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HomeMy WebLinkAbout10148 (5) C1TY OF DIAMOND BAR - COMMUNTfY DEVELOPMENT DEPARTMENT �� ,�.� Z��o�.cop��yn�;��su�i90 PRESS (909)R643195 Fax(909)861-3117 �'� BUILDING PERMff APPLICATION FIRMLY � JOBSITE /)/► APPLICATION P6RMIT /d�L.l4�, p/C � � ADDRESS �S A'4 DATE NUMBER v 1� � c� ISSUE TYPE OCC APN LOT TRACT _ DATE CONST. GROUP p OWNER �'` ADDRESS ZONING SETBACKS z CITY ZIP TEL �' REART RW ❑ 4 APPLICANT TEL. - SIDE/SIDE STREEf RW ❑ � CONTRACTOR SIDE ❑ � ADDRESS PROPOSED USE � CITY ZIP TEL. w ARGtUENG! �_ "� W DESIGNER �,�^�-�, NO.DWEL NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. y DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BI:ILDER DECLARATION SFRlADD/REM O 1 HENEBY 11FFlIM1 lBK1ER PENAL7Y OF VEiUURY THAT 1 AM EXEYV7 FpqA TME CONTIUCTaiS Lh ����rc W CBJSELAWFORTHEFOILOWWG��`..�N(SFC.7o31.5HU51NE55AND9ROFE5S70N5CWE:MIYGTVON (n 's U Cd1NriWHIpIPEOUIPESAPERIMTOCONSTRUCT,/L7ER�M�PROVE.DEYaJSM.ORNEaNRdNYSTAUC- W PBfb/DBCk � W 7UqE,pRpq TO ITS ISSUMICE,AL30 REW IWES TNE APPLICANT FOR SUCH PEPNIT TO FllE�3�ONED � STATFyENT THAT HE OR SNE IS LICENSED PURSUANT TO THE PPOV1510N5 OF THE CQMRACT�iS L4 � CFIiSE WN(CXAPTER Y�GOYYEWCWU WI7H SECTN]1170D01 OF DIVL410N 7 OF THE BUSI�SS AHD PRO� � P�� � FESSION6COD�OR7HATHEORSHEISEI(EAIPTTMEREfHOMANDiHEBASISFOPTIIEALLE0EDE1(EMP- TION.AMYVIOLATIOMOFSECTION7W1.5B1'NI`/MPLICNffFORAPERMITSU&IECTSIYiEAVPlICM7TTO Z Rg-Fipp( � � A CN1L PENALTY OF NOT NORE TNAN FNE HUNDRED DOLLAAS(tboo�.): ^ ❑I,ASOWNEROFTHEDROPERN,ORYYEM9LOYEESWITNWA(3ESASTMEIRSOLECOMPENSATION, 0 COrt1TBfCIeI L Wq,L p0 THE NpRK AND iFE STRUCiURE I&NOT MITENDED OR OFFERED FOA SALE(SEC.70M.BU51- _.I NESS MA PROFE9510Nf+CODE:iHE CONTRACTO0.S LICENSE LAW�OES NOT APPLV TO Ml dANER OF � PqOPERTYYAlOBUkDSORiMV110VESTHEREON.N10YM1i090ESSUG1V/ORKHIYSfIFORHEiL5ElF9q = I (L TNPOUfiHNISpRHEROYMEYPLOYEES.PROVIDEOIHATSl1CNWPROVfNENTSMENOTWTEQDEDOH m W� OfFEqEDFOR3ALEIF,HOWEVERTMEBU1lpMfiOtIWPRDVEMENTI550lDWIT1IWONEYEMOFEOYP'LE- � Z TION,iHE ONMER-BU�LDEH YNLL iNVE THE BUFDEN OF PROVIN(�THAT HE OR SHE DID NOT BUq,p pq � YPRDVE FON TYE PURPOSE OF&LLtl. ❑6�OMRIEq OF TNE PROPERTY,AN EXCLUSNEIY CONTRACTINO WITH LICENSED CONTAACTOR6 Q TO CONSTRUCT T/�PPOJECT�SEC.7DN.BUSINE55 AN�Pf�FE5510N9 CODE THE CQMH�CTO0.5lJ- V81UaU0f1 � AO.J.AREA � CENBELAWDOEBNDTAPPLYTDANONMEflOFAPNOPERTYWHOBUMDSOPWPRD4E5T1EREON,/yp WNOCONTRACTSFOA3llU1DRO.lECT5W1T1ACONTRACTOR�S�LICENSEUPURSUAIifTOTMEODMTRAC- QU/WTITY DESCRIPTION FEE � TORSIICENSEWN.7. J Q ❑1 N1 EXEMPT UN�ER SEC. 8.\P.C.FOp THIS PihSOAI � � � LL DATE OWNER �` � w r�[ UCENSED CONTRACTORS DECURA710N w � CC IHERE9YAFFIiWIW�EROENAITVOFGERAIR'�77uT1A►ILICFNSEOIAIOERPROVISqNSOFGUPTER V. � Y�GqWENCNYO WITN SECTION 70W)OF DMSION 30F iHE BUSINE38 AND GROFESS10N3 CODE.A!A Z ��� NY UCENSE IS W FU�I F EFFECT. � LL � � � UCENSE S L1C.ND- � J V p�7E CONTMCTOR Q- W � WORKEHS'COMPENSATION DECLAF1AT10N � � I I�REBY AiFlRM UdOEH PENALTY OF PEFUUFh'ONE Of TNE WILOWINO DEQAMTK7N3: U N Z Q � �I HI1VE AIA W�LI MAM7AIN A CERTIFlCATE OF OONSEHT TO SELF-INSURE POR WORIIEHS' _ � COMPEN6+171ON,l�SPtiOVWEOBYSECT10N9'/OOOFTNEUBORWDE,FOi1iHE�ERfORYANCE W `OF THE M/ORK FOR WHICH TH�S PERMIT IS ISSUED. � O i/ W Y I WNE AqD WILL YAYtfAN7 N'ORKERS'COMPENSATION IH4UpANCE,AS PEOUIqED BY SECTION Q 770o OF THE U�BOR COOE.FOR THE PEPPDRM7JICE OF 7HE WOPK FOR WHK71 iH15 VERMR iS ISSUED.MV WORK DENSAr,�p�yj INSUMNCE CARRFP AN�VOLICY MA�ER J1XE: CONSTAUCTION � GRAIEP �P�1Pt'/.+ — � . PIAN REVIE4V { 0 vaicrNUMeER y [�,,,,,I ELECTRIC Q (i7+BSEctlOatE�eqreEaaA.ET�oin+EVEf►/rt6FOita+Erwlat�oal�asR��lattf�} VLUMBfNG �• y✓ � 5 Cf � Z 1 CERTIFY THAT W 7HE FEAFOMUNCE OF THE NRJRK PDR NTiIC71 TH�S PERMIT IS ISSUED,I MECHANICAI (7 $HM.L IqT EMOLOY I1NY PERSIXi IN ANY MANNER SOA4 TO BECOME SUBJECT TO TNE �� � WORKEPS'COYPENSATIONUWSOFGLL�WRNIAANU�GREETMAT ISMOUIDBEODAIE INSPECTIONFEE rt � SUBJECT TO 7ME WORKEFi3'COMVEHSATIDN Pf WW S 3 Of SECT 77oD OF THE LABOR -�A� d� � c�oq�r��n+coua�rrn �a s � ISSUAMCE p OATE: `�L �FFL�ArdT. SMIP W ENERGY P/C WMNUNi:FVLURE TO SECti7E YK11tl(ERS'COMPENSi1TqN COVEPAOE IS UNU AND SHqt1 BE �'y SUBJECTANEMPLOYER70CRWIN.�LPENALTIESANOCMlFWESUPTOONENUNDFEDTF10U8MID ENERGYPERMIT - pp�Uq$(f�pp,pro),W 11�ITIpN TOTHE CASTOF Cq/PEN4AT10N,�ANAGESAS PHOVpED PoR IN aSECTIDN 97M Of TFfE UBOR COOE.MdTERESi.ANDATfORNEY'S FEES. RET�NTION FEE: Q CONSTRUCTION LENDING AGENCV PRE-ALT FEE: � i IHEREBYAfFIFWUtAERPENAITYDFPERJURYTHATTNENE�SACONSTqUCTIONLENDW0A0ENCY Z FOR 7HE PERFONMANCE OF TME N�Of7K iON MMICII 1M15 VEf WIT IS ISSUED(SEC.30W,CIV.CJ. � U7 ' � IEHDEH9lMME I ' F� lE1l�ERSl1DDNE53 � ICENT�FYTHAT�Yi��EREADiH�9APPLICATIONANDSTATETH�TTHEABOVEWFOiq.1ATqNISWRRECL TOTAL I�EES 3�S � �� . � I AOREE TO fY�M7LV M9TH ALL CITV AND Cd1NTV OF�WANCES MIU STATE UWS REtATINO TD BU0.DING �� CONg7qUC7qN,ANDHEAEBY 2EREPRESEMi�TIVE50FTi15COUNttTOENTERUPON7HE S�' AapvE-MEHrpNEDD Tv SPEc7qNvuaaoSES. COMMENTS O ���� � m PE NAME(G jMJ � `r�O • � /�+7 I � NREdFPE�WITTEE D�TE �J O-/ / PAIDBY � �CPr.rw. ��//2'1 vAUD�ro� i WHtTE—Dapartment Capy,YELLOVY�iner�Copy.PINK—Assaror CopY.GOLDENROD—File Copy,QREEN—Appliark'o Copy � �;�,,.y i p�' �. ':►��"l�� s'��.ti ��� �.��•1'�a.. . . . �� � _�.: < .��t� �� �� , r ,� �� � .:� :,,�, , . � .� � .. _ �_ _ -,-. -•- - . . -__. _ . .._. .. . _.. . _ . - . . , , - . . . c--T .=ri,� ! 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' . . . . . .._ .__._._._. _... . __._.___... ..,r.._._ '__ _ � 's .<<.. ., �. ._, � ! ��,+'.-.�� '� i.._i`0 � ti_: ' _ ... . . ._. _ . _.. . _ .. ._._�___.___.. .._.._______.__._ . .. $ b i I ,. , � . - _ __._�__ ._'-_ -� ------- - - ----.� . __._.__ _. __..--- --._�-._ - .- - _ _�_..__._.._.---_-.__. r � ' . . � - __ ____ ___ --�-- ---- ------- -- - -- - , a '._.T._ ----------___..__. _._ _- - _...------------- __-------------- -- --- �- ---�_�-._ i a o�;�� -� �^��^ . . ..._'"!i v Tr�,i:ri:�1 ._ ----.— �: = ' �-°Ii7v 51:i� ___ _ _ ----- __--- . __ . _ -- --_ ------ --------__ ____ . , .�_>_, _ —__. _ ': I ----- _ __ _--- ------ -- --_ ___ _ - -- _.._...___-__._ --- ------ - _____ _ �_ ; i 1 i ; � _.�_...�_._�_—.�._._.__._..._.,_�"_"_".._._�_'.___ '_'_"... ..._.._'—'_—_"—__—..._-.—..._.._.*_—_ " � +1 ' �_....._��_....��. ,____._..._.e.,.....�____._..._._.....a_.___"_._....JL..._�_ _.;�. ._..._�.__.__:. :� '____. ___'. .. � t 3 �_.....W'_._�. ___ .�...__......._..__-_�-.- - �,-.--�.-�...____�.__ _.��_. _.__� �--._ _�.....�o-.- _ ._._...�._,....�___,�--.--� ' COUNTY SANfTATION DISTRICTS �n�io W'ti.ff�qlM�plM OF L�S ANGELES COUNTI�` 1955 Workman Mill Road I Roam 207 I Whittier,Califarnia CHARLES W.CARRY �j Maiiing Address: P.O. Box 4998,Whittier,Calffornia 90647 Chief Engineer and Genera!Manager f Telephone:(213)899-7411 /From Los Angeles(213)685-5217 � Hours:7:00 a.m.-4:30 p.m.Man.-Thurs. �'�� �� , � 7:00 a.m.-3:30 p.m.Fri. h°°���'" --'� ��"!-- i SEWERAGE SYSTEM CONNECTION FEE °�"'°'°�� `T � Completa ltems!fhrough 10-PEEASE TYPE O!i PRINT � Dele: _�D I � / `?Y �MowrH� io�r��n� ! 1. Property Owner n�� { � M � � � �? �41.�Ji�R�� !�'i'�i_�T _�"� _ . ___ � _i_J l_. . _ g.._Facitiiy Name_i„q������ '�l��a c ..... .. ... I I[ 3. AddFeas of Property �`�Z• D I t1 ND �`L i �'R- I ICIT`n ISTATE) (ZIP) i� I Major Cross Streefs ������ � 4. Contact 'n^^, (�-�` . Phone Number.(„3{� ) �`� -�'�� nn� �id� � �?� � �'L.� Vi�..� 'lE'1 �( '-.�/"e�l�.t i t7�"T�'�J�i 5. Mailin� + , Ili UIFF NT FROM ABOVE) � (9TREE� ICITV)__ (�Tg � IZIP) � 6. County Assessor ap Book,Page,and Parcel Number: � ' �a�- ���1G� 4 ,7., Sirucfure is: Proposed ❑ Existing,De4e of Construe4ion C � 8.�User Category and Units of Usags:(Cheek the appropriate box and p�ovide ihe spplicable information) � a. Residential: . SingVe Family Home(s) Traet N 4 Lds � M Number of Unit&: ❑ Du lex ❑ Triplex ❑ Four Vex ► FFumber: ❑ Five Units or More ► Numbsr of Units: � ❑ hAobile Home Park r Num�er of Spaces: ❑ Condominium ► Number of Units: b. Commercial: ❑ Hote4/MOEeI � Numtser of Roa�ms: �' ❑ Convalescent Hoapital/Home for the AQad ► Numbar ot By�Js: f�. ❑ Other( eci A Improvement Square Foo e: c. Institutional: ❑ CaIF IUniversity �� � � ►- Number of Students: ' � ❑ PrivaSe School ► Improvement Square Foo ❑ Church �► Improvement uare F d. Induatrial: ❑ All Cata3ories ► All induetriai diachargers must obtain a permit h�r indu�rial westewater d'taeherge. s. I�r orcFer to process this appPication a compfete set o4 architeclurai blue prints must be submitted. Thia is not required for aomreraion from septic tank to sewer oannectinn. � io. I c. ' at e informaEion provided in thia applicatiora la true and c�rrect to the best of my knowEedge. ❑ OWNER , ; -.IGG �i�S 3f rb�q�' �AtiEFfT FOR OWNEii �BICNATURE) . (DAFff) . Pisaae pay by check ar money ader only.(Cesh wiq mN be oce�ploQ.) Make cheeks payeble to:COUNTY SANiTATION DFSTRfCTS OF LOS ANGELES COUPITV. � Relurned chacks will hs subject to a p�alty. . - FEE CALCULATION FOR RESIDENTIAL,COMMERCIAL,AN7 INSTITUTIONRL CATEGORIES � / : �/.� ' E � f� i ; _ � ! X $ � � $��J (, "G F _Number_af Units of Usage Connection Fee Per Unit of Usege Connection Fee ,.._ _._ . _. . _ . . , . .. . . ..__ _. .._.._.__....___ .. .-..._ .._ _.....,. .. .. _. ._.._.. � _ �. -- __.._...... _. . . . ..� . $PECIAI CRE�iT3(OnFy if Applicable) ❑ DEMOLITION CREDIT' `In order to receive credit,proof of demoktion or former uae muat be sc+bmitleEi with your _ $ ❑ CHANGE IN USE CfiEDIT` application(e.g.Dema4kion Permits,orig4nal ❑ AD VALOREIM TAX CREDIT P��%d� Annexe�Fort Data � , +f ; , z ; , � $ , � �/ � (Ii Leas Than Zero,Ertier Zero) � `- " '� � f con�;4cno�,r-ae�ue -7 /�� ,i � � RECEIVED: «���3 Processad b Q�� ."'"" - ,� FE€PkYM¢NT . { � •� � -� y� �'c.":�'��,� e;� f From-r � �t� �� ^ :�f �_� �fY.C� ❑ Yes � Mo Approved / �•'`� 1,��_¢�+ �f i i � /�/ �f�� �/� �-'"�; `I f '' ��. :.,,{,•�/� I..��:t � Amount:$.L—_Ck.No. �� Permit No.: Dals: y�� _z_,��— i ' - d r � � . � WHITE COPY—COUNTV S4MITATION OISTRICTS OF LOS ANGELES COUN � ,� � � � ' '-'�� ' . . Y6LLOW COPY—BUIi_�Mif DiPARTMBHT ."`� .--.-.-`.. '"�' ....�, . .. F arµc cow-n�iewa'r „"'....---�-......__:J 0o Har sePnw�sE �� � - - ---- - ---