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HomeMy WebLinkAbout10433 (5) f � CTTY OF DIAMOND BAR COMMUNITY DEVELOPMENT DEPARTMENT; l � 21660 E.Coplcy Drive Suita I90 PRESS � (909)860-3195 Fax(909)861-3117 �'M' BUR.DING PERMIT APPLICATION FIRMLY N JOBSITE q APP{�ICATION / „ �O (�j PERMIT b JC � AD�RE6S L.. Z�- - DATE �S� � NUMBER N $ ISSUE TYPE OCC APN LOT TRAC DATE CONST. GROUP p OWNER ADDRES `'!t "T' AILE 20NING SETBACKS 2 CITY�� ZlPQ(,'�'�TEI._�DS� ��I`Zt� REART RW ❑ � APPLICANT TEL. SIDE/SIDE STREET RW ❑ CONTRACTOR t�. SIDE ❑ o ADDRESS O PROPOSED USE � �./ � CITY ZIP�TEL. ��J-B/5'� w ARCWENG/ ;-� �. -�y_1 � ��� Z DESIaNER 1�. ��� r NO.DWEL. NO. NO. y ADDRESS �S'�C t5 Y'P'QAI[t ✓ _ - — UMTS STORIES BEDROOMS � CITY ZIP TEL. N DESCRIPTION SQ.FT. FACTOR PSP ADJ.AREANALUATiON � � OWNEp•BI:ILDER DECIARATION gFq/pp0/REM � l O � I HEREBY 11fFlRM UNOER PENAITY OF PERJUNV THAT I AA1 EXEMpT f{iON THE 00�lTFAC7d7S L4 GBfflQ�CefpOR - (yJ CENSEUWF�ITHEFOILOWIN6REI�SON(5EC.7031.58U31NESSAN�PROFESSIONSCOOE:ANYCI7YOR (n U COIXJTYWHKxiRE(]IIIRESMPEiMITT0000lSTNUCT.ALTEN.IMPRpVE.DEAla15N.ORREWJRANVSIAUC• � Paz��� � NRE,VR10R TO ITS ISSUAMCE.I150 NEWIRES THE APPLICAM Foii 3UCH PERYIT TO FIIE A S�ONEO W � $7ATfNENT 7HAT 11E OR SNE IS LCENSED GURSUANT TO THE PpOV1510N5 OF THE CONiRACTOHS LI- _ � CENSE WN(pMOTER Y(COYNENCING NATH 6ECTION 7Wo)OF DIVISION 3 OF THE BUSINE55 ANO PNO- LL POOUSpH FESSIONS CODE)OR THAT HE OR SHE IS E%EMPT TNEREFROM AND TME BISIS iOR THE ALLEOEO E%EYP- V TION.MIVYIOLATqNOF5ECT10N]031.56YANYAPPLICAN7FORAPERYRSI/8JEC75THEAP➢LICANTTO z R9(jpp� . F 11CMLVEN�LTYOFNOTNOREiNANfNEHUNOREODOLlARS(f5oo).): � ❑I,ASOWNEROFTHfPROPEATY.OAMYF1APlAVEESWIhIWA�E5A5hIEIR50LECOMPENuAT10N, � COrt11I1BfCi81 �� WILL 00 THE W4PK,AND THE STHUCNRE IS NOT WTENDED OR OfFEAFD FOR SILE(SEC.7ou,BU51- J � NE59 AND PHOFESSIONS CWE:TNE CONTRACT�FS LICENSE UW WFS NOT MPIY TO M!Q'NNEH OF y PflOPERTYWN08U1LDSONW�IWVESTHEQEON,MdDNMO00E5SUpIlWRKNl4SELFOANERSELFOR = � � THWIX�`NMISDfiHEFOMMENPIOYFES,PROViDEDTUTSUCXHAPROVEMENTSMENOTWTENDEDOR m QFFEPED FORSKE IF.NOWEYEti iHEBUkD�NGOR tlM➢ROVENENT ISSOLD WITMW ONE YEAROFCOMPtE- 2 TIpV.TNE OWNEA�B�I4DER WIIL NAVE THE BURDEN OF PROYINO THAT HE OH SHE O�D NOT BUILD OR MIPIWyE FOq iHE PUPPOSE OF SALE). � W ❑I,ASOM�NEROFTMEPROPERTV,.WEXCLUSNEIYCONTMCflNCWf�{ILICENSE�CONfRACTORS � Q TO CONSTPUCT iNE PROJECT(SEC.704/,BUSWESS A�+�PROfE5510N5 COOE:TME CANTRACTOR3l1- V81U8IIM ADJ.AREA W CENSEWNDO£SNOTAVW.YTOANONiJEROFAPROPEA7YWHO8UH.DSONMPROVESh1EREON,AND F NMOCOIVTF�CTSFORSUCMPRQtECT5WI7tiACON(MCTORiS)LICEN9EOPURSUAMTOTHEWNTRAP QUANTITY DE5CfiIPTtON FEE � TORSLJCENSEUW.). � � I O ❑1 PA1 EXEAIPT 11N0ER SEC. B.8 P.C.LOA TM4S pEASON U � LL � �� � DATE OWNER �'" -r � Z W L t/ � � LICENSED CONTRACTORS DECUAA7lON W C y, Z � IHEREBY�FFiFYU1�ERPFNALTYOFPERJURYTUTIAMUCENSEDUNDEflPRON310N50FCHAPTfR �i / � Y(WYMENCW6 WITM SEGTION 7000)OF DMSION�OP THE BUSINESS AND Pi�FE55lON5 CODE,AND Z L MY LICENSE IS IN FULL IORCE M1D EfFECT. � 0 LlCENSE CUSS �^~ LIC.NO. � l /a�Z '�� �J ^� v � Y V DATE G? CONTMCTOR ��f•i �_ a ` I W � WORKERS'COMPENSATION DECLARATiON � N U � I NEREBv RFFlRM UNDER PENALTY OF PERRIRV ONE OF TNE FOILOWING DECLAMTIONS: z t t � O IHAVEANOWILLMAINTAINACEHfIFICATEOFCONSEMTOSELF-INSUREFORMIORKERS' _ Z �WMPENSAtiON,�S PAOVIDED BY SECTION 3700 OF tME LA60R CODE,FOR THE PEH WRMANCE U Q q►THE WOHK iOR WH1CM THIS PERMIT IS IS8UED. � W / I �� 1 HAVE AND W�LI MAIMAIN WORNEHS'WMIPENSATKKJ INSURANCE.AS REOUIfiEO BY SECTION � Q 9700 OF THE UBOR CODE,PoR lHE PERFORUM7CE OF THE WORK FOH WHICM Ti15 7ERMR IS � ISSUED.MYWORKERS�ENS/��J�NS�ECAftFfERMJDPOIICVNLWBERARE: CONSTRUCTION � GiRAiEq ��G1. ,T\J PUN REVIEW �Z POLICYMI�IeEH 'yZL1 OU I ELECTR�C � 4 � � RµggELTpNryE�Hp7pEppMqFTEDpFr.EpEpNtSFopoNEH�.ft7REopalMs{sltooloatfSS} PLUMBING Z I CEPTIFY TMI1T M THE PERFORMANCE Of hiE WORK FOfl WHICH THIS PERMIT IS ISSUED,I MECHANICAL (� SNF(L MOT EMPLOYANY PEfl50N iN ANY rdANNER SOAS TO BECOME SU&IECT TO THE UJ WORKERS'COMPENSATION UWS OF CALIWRN10..�NDAGFEE THAT IF I SNIXllO BECOME INSPEC710N FEE � � SUBJECTTO THE WOflKERS'WMPENS�TION PROVISpN50F SECTION]1000F TME UBOH �SSUANCE � WOE.ISHALLFOi1T/WITNCOMPLYVA7MTlbSEVROVISI0N5. � 0 SMIP � p DATE: APPLICANT: � � ENERGY P/C WAqNINfi:fA0.URf TO SECUFE KORKERS'COM�ENSAT70N COVEMOE IS UNLAWFUI.AND SH/LLLBE � SUB.IECT�NEYPLOYEHTOCRIMNULPENALTIESM'OCIVIIFINE6UVTOONEHUNDREDTFKK15AN0 ENERCaYPERMiT pOIUAs iitm.000),IN ADDRION T07ME COST oF COMPENSA710N,DAMAGES AS PROViDEO FOR M! ., ^ � �/�/� ¢ SECTIOM970lOFTMEUIBORCODE,RITEREST.AND�TTORNENSFEES. RETENTIONFEE: __���(]��y�,�� a CONSTRUCTION LENOING AGENCY " F� �� ��� pRE-ALT FEE: � t MERE9Y AFFIRM VNDER PENALT'OF PERM1IRV TNAT TNEAE�5 A CONSlRUCiION LENDING AGENCY FOq TME 7ERFORM�NCE OF THE NK1RN FOR VAi1CH TMIS PEPMIT IS ISSUED(SEC.f�7,CIV.C.). Z W � LEI/DER'9 NA1AE � LENDER'S ADDRESS L � ICERTIFY7HA71HiWEREADTNISAPWJC�TIONANDSTATETHATTHEA80VE1NWNMATIOHISCORRECT, TOTAL FGES � �AGNEE TO COYPLY M7TH AlL C17Y AND COIRiTY ORDINANCES Ml�ST�TE UM1S REUTMG TO BUNAING CONSTPl/CTION,AND MEREBY IIUTHOFi�ZE REPRESENTATNES OF TW S COUNTY TO EMER UPON THf S�. A80YE•MENTIdJED PROPENT'FOR INSPECTION PURPOSES. COMMENTS � �q L , Sroo�i _ m pERY1TT N/iME(PRINn Q � EOiPEiWITTEE � E � RECPT. PAID BY VAI.IDA � WH17E-0epertment Copy,YELLOW—Firunce Cc�t PINK—Assessa Copy,GOLDENROD—Fib Copy,GREEN—ApplkenYs Gopy ,_ , . . -,�,- , _ , � 'V1 f � �✓�d..�'7i"!4'YI���i��'R:J S7�I� Y�V�` L.T`: 6�4�i�. �A�wf���tiiF...4 a_ 1. 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