HomeMy WebLinkAbout16-2438Cc
r
E5
-'T w
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21810 Copley Drive, Diamond Bar, CA 91765 PRESS
_,,.� (909) 839-7020 Fax. (909) 861-3117 Building Inspection Hotline (909) 839-7027 FIRMLY
'pw' BUILDING PERMIT APPLICATION ww.cityofdfamondbaccom building@diamondbarca gov
JOB SITE ADDRESS
`D -1 0 I ` • �7 1 1 E•
APN LOT TRACT
OWNER
ADDRESS 0/�t
r1
CITY ZIP TEL L/ J -'C/7 • I1DV-1
r
APPLICANT TEL
CONTRACTOR
ADDRESS 1111
CITY ZIP TEL
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BOLDER DECLARATION
I hereby Binmi under penalty of BeQury mat I am exempt trod the Contractor a Stale License LBw to the Mounts)
Indicated below by the comWork(s) I hew placed next to me mulaaO lights) [Section 73315, Bohm and
Fofmrorw War Arty city or country that requests a permit to comsba ct alter, approve, Baseball, a rty repair a
amlwilvo, prior b ro mswrio, also spur® iti appsarl b Ilw permdtb fib a pgre0 aoammt Owi hB a and
s Ile poMsnoalb Cmbstode Slobdheor law (OelaplvrolCmisloeagwMSSIm
ofOlpon 3of
a DMstmsatleBoboonsale
tiWoebeCab)aDoiheordehuemje1mmltcensueendtendpeLnla
ehamptlm Any 70315 by any eppllanl for apermit mblecb meepplkantroetlNl penalty
of not edcomaSealer
of not more man five hundred dtllere ($500)
U I, a alyler of inn property, or my empNWes with wages es mdr ads compensation, will do U all of or potions
of the work, and inn Nucleus is nor Inbreed or one, for said (5abm 70" Blmrvm and Prdessbo Cade The
Cartagena State LYNese Low does vim apply to on order of property no bosigh employees aPa. eflod bulbs
or Improves me property provided that me Improvements are not Intended or offered to sale If however, me building or
Improvement Is Hold within we year of completion the Owner Builder MII haw the burden of proving that It was not built
or Improved for me pumcee of NIB)
U 1, all owner of the properly, an exdush" contracting min licensed Comaoore to codmNtt tee projca f—com
7044 Bolles and professions Cnde The Commaers Stale License law, does not apply m an owda of property who
rimprovesllhermn and who 001MMM fa the projects with a licensed Contractor pursuant to DN Contractors, state
I Law)
U I am exampl from IIWIuura under me Countesses Slate Ncenve law for the fallowing moonfin
Sign
By my signature below I acknowledge mat, except for my personal residence In Much I must haw raldnd for at Most we
yea prior to conxietlon of the Improvements covered by this permit,) cannot legally Ball a structure that I haw built as an
bulkier N N Ins not been cnesbucu d In Its merely by licensed cmbacuum I understand Dot a dopy Of the
applloaGN taw, Section 70" dine Bslros and Professlo s Code a available upon request when doh appiapm Is
5ubMMW or at me following Web SN lddanwww kgirdo a goAalaw blond
LICENSED CONTRACTOR'S DECLARATION
I hereby afnrm under Bergey of perjury thal I rim licensed under provisos of Chapter g (commencing win Sedlm 7ODO)
of OMslar OSBsinesad Rolestlau Code end mylkase Is N Mildness enecl
ULENSE CLA55 t UC NO OC 2 2
EXP DATE �,GT� CONTRACTOR
WORIIFrs cipjapEnsanaN
glFammom
I HEREBY AFFIRM LONGER PENALTY OF PERAMY ONE OF TIE F WING OECIARADONS
awe NO we maintain a Certificates of Casein o Sell Insure for Wolter a Compensation a provided by
pn 3700 a the Lebur Cone, for the performance of the work for which this permit Is Issued
l have add and maintain Workers Compensation Insurance, as rapulred by Section 3700 of the labs Coda for
tie pedanance of the wok to which ins permit Is Issued My Worker B Canposatim ins ance Carrier and
policy NW ae5 ecy�lel'E' NPH CARRIER
POKY NUMBER
(TI6SEC11CNNEFD NOT RE COMPLETED IFTHE PERM is FOR Off HINGED DOlN6 SIOO ORLESS).
IamlymN Ingo parlanma, athn work by wltltldtidapmm hliaM1 Iddl Ira engloy erty prim In erty nondrm W th
MOO W the WOWS Compensllon Land a Calbpla And apree the If I mind bane subject m the Wakel
Compensated provisions of Secdon 3700 of the labs Code, I Mall famwith comply with dome pmdslo s
APPLICANT
WARMNG round to snome Wavers Compambm cumnage Is unlawful add doe subject an empbRr to undue
Damage and land lines up W one hundred thousand dollars (EI00,000), In Watlm In the coal of Ore dompelualbn,
damages as provide0 la In scrim 3708 of the tabs code Interest, and aterney's Ides
CONSTRUCTION LENDING AGENCY
I thereby ofBr11 under Broadly of perjury the there is a Cuebuclum landing Agency for tie performance of ine work by
which ins permit is kwed(i 3De7 Car C)
LENDER'S NAME
LENDER'S ADDRESS
I mrgry Doi I have novel cols appllabon and stale Vol the None Inldnmdkm is mRatl.l agree to canply with all city and
odinanim and go town relaadp to Bug and hereby Novellasrepreselgthws of Do county to
e11Nr Boom the Dee coed propto �pcondWutllon
/depmas
1 a- (Ole-4
PFAMIT,EE NAPA "Off)
- 1 -7
so
SIGNATURE O PERIAff7EE DATE
APPLICATION DATE PICII/
ISSUE DATE PERMTTII
TYPE CONST OCC GROUP
Scope of Work
N DWEL UNITS N STORIES N BEDROOMS
DESCRIPTION
SO FT
FACTOR PSF
ADJ AREAVALUATION
SFR/ADD/REM
GaragelGarpod
W
Bodoni
LL
Poovspd
ZRe
-Roof
9
Curmaclal
DO
m
Veluetlor7 Adl Area
QUANTITY
DESCRIPTION
FEE
a�
G
fD
2
ya
O
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
,D6 ��-
SMIP
ENERGY PIC
ENERGY PERMIT
RETENTION FEE
PRE-ALT FEE
Z ON
BASF
PLOT PLAN
ZONING CLEARANCE
TOTAL FEES
COMMENTS
D.
/t d�Q r ` 1
P/C PAID BY VALIDATION
RECEIPT PAID BY ✓.�o�q VALDAnON
/7
WHITE — Department Copy,YELLOW— Fknalce Copy PINK —Assessor Copy