRACTOR Of
WORIOWSCom; And EC TIOA N
I HEREBY AFFIRM UNDER PENALTY OF PENIURY ONE OF THE FOLLOWING DECLARATIONS
I eve and will mamben a Conditions N Consul M Sol Impure for Warker'a Cmpensaton as pmnded by
Sectla 37DO N me Leal Code by the performance of the waik for Mich rub pemff Is hued
I have and will malnialn Werker'e Compensation Insurance, as required by Section 3700 N me Taber Cade for
me perfaimun N me wok for "in mia pemft Is Naad Myybrker a Compensation Insumnca Carrier mmd
Policy Number a!@.,
GNRER (�E er) Ili' /11
POUCy NUMBS— �T-r/n(.y-3 7L /, QP
THIS SECTION NEED NOT BE CONFUM I1`4 Fell B FOFIONEHLA DI -All fil OR LESS)
1oD"teInmeparformanceNonew forMichmlapmmNla Issued 15hallndempiWaNp nInanymanrarmmb
HWIne sublet to the y(ldmrs Carbonell Lam N Galmfmma And agree Nwt d 1 should L6bne sulect o the Workers
Corpan pmWa mNot Sm37DONde Labor Code,l&UlfoMWthmplywlhd pm Lvbm
GATE A "Pull
WARNING fallum to secure Ybrtara Carnp on oemge b unlawful, mid sham eub)ect an employer to criminal
perms and cMl firm up te one hundred 7auand dollar (S1D000D), In addition to the cat N the compenatlon
damages as provided for in section 3708 N the labor code, Interim and aamey a rues
CONMUCTIOM LENDING AGENCY
I hereby affirm under penlly at penury mat mom b a Cerebral Landing Agency for me performance N to waik for
Mich rub perrri Is Issued (Sec 3077 Clu C )
LENOER S NAME
LENOER S ADDRESS
I al mat I eve mad they application and state tat me above Information Is correct I fibre to comply with all cNy and
coudlr radiances and elate lave Mal to Chiming foreshadow and hereby auUenie mmesengwes N this county to
enter upon me Blot-mmemned property for Inspection purposes
PBiM lRil
1
SIGNAT1.15,DPIPERNIFEEDATE
APPLICATION DATE
ISSUE DATE 11/10 1 Ul
TYPE CONS7
P/C#
PERMITO 9R 19 - 5-0 4 2
OCC GROUP 1
ZONING SETBACKS
FRONT
REAR
SIDE/SIDE STREET
SIDE
RW ❑
❑
RW ❑
❑
PROPOSED USE
If DWEL UNITS N STORIES # BEDROOMS
DESCRIPTION
SO Fr
FACTOR PSF
ADJ AREA/VALUATION
SFR/ADD/REM
Gamge/Carpod
W
Petio7Deck
cony
PooVSpa
Z_
Re -Roof
9
7
Com ,mclal
m
I
I
I
Valuation
Atli Area
QUANTITY
DESCRIPTION
FEE
T
I
ILI
o
m
a
G
T
c
Q
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CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
90.49
INSPECTION FEE
ISSUANCE
S- $
Ell
ENERGY P/C
ENERGY PERMIT
RETENTION FEE
PRE-ALT FEE
2 a
BSAF
I
I
TOTAL FEES
COMMENTS
7
I
I
I
RECEIPT# 21 4S PAID BY Z. VALIDATION_[F
WHITE— Department Copy, YELLOW —gnarl Copy — Assessor Copy GOLDENROD —Flee Copy GREEN —Applicant 9 Copy