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HomeMy WebLinkAbout15063 (20) t CITY OF DIAMOND BAR ,� . � I �- ���-- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � � � ��. .' n 216b0 E.Copley Drive Suite 190 I ,,. �,,,� (909)860-3195 Fax(909)861-3117 PRESS ' '��" BUILDING PERMIT APPLICATTON FIRMLY I Q AD R�ESS/��'�� A�/H�1 Fj�D k�r7l'L ��U �� � �- APPLICATION �' -^•� �� PERMIT � P/C���1 f�J � p DATE NUMBER �` # �0 E ISSUE /� TYPE OCC � � APN LOT TRACT DATE / CONST. GROUP � � OWNER p ADDRESS�f��r^� �[�. 9 � '}� ZONING SETBACKS �W CITY �j.�JL�O�(.J�/�A�ZIP��v_ TEL. - REART RW �i----- � APPLICANT TEL. SIDE/SIDE STREET RW I.1 � CONTRACTOR ' L �', SIDE ❑_� o. ADDRESS � - ' � , PROPOSEDUSE �� c/�� � r- o ciTv �n u�� ziP 9l�?? TEI n� _ J E w ARCH/ENG/ — z DESIGNER�OvcS� [1'/r/��',�1�ifG � w NO.DWEL. NO. NO. iy ADDRESS�'/,�fJ�.^" UNITS STORIES BEDROOMS a � CITY 21P TEL. - — cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION i � OWNER-BUILDER DECLARATION 8FR1ADD/REM O �. Q i HEREBY AFFlqPA UNDEfi PEN0.LTY OF PERIURY TNAT I pld FXEMPT FROM THE COMRACTORS LI- G8fdgB/CflfpOff (� W CENSEUWFORhIEPDLLOWINOREA50N(SEC.7031.581JSINESSANDPROFESSIONSCODE:ANVqNOH � (n >, zCOl1NfYNM1iICNREQUIHESAPERAlITTOCONSTRUC7,AL7ER.IMPROVE,DE40USH,OqREPA1RANYSTRt1C- W PatiO/DBCk " TURE.PNIOR TO ITS ISSUANCE,AL50 REQUIHES THE APPLICANT FOR SUCH PERMIT TO FILE A SIONED W' STATEMEM THAT HE OH SHE IS LICENSED PURSUANT TO THE PPOVISIONS OF THE CONTRACiOR3 LI� W K � CENSEIAW(CHAPTERB(COMMENdNOWITH3ECTION7W0)OF�IVISION30FTHEBUSIItlE55ANDPRO- � � POOVSp2 2 FE5SION5 CODE)Oq THAT HE OR 5HE IS EXEMPT THEREFROM ANO THE 6A515 FOR THE ALLEGED E%EMP- T�ON.ANYVIOLATIONOFSECTION7031.SBYANYAPPLIGANTFORAPERMITSU&IECTSTHF.RPPLIL'PNTTO Z RB-ROOf " r ACINLVENALNOFNOTMOqETHANFNEHUNDNEDDO�LARS(5500).j: � � ❑I,ASOWNEROF7HEPROPERTY,ORMY[MPLOYEESWITHWAGESASTHEIRSOLECOMPENSATI�N, A COrt1RI0fC18I WILL p0 THE WOPK,pN0 THE STRUCTUflE IS NOT INTENDEO OR OFFEREO FOR SALE(SEC.7044,BU51- J NE55 MID PqOfE5510N5 CODE:THE CONTRACTORS I.ICENSF.LAW DOES NO'�APPLY TO AN OWNER OF � N PqOPERTYNM1IOBURDSORIMPROVESiHEREON,ANDWHODOESSUCHWORKHIMSELfORHERSEIFOR � CC TMROU6HHISORHEROWNEMPLOYEES,PROVIDEDiHqTSUCMIMPRUVEMENTSAqENO7MTEN0E�OR m . W OFFEHEDiORSALE.I(;HOWEVERTMEBUILDINGORIMPROVEMENTISSOLDYIITNINONEYEAROFCAMPIE- ' ZTiON,TNE OWNEfl-9UILDEfl WILL MAVE iHE BUflDEN OF PRDYING TMAT HE OR SME DID NO�BUILD OR � � iMPROVE FORTHE PURPOSEOF SAIE). ' ❑1,AS OYMER OP THE PROPERf'!,AM EXCLUSIVELY CANTRACTING WITH LICENSED CONTRACTORS L�' � TO CANSTRUCT hIE PRQIECT(SEC.7041,BUSINE55 PNO PROFESSIUNS CODE:THE CONTRACTORS ll- VBIUaS10I1 _�G� P.DJ.AREA__„_. _____ { CENSE LAW WE3 NOTAPPLY TO AN OINNER OK A PROPERTY WHO BUILDS Ofl IMPROVES TH�qEON,PN� 4 Y1FIO CONTMCTS FORSUCH PR0.IECTS WITilACONTRACTOR(S)UCEN5ED PUFSUPNT TO THE CONTflAG !' � tonsuceriseuw.y QUANTITY DESCRIPTION FEE � �. o ❑IAMEXEMPTUNDERSEC. 9.&PC.FORTHISREfSON U � J? _"'_ '� � i' LL OATE OWNER_ _ U �' � w � LICENSED CONTRACTORS DECLARATION w g� �' � �HEREBYIIFFIRMUNOEflPENALTYOFPEPJUflY7HATIAMLICEN6EDUNUERPftOVISIONSOFCHAPTCR ' d B(COMMENCINO WRH SEC710N 7000)OF DNISI04 30F 7HE OUSINESS AND PROFESSIONS CODE,AND � � MV LICENSE IS IN FULI FORCEAND EFFECT. Z F, r `� m f. � LICENSyE yC�LA/S/S', `� �� LIC.NO. .�5/ j . j 'p` U OATFJJ[��_��CONfRACTOR � � ._ ,G„� d � � W � .. � � WORKERS'COMPENSATION DECLARATION a P� y� . � 4 � Ih1EREBYAFFIflMUNDERPENALTYOFPER1UqVONEOFTHEFO�IOWINGDECLf�RAT�NS: U � �' cn za �''_ , - � � �IHAVEIW�WILLMAINTAINACEfiTIFICATEDFCONSENTTOSELFINSUREFORWOFIKERS' 2 n�, y� COMPENSATKNJ.ASPROVIDEDBYSECTION97000FTHFIAEORCO�E,FORTHEPER�ORMANCE U L`� �CAO�r^� � J� OFTHE WORK FOR WHICH THIS PERMIT IS IS5UED. 6 � W _IHAVEAN�WILLMAINTAINWORKERS'COMPENSPTIONINSUMNCE,ASREQUIREf76YSECTION /� l € Q 3]ooOFTNEUBORCOUE,FORTIEVERFORMANCEOFTHEWOqKFORWNICHTHISPERMITIS � ISSUED.MY WORKEflS'COMPENSATION MSUMNCE CApPIER AND POLIGY NUMBER AF[: CONSTRUCTION ��� � _ .. ."'_____"'__" / ' � r � ELECTRIC �� ,, a ..------.... ( CpRRIE��� � PLAN REVIEW ___ _._,_ s � POLICY NUMBER__ i.� Q (fHt55EC1KNN�NDTBEOCA�LFfIDOFTHEPEFNMISFORIXJEMJPAHED�OLlAR5R10�)ORLFSS�. PLUMBING ..-_ .------�---��-- - �--�-- �. W 1 CERTIFYTHAT IN 7HE PERFOHMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSl1E�.1 MECHANICAL ����� � Z ----.. _._.—_,..�. -�---�'�-�-�1 �. (J SMAl4NDT EMPI.OYANY PEHSON IN M1Y MANN[R SOAS TO BECOME SUBJECT TO i HE 5 � WDRKERS'COMPE4SATION LAWS OF C\LIFORNiA, U AGREE THAT IF I SHOULD dCCO �NSPECTION FEE ._ _ �__�_ . ?:^�A e�d _�_ , F SUBJECTTOTHEK'ORKFRS'COMPENSATIONPRO SIONSOFSECTION37000FT AB �`�.0 �`r 4� CADE,ISHALLFORTHWITHCAMPLYWITH Rqyl ISSUANCE �� � f '--_-_----'�_- .`.�i�^� �, p DATE:�_S:L_v� APPLICANT: �� SMIP ____ .. . � ____ _'_ __ �� �:A�;•�: �: J WpPNIN6:FAILUHETOSEGUREWORKERS'COMPEN9ATIDNCOVERAGE19UNlA UL.AN ALLBE ENERGYP/C __ .___ �T'_.�;��., '�_� � �� _ Ey �y SU&IECTANEMPLOYERTOCRIMINALPENALTIESAN�CIVILFIN65UPTOONEHU RED N USAND ENERGYPERMIT ____ h pOILARS�5100.00o),INADDITIONTOTHECOSTOFCOMPENSATION.DAMqGE3A3P IDEDFORIN ---------- ---- -------- —�.�-yJ�yp- � J SECTI04 s708 OF THE LABOR CODE,INTEREST,ANDATfOPNEYS FEES. RETENTION FEE: �_w, V � _ —_ "-__"—' — �' � CONSTRUCTION LENDING AGENCY PRE•ALT FEE: �y � ________,_ � � IHEREBYAFFIflMUNDEFlPENALTYOFPLRJURYTMATTMEREISACONSTpUCTIONLENDINGAGENCY _ �� _ __ _ i• FOR THE PERFORMANCE THF WORK FOR WHICH THIS PERIAIT IS IS5UED(SEG?097,CIV,C.). -�-- - �; � ' "_.--_. _"'_"_' '.._.—._ _'__ k � LENDER5NAME ��..' __" �E T �. . - _'_ ""'____ _'__ � .�'�'_ �4 F� LEN�ER'SAODRE55. _ __ �-.-. __—_- 'N W ICEFiTIFYTHATIHAVERE.ADTHISAPPLICAT10NM1DSTATETHA7THEAF30VEINFORMATIONISCARRECi TOTA�FECS ��L.�f. � a, IAGREETOCOMPLYWITHALLCITYANDCAUNTVORDINANCESANOSTA7ELAW3qELATINCi706UiL�ING / «� � CONSTRLICTION,ANDHEfiEBYAU7HORIZEREPRE5FN7ATIVESOFTHISCOUNTVTOENTERUPONTHE � ABOVEMENIKKJEOPHOPERNFORINSPECTIONPURPOSES. COMMENTS __ _._ __ � �-'V {�,,� -- --- --- � — -F"f - m PER TTEE E(PRI _, ¢ ��L' --�- " — � � •. � � ATE � { � RECPT.NO. - PAID BY _._� VAUDATION__ _ S WNITE—Departme opy,YELLOW—Finance Gopy,PINK—Assessor Copy,G(JLOENROD—File Copy,GREEN—ApplicanPs Copy � a . .__ -. ---'... . .... - --- xri . : , _ .._ .. i - _ _. .._, . _._.__._ , .._ .. _ _. . _ _ _ . . . t�._ � . [ � , ( � � � I v'� � i � � i � , � i � ; , ; � , , �,�.; � I ; � ' l . 1 � : �' , � , � . � _ � �, , i � , , ; � , b • . : ' . . .. � . . � : ' 1 . .. � ; I � ; ' : i � ' � - � _ � � ,_ � • 1 � ' 1 � . • i . . . . � � ' � � , I � I � � � � . � I - . . � ; � . ; i ��: ��4r� � : i . . - ' � � ' a • i ' � . - _T . .. , . , � � - 4. i .�._. .. .,..� . ___ ._ _.._�. - �___.. _ _ _ ._ .._ _i ' ' , 1 �'.<a ' , ; , ' � " i ; . 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