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HomeMy WebLinkAbout12582 (14) I %._1 _�,� CITY OF DIAMOND BAR r � DEPAR.TMENT OF COMMUNITY&DEVELOPMENT SERVICES •` � 21660 E.Cop]ey Drive Suite 190 �� PR ESS (909)860-3195 Fax(909)861-3117 I �'^�"� BUILDING PERMIT APPLICATION FIRMLY ; � JOBSITE [Q ! o ADDRESS f,�� �1���*l'f°�� �'-,� � l�c- DATE�CATION � �q �i�, C2 NUMBER ��-J v�#lC � I U �. � ISSUE TYPE OCC APN LOT TRACT DATE. O Z CONST. GROUP p OWNER S� �t t� I�(� I�� — p ADDRESS ��Ly,�,` .S._ Df{�(Y[�Z���(o �� ZONING SETBACKS � FRONT RW ❑ z CITY •h:f.+riAr�n RA-1� ZIP C�' ,�' TEL.(�'y�5�7.x� �.�r,%�,r'/,, U-- � a APPLICANT ��-_� �cl Y'c tiLr TEL. _ REAR �r SIDEJSIDE STREET RW`_ I� � � CONTRACTOR �.( � "�� SIDE L � ADDRESS p l �- PROPOSED USE '—' � � � a CITY L�• [�- ZIP � 'C .TEL.(;i��T']-Ls(,t� � � w ARCWENGI z DESIGNER w - NO.DWEL. NO. NO. a ADDRESS �n UNITS STORIES BEDROOMS p �.. CiTY , ZIP TEL. �n DESCRIPTtON SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFWADD/REM O � I HEREBY AFFIHM UNDER PENALTV OF PEHJURV THAT I AIA E%EMPT FROM THE CONTRACTORS LI- G8f8QB/CafpOff W CENSELAWFORTHEFOILOWIN6REA50N(SEC.7037�UUSINESSANOPROFESSIONSCO�E:ANYGTVOR (� U COUNTYYhiICHHEOUIRESAPERMRIT7CON5TRUCT,ALTER,IMPHOVE,OEMOLISH,ORREPAIRANYSTRUG � W A8f10/�BCk � W TURE,PRIOH TO ITS ISSUANCE,AL.90 REdUIRES THE APPLICANT FDR SUCH PERMIT TO FILE A SIGNED W STATEMENT THAT ME OR SHE IS UCENSED PUflSUANT TO THE PqOVI510N5 OF THE CONTRACTORS L6 �� CENSE lAW(CHAPTER e(CAMMENCING WITH SECTION 7aoo)OF OIYISION 9 OF THE 6USINESS AND PRO� ' �'�' POOVSp3 � FESSqNSCODEJORTHATNEORSHEISEXEMPTTNEREFROMANOTHEBA515FOR1HEALI.EGEDEXEMP- (!f � V TqN,ANYVpLATIONOFSECTI0Y7o3t.5BYANYAPPLICANTFORAPERMITSU&IECTSiHEFPPLICAN7T0 Z RB-ROOf n F_ ACIVIL PENN.T'OF NOT MORE THPN FIVE FN�DqEO DOLUHS(S5ao).): g � Cli,A50WNEROFTHEPROPEATY,OflMYEMPtOYEESWlTHWAGESASTHEIHS�IECAMPFNSA7lON, � C0111f119fCidl g Z WILL 00 TNE WORK,AND TME S'fpUCTURE IS NOT INTENDED OP OFFERE�FOH SALE(SEC.7044.BU51� J NE55 AND PROF�SSIONS CODE.THE CONTRACTOflS LICENSE V�V�nOE:t�OT APPLY i0 AN OWNER Of ? � PIqPERTVNAIOBUILDSORIAIPROVES7HEflEON,MIDVMODOE55UCHWORK111N5ELFORHERSELFOR ,�j Q iHHOU6HHI50RMERUWNEMPIOYEES,PflOVIOF�TFIATSIICHIMPROVEMENBAFENOTINTENDEDOR m � n OFFEREDFORSQE.IF,HOWEVEfl,THEBUILDINGORIMPROVEMENTI550LAW1THINONEYEAROFCOMPLE� � Z TION,iHE OWNF.Fli3UIlDEF WIIL HqVE THE 6UflDEN OF PROVING TNAT HE OR SHF 01�NOT BUII O OR � IMPROYEFORI'HEPURPOSEOFSALE), W C71,ASOWNEROFTHEPFOPEHfY,AME%CWSNEIYCONiRACTWGWITHUCENSEDCANTRACTOR3 � TO CONSTRUC7 THE PRQIECT(SEC.7oI4,BUSINESS AND PROFE3310:J8 CO�E:7HE CONTFACTOPS LI- V91118tI0I1 ____pDJ.AREA __,,_____ � W CENSELpWDOE5NO7APPLYTOANOWNEROFAPROPFRTVWHOBUILDSORIMPROVESTHEREON,NJD EE � Vh!OCANTMCTSFORSLICHPHQIECTSWITY.RCONTRACTOfl(5)LICFNSEDPURSUANTTOTMECONTRAG �- TOR.4LICENSEI.AW.� QUANTITY DESCRIPTION F ; � ❑IAM EXEMPT UNDER SEC. 0.8 PC,FOR THIS REASON a � . U h G � ------ � � � DA7E __,�_ _OWNER__..._—"_'_-- F � U �Q L(CENSEU CONTRAC70FS DECLARRTION W 2 I HEREBY AFFRM UNDER PENALTY OF PERJURV THAT I AM I.ICENSCD UNUFR PROVISIONS OF CHAPTEA � S 'O (L �B(CJJMMENCLVOWITHSECTKKJ7000)OFDIVISION30FTHE6USINESSAN�PROFESSIONSCO�E,AND Z X MY IICENSE IS IN FULL fORCEAND EFFECi. m N r,,, - ;� Y �� O LL1 � 7 O L�CENSE CLASS�_��LIC.NO._��,�'�'C� f A J r .-N�r �,� (�e/ O � DATE 4���_5_�--� CONTRACTOR .7/AG�'�� ,/.!� Al6�'(�- d t � WORKERS'COMPENSATION DECLARATION Q ��� a � 1 MEREBY AFFIRM t1N0ER PENALTY OF PEPJURY ONF.OFTHE FOLLDWINR DECUFATIONS: Z z ___INAYEANDWIILMAiNTAINACERTIFICATF.OFCANSENTTOSELF�INSUFEFORWOr7KF75' _ � � C0IAPENSATION,ASPflOVIDED8Y5ECTIONatooOFiHEL480RCCDE,FORTHEPERI�ORMAI:Cf: W Q OF THE WOPK FOR WHICH TIIS PF.RAiIT IS ISSU'cD. � F __.IHAVEANDWILIMAINTAINWORKERS'COPAPF.Y3ATIO�INSUHANCE.ASFEOUIHEDRYSF.CTIUN � Q 3]0o OF THE LADOR CODF.,FOR'fHE PERFORMMICE OF THE WORK FOR WHICH THIS PERMI'i IS -- — � ISSIIE�.MV WORKEFS'COMPENSATION MSl1FANCE ChFR1ER PND POLICY hUM�ER I1R[' CONSTRUCTION Q _.._ � caaai�Fl____ ________. PLANREVIEW ___ __ Q Pa.ICYMUMBER .-- ELECTRIC � —'-------.—...------ ----- - Q c�� 1./7 U (TFi16SECi%7NNEQJNDTB[NM�LEffDOFTHEPERMrISFORQVE4iU!JNiEDOIX.I.ti3S(5f00)ORLESS) U BIN J.f7A�� __ _ ,( v �OO � ICERTIFYTHATINTHLPERFORMANCEOFTHEWORKFORWHICHTHISPERMITISISSUED,I MECHANICAL __ .__.______ (.�} SHALL NOT EMPLOV ANY PERSON IN ANY MANNER SOAS TO�[COML�UE3JCCT 10 THE � WORKERS'COMPENSATIONLAWSOFCAUFORNIAANDAGREE7HA71FISHOI�IDBLC041C: INSPE IONFEE _____"_____._.."_'___"-_''.___.._.,--"' Sl�&IECTTO THE YVORNEflS'CAMPENSATIO�PROVISiONS OF SECTIOV 3700 Of THE LABOR (� � �� fi ��D � CO�E,ISMALLfOHTHWITMCOMPLYWITNTHOSEPROVISION3. ISSUA C _.._,_Q�,�_L l.� "��J�D_ ____ __ __ L o N'v-'-1\J O 0 �ATE: __ APPLICANT.„"__-_'"' MIP __—_""""_"'— ��O J WARNMIp:FAlLUAE TO SECURE WORKEAS'f.OMPF.NSATION COVERAGE IS UNUIWFUL,AhD SHALI.BE ENERGY P/C qp���TjT��T o�ri DIApy��y�.r�,Nr,�� ___. . .__.___.__ ___ �y SU&IEGTANF:MPLOVEH"fOGRIMINAIPF.NALTESANDCIVILFINFSUPTOONEMUYDRE�THOUSAND ENERGYPERMft'v��✓�1VG_ !'4 �IVl.1 S/�,��'S�__ __ DOLWiS(51oo.000),INADDITIONTOTHF.COSTOFCOMPENSATION,DAMAGESASPROVIDF.�FOPIN -�-------.--- - �-- � SECTION37080FTHELABORCOUEINTFR[ST,ANDATTOFiNEV'SFEES. RETENTIONFEE: _.._-"_'-'____--__-______ d CONSTRUCTION LENDING AGENCY PRE-ALT FEE: p —--- --- �--- ----- � IHEREBYAFFIAMUNDF.RPEhALNOFPLRJURYTHATTHEREI5AWN5TRUCT1041.ENDIKGAGENCV _ _ __ __ FOR THE P[RFONAIANCE OFTHE WORK WR WHICH THIS PERMIT IS ISSUED(5[C.3o97,CIV.C.). Z W '-� -�--.._..-�--- --_._.—__.._.- � LEN�EH'SNAME�____"' _"'—_"'- _"' _'_—__"'___'_—.. F- LENOEq'SADDRE55.. _--_.... --._-- .-- � TOTAL FEES .J( � ICEfiTIFYTHATIHAVEREADTHISAPPLICM1TIONAN�STATETHA(THEABOVEINFORMqTIqNISCORqECT. G����.�/�� � W 1 AGNEE TO GOMPI.Y WITH ALLCITY AND CAUNTY ORDINANGESAND STATE LAWS RELATING TO BUILDING --- _ %//L' � CONSTRUCTION,qNDHEREBYAUTHORIZEflEVf1ESENTATIVESOFTHiSCOUNfYTOENTfRUWNTHE �/i1A/// � ABOV6�MENTIONE�PROPERTY FOR INSPECTION PUHPOSFS. COMMENT5 9��G1 z o ., � ' • � /� �-� � .��_ ' - ---- ( /( / K.[ 1 _. �� /..�� m PERMITTEE�PINT) �V \/ a . . � -� � � ------ ---------�_ - �, ._�, j�. .��� ------ - ----.- - � � SIGNATURFOFPERMITf E -� OA7E = RECPT.NO. __, PAID BY 1'�� VAIIDATION � _ � ~ WHITE—De artmBnt Co VELLOW—Finence Co PINK—Assessor Co GOLDENROD—Flle Co GREEN—A licant's Co P PY. PX PY. PY, PP PY a , g _ _ . .. ,.. , __ , _. ... _. ,_ . e _r.. . r.. ._ _._ . .�. _, , i�` ' � � ' ` : �E � - ! � i � i � ; I . � , I , i _ , ' � B�s" . : . - . , � ���i � � I ' I � � . ( � ' . 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