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HomeMy WebLinkAbout15994 CITY OF DIAMOND BAR ��'" �'r� �y� �� � y � _ � �`�'--- DEPARTMENT OF COMMUNITY&DEVELOPMENT SBRVICES r (�Q U � `-� w 21660 E.Copley Drive Suite 190 L Q 1 � (909)860-3195 Fax(909)861-3117 PRESS "�';�°•:. BUILDING PERMIT APPLICATION FIRM JOBSITE . , ,.,. _- -- . , APPLICATION ... . PE, �, _�� ..•; � RMIT �i P!C o ADDRE55���52 ����''s��� �a DATE i /t G NUMBER � x c� ISSUE TYPE OCC APN �OT TRACT DATE � � �G CONST. GROUP � OWNER u � CA�/ ��sO.v O " ADDRESS �> ���, ��"�-s ZONING SETBACKS � CITY .4�t ZIP��� TEL��h'Es��-3 FRONT RW ❑ APPLICANT TEL. REAR p � SIDE/SIDE STREET RW ❑ CONTRACTOR�A �I�'1.v�' /�'S ���.� ,N� SIDE p ¢ ADDRESS 'S� �3 � �J ��' . a CITY l.l.?�`��r.a Z�« TEL.�/�,"L-��L-'� PROPOSED USE o ARCHlENG/ � pESIGNER NO.DWEL. NO. NO. ApDRESS UNITS STORIES BEDROOMS � CI7Y ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � Q OWNER-BUILDER DECLARATION SFR/ADDlREM O � 1 HEREBY AFFIRM UMDER PENA4IY OF PERAJRY THAT I AM EXEMPT FROM THE CONTRACTORS U� � GaragelCarport W C915EUWFORh1EFOL4MV�NGiiEA50N(SECJo31.68U51NESSAN07i70FESS10N5CO0E:ANVCI7VOR y COUMYriHICHREWIRESAPERMiTNCONSTRUCT,ALTEq,IMPROVE,DEMOLISH,ORHEPAIRANY3TRUC� W pgti0lDedc � TURE,PRIOR TO ITS ISSUANCE,ALSO RE�UIRES THE APOLICANT FOR Sl1CH PERMI7T0 FILE A SIGNEO W STATEMENi THAT HE OR SHE IS LICEN&EO PURSUAN7 70 iHE PROVISIONS OF THE CONTRACTORS U� � CENSE LAW(CNAVTER 9�COMMENCINO WITH SECTION 7N0)OF DIVISION 3 OF THE BUSINESSAN�PRO� � POOUSpe FESSpN50ODE)ORTMATHEORSHEI9EXEMIPTTHEREFROMANDTHEBASISFORTHEALLEGE�EXEMP� '� V TION.ANVVIOLATIONOFSECTION7031.68YANYAPPLICANTFORAPEp1AIT5U&IECTSTHEAPP�ICANT70 Z R8-ROOf � A CML PENALT�OF NOT MORE THAN FNE HUNORED DOLURS(SSoo),): � Ot.ASOWNEROFTHEPROPERTY,OflMVEMPLOYEESWITHWAGE5A5THEIR50LECOMPENSATIDN, � COII1f710�C18I - WILI DO THE YJCNiK,AN�THE STRUCNFE IS NOT INTENDED OR OFFERED FOR SALE(SEC.704/,BU51- J NESS ANO PROFESSIONS CODE THE CONTRACTtlRS LICENSE UlW DOES NOT APPLY TO AN OWNER OF � PROPERTYNM1IOBU4DSORIMPROVESTHEREON,ANDNMO�OESSUCHWOAKHIMSELFORHERSELFOR m � TNROUOM HIS OR HER OWN EMPLOYEES,PROVIDE�THATSUCH IMPROVEMENTSARE NOT INTENDED OR 0 OFFEREDWRSKEIF,HOWEVERIHEBUILDINGORIMPROVEMEMISSOLAWITHINONEVEAROFCAMG�E- z TION.THE qWNEH�BUIIDER WILL HAVE THE BUR�EN OF PpOVINO THAT HE OR SHE DID NOT BUILD OR � IMPROVE FORTHE PURPOSE OF SALE�. W ❑�,ASOWNEROFTHEPROPERTY,AMEXCLUSIVELYCONTRACTINGWITHLICENSEDCANTqACTORS � TO ODNSTHl1CT iHE PpQ1ECT(SEC.9044,9USINE55 AND PROFESSIONS CODE:TNE CONTflAC70R5 LI� V81U8f10� _ ADJ.AREA W CENSEIAWDOESNOTAPPLYTOANONMEROFAPROPERTVNMOBUILDSORI{APROVESTHEREON,AND � WFqCONTRACTSFOflSUGHPFiOJECTSWITHACONTRACTOR(S)UCENSEOPURSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FEE � TORSUCENSEUW.J. o ❑�AMIXEMPTUNOERSEC.� ._ �B.dG.C.FORTHISREASON U � � V" DATE ONMER.^ � U � LJCENSED CONTflACTORS DECLARATION W � I HEREBV AFFIRM UNDER PENALTY OF PERJURY THAT I AM IICENSeD UN�ER PROVISIONS OF GHAP7ER � D �//�_�. � U�.�. � G(COMMENCWO WITH S'cGTKKJ 7000)Of DIVISION 3 OF THE BUSINESS AND P(70FESSIONS CODE,AND Z �� MY LICENSE IS IN FULL FOflCEAND EFFeCT. 411 c� � � UCENSE CLASS G � LVC.NO.�Za � V DATE_ c • Y— COPJTRACTOR����._,�+�� a W � WORKEr�S'CAMPENSATION DECLRRATION Q = U � I HER�Y AFfIRM UNUER AENALTY OF CF.RJUAV ONE OF 7HE FOLLOV/ING�ECLARATIONS: � Z Q � IHAVEANDWILLMNNTAINACERTIFICATEOFCONS'cNTTOSELF-INSUREFORVJOHKERS' _ `CdAPENSATION,ASP4i6VIDEDBYSECTION370oOFTHElA80RCO0E,F9RTHEPERFOFMANCE U �� OF TkE WORK FOH WH�qi THIS PERM�f 15 ISSUF.D. � n W _IHAYEANDWILL}AAINTAINWORKEft5'CCMPENSATIONINSUftANCE.ASPEQJIRE�BYSECTION Q 37000F'H[1hE30flCODE,FORTNEPERFORMANCEOFTH�WOAKFORWHICHTHISPERMITIS � ISSIJ£O.MYVlOflKERS'COMPENSATIOM1MSUflPPICEGARftIER.4NqPOUCYNUMBERAFE: CON$TRUCT�OIV jcnaRien---- �/�''�'°��% 'C-i� PLAN REVIEW � POLICYNUMBER �-�l ������� ELEC,TRIC � Q � Q (trussEcaa�r�a>rurre=c�nrt�moF��aew.rr�sroaon�Erurn�Eoocra.nrs�ro�oa�EssA PLUMBING +� Z I CERTIFYIHAT INTME P'cRFORNANCE OF'�11E WORK FOfl WHIGHTHIS PERMIT{S ISSUED.I MECHANICAL ��� � � / (�S SHALL NOT EMPLOV ANY PEFSON IN ANY M/WNEk SOl�S TO BECOM'c SUBJELT TO THF N WOPo(ERS'CO�i9PENSATION V�•N�S OF CRUfORNIA,AN�AGREE THAT IF I SFK)ULCIBECOME INSPECTION FEE _ SUB.IECi TO TIIE WORKFRS'COMOC;NSATION PR�VIS�ONS OF SECTION 37D0 Of THE LABOR � O CODE,i SMALL F�RTMWITM COMPLV WITN THOSE PROVISIONS. ISSUANCE �� - .{„���___ F Y ,4 p �ATE: APPLICANT: _ ._ __ SMlP A� W ENERGY PfC J WARNING:FAIIURETO SECURE WORKERS'COMPENSATION COVEflAGE IS UNIAWFUI,0.Np SMALL BE - --- � SUCiJECTANEMPLOYERTOCPoMINALPENALTIESANOCIVILFINESUPTOONEHUNOREbTHOUSAND ENERGYPERMIT OOLLARS(5700.0001.IN A001710N TO THE COST Of COMPENSATION.DAMAGES AS PROVI�ED FOR IN --���----- � SECTION31oeOFTiELAeOftCO�E,INTEREST,ANDATTORNE�"SFEES. RETENTIONFEE: � CON57RUCTION LENDINGAGENCY pRE-ALT FEE: � I HEREBY AFFIRM UN�ER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCV n- fOR THE PERfORMANCE OF THE WORK FOR WHICH THIS FEFMIT IS ISSVED(SEC.309�,CIY.C.). - Z W � LENDER'SNAME_ ___.-. F- LENDER'SADORESS ___-_ _ __ � � ICERTIFY7HATIHAVEflEADTHISAPPIICATIONAWOSTATETNA7THEA80VEINFORMATIONISCORRECT. TOTAL FEES I � � I AGqEE TO COMPIV W1TN ALl CITYAND COUNTY ORDINANCES ANO STATE LAWS RELATING TO BUIl01NG 1 CqNSTRUCTION,AND HEREBY AUTHORRE REPRESENTATIVES OF THIS COUNTV TO ENTEF 11PON THE z ABOVE-MENTIDNEO PflOPERTY FOft INSPECTIOH PVRPOSES. COMMENTS � 5�-� m;. !f m PERMITTEE 1 E(PRIN� c�i� � � /C C�� � SIGNA7UREOFPERAII EE DATE. = RECPT.NO. PAID BY VALIDATION ~ WHITE—Department Copy,YELLOW-finance Copy,PINK—Assessor Copy,GOLDENROo--File Gopy,GflEEN—AppliranCs Copy . ._ . . _w; . ,. ,. . . ,.., , , , � ,. �, � , . . . . k� ����� �� ���������� ��� . . ������;����� ��.��� �r, .. .. � � � �",p� -�A� ��s �'�� :�. ._ , i� x'N-w� ��-.��,�'� ri"��� .:: -� '�i" ,� - ^� ��;,. r a :.g s � � ss :� �,� � Y - �.:? '� b.. �� �.e k� � �x� � � ,�'' k 2 �,# . ' � �.��a , 4 ��� a��� � ���� �:� ��: �� . ���' �`'�-��,„ � � �' � � .<�� ��� . t ;� , �.. 5 � : . � _ � . .. ��: . �"`��� ;„� � � .-� � E 4 ' 4 .. , I j ��� 76` ;s"� e . 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