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HomeMy WebLinkAbout10035 - CITY OF DIAMOND BAR � COMMUNITY DEVEI,OPMENT DEPARTMENT :,,,� 21660 E.Coplcy Drivc Suitt 190 PRESS (909)860-3195 Faz(909)861-3117 �' BUILDING PERMIT APPLICATION FfRMLY � ITE Q .. p APPLICATION PERMIT �/}�J P/C � ADDfiESS���!��I11L Nt� /`I L��i G �� DATE NUMBER "" / `S # �� �� c� ISSUE ��TYPE OCC PN LOT�� TRACT DATE CONST GROUP ' °G NER �� ����GM+3•Vl,J EZ-W�P.P�' � o i o A�DRE S � �ut�- E - ZQNING SETBACKS i Z CITY� r+ ZIP�/ �'�TEL_��el-���3�-. FRONT RW ❑ $ PPLICAN7 • TEL. REAR O � SIDEJSIDE STREET RW ❑ CONTRACTOR SIDE ❑ � ADDRESS n PROPOSED USE ��'�V�'✓ L� � E a I- � � CITY ZIP TEL. � � ARCH/ENG/ T u, z DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS_�_ STOFIES � BEDROOMS�_ � CITY ZIP TEL. N DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER-BI:ILDER DECLARATION �q/qpD/REAA ' O Q I HEAEBY PFFliW UNDER PEN�L7Y OF PER.IURY THA71 AM E%ENPT FROM TNE CONiRACT00.S LF G��y�rt W CENSEUWFOPTHEFOILOWIN�REA50N�SEC.7a]t.SBU5INFSSANDPROFESSIONSCOOEANVCITVOR (/� ZCOUryTYYMH'NPEWIRFS�PETiMITTOCONSTRUCT,ALTERIMPROVE,DENOLISM,ORREPAlflAN'(STRl1G W P8li0/D9CJ( W TURE,PHIOR TO ITS ISSU�NCE,AL50 REW IRES TlIE MPlICANT FOR SUCIi FEiqA1T TO FlLE�51CN£D W � STATEMENi TiMT ME OR SME IS UCENSED PURSUMIT TO T1E PROVISIONS OF THE GONTMCTOflS LI- � CENSE UMV(CHAPTER 0(COYYENCWG MATH SECTION)000)OF DIVISION 3 OF 7HE BUSINESS AND PRO � POOI/SP8 FESSIONSCODE)OqTHIRHEORSNEISEXEMPTTMEREFRONMID7FIE8ASISFOPTYIEALLE6EDEXENP• (� TION,NM/VIOLATIONOFSECTIONt031.5BVANYAPPlICA/7TFORAPERNITSUBlECTSTNEAPPLICAHfTO Z R9-Rpp} r A L EN�L7Y OF NOT MORE TNAN FlVE MUNL1flE�OOLURS(f5o01.1: ^ ASOVMEROFTHFPROPERTV.OPMYEMPIOVEESWITHNNOESA5THE1R50L.ECONPENSATqN, ❑ (`,pTRIBfCiBi L WI 7HE WAHK,A!O 7tiE SiRUCN1iE IS NOT INTENDEO Oq OFfEFED fOF SAIE(SEC.7ou,BU51- J NE33 ANO PROFESSIONS COUE:TNE CONTMCTORS LICENSE UW DOES I�pTAPPLV TO AN OMINER OF N PNDPERTYWF70BURDSOHAIPROVESTNENEON.M�DNR70DOESSUCHMM1]RKHWSELFOqHEPSELFOR m (t T1IHOUGHHISORNEROMMEYGLOVEES,PpOVtDEDTHATSUCIIWPROVENENTSAaENOTMffENDE00R Q4FFEREDFORSKE.1F,Hd1hVERTMEBiRLIMNGORINPROVEl1ENi1550i.DMflTMNONEVEAROFC�MLE Z TION,TME ONMER�BUIIDER WILL IMVE THE BUf10EN OF PqWMO TMAT ME OR SHE DID NOT BUILD OR , � BWiqVEWRAiEPl1RPo5EOFSALE). ❑1,ti5 ONR/ER OF THE PROPEHTV,AM E%CLUSIVEIV CONTMCTMa 1MTH LICENSED CONTMCTORS WW TO CONSTRUCT 7HE FRWECT(SEG�Ou.6USMESS AND PROGES$IONS CODE:TNE CWTWICTORS LA. 81U8UOf1 ADJ.AREA CENSEIAWDOESNOTAPPIYTOMlOWNEROF�PROPEflTYXRiOBUiLD50RIMPRDMESTF1E11E0N,�Np � wramMrw�eTsroasueHvaaEcrsMnm�ca+riucron�s���NseoauPsu�r�rmrnemrrw�c QUqNTITy DESCRIP710N FE5 � TORS UCEN9E LAW.4 J � ❑1 AN E%ENPT UNDER 9EC. B,t P.C.FOR THIS HE�SON e� 3 � ¢ u' OATE ONMER U W �a UCENSED CONTRACTORS DE TION W K IHERE8YIIFFIAMIR'AERPENAL7YOFiEPJURYTMATIAMLICENSEDUNDEPPNOVIS10N50FCFiAVTER � s i(CdAA�ENCIN6 WIiH SECTION lOm)Of DMSiD1i 3 OF THE BUSINES3 AN�Pi�FES5RMi5 CODE,MI� � u� W IICENSE IS NI FULI WNCE AN�EFFECT. m ,�;i 1 � � � F, IICENSE CLASS LIC.NO. J V OATE cdJTMCTOA a W � WORKERS'COMPENSATION DECLARATION Q N I MEREBY�FFIRM UNDER PENALTV OF CEPJURY ONE OF THE fOLLO'N�Nfi DECUMT10N5: � "—' a � I HAVE AN�WILI IAMNTAW A CERTIFlCATE OF CONSINT TO SELF-INSURE FOR V�KMKERS' S � COYPENSATION,/S VHDVIDE�Bv SECTION 3)00 OF THE UBOH CODE,fOR THE FERf-0iqi+1NCE � OFTHE WORK iOR WHICH TN�S PERMIT IS ISSUED. � 0 W _I NAVE AND W!LL MNHTAIN WOfiKER9 COEIPENSATION INSURANCE.AS PEWIREO BV SECTION Q S7ooOFT7EUeORCODE.FOHTHEPERiORMANCEOFTH£wOAKWRWHKXfili\4PERY1TI5 � 0 ISSt7E�.MYWORKERS'WMPENSATIONINSURANCEGFRIERANOPOIICYNUMBEPARE: CONSTRUCTIOM jcAnRtEn PIAN REVIEW Z POLICYNUMOER ELECTRIC Q � (n�sEcnorrr�wi�c�FooFn�aEwarswac��oa�piao�ori�sl PLUM8ING W I CEPTIFY THAi W THE PEPFOHMANCE OF iHE WORK FOR WFlld/TXIS PEftl�liT IS ISSUED,1 MECHANICAL -�-� SHALLMOT EMPLOY/WY PERSON W ANY MANNEfl SO�5 TO BECONE SUBJECT TO THE � VK7Po(EFS'COGPENSATpN UwSOF CALIFORNI/1,N1D WREE THAT IF 1 SiqULD BECOYE INSPECTION FEE SUAJECi TO THE WONKERS'f)OEIPENSATION PROV�SIONS OF SECTION 3700 OF TME UBOR Ocoo¢.isM,u�wrmrvnrncoMvirvnn�nroserrrowsroNs. ISSUANCE / p DATE: APRICANT`. SMIP �J� W ENEFiGY P/C 'J WMWdIN(i�,F/dLURETOSECUREWORKERS'GOMPENSRTIONODVEAAGEISUMANhlR,11/ASHAliBE J � SUB,IECTMiEAAPLOYERTOCRUAINALPENALiIESANOCMLFWESUPTOM�EHUNDREDTF1IX15AND ENERGYPERMIT UOLIARS(f100.00D�.IH ADOITION TO iHE WSi OF COMPEN3ATION,DAAIAGES AS PROVIDEO FOR IN � SECTION 970!OF TF1E 1A90R CODE,e1TFNE5T,AND A7TORNEY3 FEES. RE7ENTiON FEE: a CONSTRUCTION IENDING AGENCY PRE-AlT FEE: � 1 HEREBY AFflRM UNDER PENN.TY OF PERh1RY TUT TNENE�5 A OON57RUCTIDN LENDING AGENCY FOIi THE PERFORYANCE OF 7HE WORK FOfl WF11CM 7MIS PERMIT IS tSSUED(5EC.3097,CIV.CJ. Z lil � LEI�ER'S NAME H LENOE�'3�RE55 ,,�, I CENT��F`I7M�T I HAVE RE�TH13 APPLICAMNi ANO STA7E iFI�T THE ABOVE INWNIIATION IS CORRECi. TOTAL FE ES ! �7 /r � � � I KiREE TO CWPLY MITM 11LL CITY AND COVN7Y ORDMANCES M1O STATE UW5 REUnNG TO 8UILDINC � �- CWyqTRUCTION,AND HEAEBV AUT110RIZE pFPRESENTATIVES OF TlUS CIXINTY TO ENTFR UPON TNE �. 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