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HomeMy WebLinkAbout15261 - 2621 INDIAN CREEK _ _ _ -. _ __ _. _ � � � �_�F-_ _ `, CITY OF DIAMOND BAR - --�� - DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � w 21660 E.Copley Drive Suite 190 f (909)860-3195 Fax(909)861-3117 PRESS �'�"�� BUILDING PERMIT APPLICATION FIRMLY ¢ DDRESS ��� � �N pt/�N C�t.C-�l< ��� APPLICATION �c,'� PERMIT �� �/C�j_r�� p DATE -a NUMBER � APN LOT TRACT�c7�I'��✓ �SSUE � TYPE OCG DATE CONST. GROUP p OWNER __ L�'�/,f • GO�l�2- p ADDRESS � �^ ✓-�' � ZONING SETBACKS �W CITY l� ZIP TEL. RE�AR RW � APPLICANT �'�'j�3�d 1SV 1�-A TEL.�2��-�� �i SIDE/SIDE STREET RW ❑ � CONTRACTOR I.) G�• SIDE ❑ ADORE55 � CITY ZIP TEI. PROPOSED USE �/h�l o �� � DESIGNER �-'�U V�(- ADDRESS NQ.DWEL. NO. NO. � CIN Gf' . �"T�.�q ZIP Go��TEL?j�� UNITS I STORIES �-- BEDROOMS v� DESCR TION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR1A �lREM O 1 HEREBY AFFlRM UNDER PENALTY OF PERJURY THAT I qM E%EMP7 FFiOM THE CONTRACTORS LI- G818 JB/C81pOlt W CENSEIAWFORTViEFOLLOWINCRF.ASON(SEC.7031.58USINESSANDPROFESSIONSCODE:ANVCITYDR (n COUNTI'NhiICH HE�UIRESA�ERMRTO CONSTRUCT,ALTER.IMPROVE,DEMOUSH,OH REPAIR ANV S7RUP W TURE.PRIOR TO ITS ISSUANCE.Q50 REW11RE5 THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W P21i0/DeCk STATEMEM THAi HE OR SHE IS UCENSE�PU0.SUANT TO THE PROVISIONS OF THE CONTRACTORS LI- � CENSE UW(CHAPTER D(Cd.11UENCINO WYTH SECTION 7000)Of OIVISION 3 OF THE BUSINESS AND PRO- � POOUSpd � FESSIONSCODEjORTHATHEORSHEISEXEMPT7NEREFHOMANDTHEBASISFORTHEALLEGEDEXEMP- (� V 710N.M1VVIOLATIONOF6ECTION7031.5BYANVAPPIICANTFORAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Roof � A CML PENALTY OF NOT MORE THAN FiVE HUNDRED DOLLARS(SSoo).�: � ❑I,ASOWNEROFTHEPROPERTY,OPMYEMPLOYEESWIiHWAGE5A5THEIR50LECAMPENSATION, � Commerciai - WIU.00 THE WORK,M10 TIiE STRUCTURE IS NOT INTENOED OR OFFEHED FOR SALE�SEC.704d,9USI- J � NE55 AND PROPESSIONS COOE:7HE CANTRACTORS LICENSE UW DOES NOT APPLV TO AN OWNER OF � PROPERN WHO BUIIDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR � THROU(3HHISORHEROWNEMPLOVEES.PROVIDEOiHATSUCHIMPROVEMENTSARENO7INTENDEDON m QOFFEREDFORSN.EIFHOWEVERhIEBUIL�INGDRIMPROVEMENTISSOLDWITHINONEVEAROFCOMPLE- Z TION,THE OWNER9UILAER WILL HAVE THE BUADEN OF PqObINO TNAT HE OR SNE DID NOT BUIIA OR � IMVROVEFORTHEPUAPOSEOFSALE�. � ❑I,ASOVMEROFTHEPROPERT1;N.fEXIX.USNELVCONTMCTINGWITHlICENSEDCONTIiACTORS � TO CQNSTRUCT THE PROJECT(SEC.7oW,BUSINESS PMO PROFESSIONu^CODE:THE CONTRACTORS LI- V2IU3�IDf1 ADJ.AREA � CENSEIAWDOESNOTAPPLYTOANOWNEflOFAPFOPERTYWHOBUILD50RIMPROVESTHEREON,AND W}IOCONTRAClSFORSUCHPRQIECTSWIiHACONTRACTOR(S)LICENSEpPURSUANTTOTHECONTRAG QUANTITY DESCRIPTION FEE � TOFiS LICENSE LAW.). J F�'l�JC .S c�ct� � ❑I AM E%EMPTUNDER SEC. B.8 P.0 R THIS R SON Q 3 � � L� � �=" �A7E0�� � Q OWNE � � U � ��7 LICENSED CONTRAC S DECLARATION w J � W 1 HEREBYAFFIRM UNDER PENALTY OF P'cRJURY THA71 AM LICENSED UNDER PROVISIONS OF CHAPTER �7{ � 9(COMMENCINCiWITHSECTtON7000jOF�IVISION30FTHEBUSINESSANDPROFESSIONSCODE,ANO Z __ / '`�d � - MV UCENSE IS IN FULL FbRCE AND EFFECL m ) �'�, � IL � 1 0 UCENSE CLASS__ LIC.NO. � � F, J V DATE CONTRACTOR d = WOAKEAS'COMPENSATION DECLARATION Q � 1 HEREBY AFFlRM UNbER PENQTV OF PEiLIURV ONE Of 7HE FOLLOWING DECLARATIONS�. Z � _IHAVEANDWILLMAINTAINACERTIFlCATEOFCONSENTTOSELF-INSIiFEFORWORKERS' 2 � '�A Q CqMPENSATION,AS?ROYIOED BV SF.CTION 3'!0o OF7HE LABOR CODE,FOP THE PEiiFORMANCE w OF TVE WORK FOR WHICH THIS PERMI715 ISSUED. � O W _I HAVEAND WILL MAINTAlN WORKERS'COMIPENSATION INSURANCE,AS REQUIRED 8V SECTION �/ O 97ooOFTkEIABORCOUE,FONTHEPERFORMANCEOFTHEWORKFORWHICNTHISPEFM1T15 � ' / ISSUED.MVWORKERSCOMPENSATIONINSJAANCECARflIERAN6POlICYNl1M8ERARE: CONSTRUCTION � jce.aaiEa _ _ PLAN REVIEW 1 2 Pcx.icYriuMB[R _ — ELECTRIC T Q Q (TFiSSECTqNNE�NDT9E00MPLEfmOFh£PEWNTISFOROh'F.ViINJ�REDDOLLAR3(S1ao�ORIESS�. PLUMBING � ICERTIFYTMATINTF1EP�flFORMANCEOfTHEWORKFORWNICHTH157ERMITI5155UED,l MECFIANICAL Z (,� SHALLNOT EMPLOY ANY PENSON IN ANV MANNER SOAS TO BECOME SUBJECT TO THE ((� NlORKERS COMPENSATION LAWS OF CAI.IF9RNIq AND AGREE THAT!F I SHOUL�BECOME INSPECTION FEE SUBJEC7 TO THE WORKERS'COMPENSATION PRCVISIONS OF SECTIOIV 370o OF THE LABOR � � COOE,I5HALLFORTHWITNCOMPLYIKITNTHOSEPHOVIS�ONS. �SSUANCE 0 r p �ATE: APPLICANT. SMIP c � ENERGY P/C .� ___, WANNINO:FIUIURE TO 9ECUflE WORKERS'COMPEIVSFTION COYERAGE IS UNLAWFUI,AN�SHNLL BE � SUBJECTANBdPLOYERTOCRIMINALPENALTIESANOCIVILFiNESUPTOONEHUNOREDiHOUSANO ENERGYPERMIT ' DOLURS(f100,0001,�N ADDITION TO THE COSTOF COMPENSATION,DAMAGES AS PROVI�ED FOR IN � SECT�ONa70HOFTHELA90RCODE,INTEREST.ANDAITORNEI^SFEES. RETENTIONFEE: " a CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O Q 1 HEREBV AFFIRM UNDER PENALTV OF PERJURY THATTHERE IS A CONSTRUC710N LEN�ING AGENCY FOR THE PERWRMANCE OF iHE WOFK F-0R WHICH THIS PERMIT IS ISSUEO(SEC.3Ds7,CN.C.�. . Z W � LENOEfl'SNAME _ f- LENDER'SADORESS � TOTAL FEES � I CERTIFV TMAT I HAYE READ THIS APPLICATION AN�STATE THAT i HE A60VE INFORMATION IS CARRECT. W I AGREE TO COMPLY WITH ALL CITV ANO COUNTY INANCES AND STATE LAWS RELATING TO 9UILDMG � � STRUC710N,AND HEREBY AUTN IZE fi S TATIVES OF THIS COUNTV 70 EN7ER UPON THE Z �MENTIONEDPROPERTYFO IN PE IONP RPOS2S.'�- Q COMMENTS � m PE��R7M�I NAME(PRfIN�ry�� . U? /Q�� �l '� `��'�Q��� � SIGNANREOFPERMITTEE DATE � RECPT.NO. PAID BY VALIDATION WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GO ENROD--File Copy,GREEN—Applicant's Copy .—. , ... . ,--._ ,...,., . �::. �,. � .�.,< . , . _ . , . �. ;� ���� ���� ��������� �� ������``�'��� ���:���.� � � ���� �� `' � ��,��a, `�.�•� �a"`� �s �' �'E��r�ss �'� .� a�� ':i-ur�€� ����� �g�� �� � a _�,: ...,, ,�,� �., m :,��" � �`- ���.� . �� �.��r��.�a�.:� �.� � *� � � � . ���°'�. � ���� �s�� � �� �... ��:� .� �� .".�,»�s�.'. s'�'�+4"': � ...,�•� ;�...x....x... 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