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HomeMy WebLinkAbout14163 (17) ��CITY OF DIAMOND BAR � - DEPARTMENT OF COMMIINI�Y�D E MENT SER CES ��A�� � � 21660 E.Copley Dtive Suite 190 �O ` BU)II.pINGS FI'ERMiT APPI.ICATIOl1T OCT n v�? �RMLY1 A ;.,�..:. � JOBSRE _ ^ � APPLlCATION PEEIMIT P/C!.'��',.., ,./ !� a ADDRESS �- ��� b� �� �1 � l/ p DA7E NUIy18ER z= M � _ ISSUE TYPE OCC APN LOT TRACT � DATE CONST. GROUP p OWNE��1P... �'tt,y3• o ADDRESS �....� 20NING SETBACKS Z CITY ZIP TEL. REO�NT RW Q �, � APPLICANT �/G-flp,�, TE q�� � � �'O 'f'^�'"7` �7'�'""`��nd SIDE/SIDE STREET RW ❑ i CONTRACTOR SIDE p ¢ ApDRESS A - r o CITY� ZIP�..+L�i TEL�rp,y r P�OPOSEDUSE _' � (�_-�i�'1� . _ , � r 8 ARCFVEN ! ` ` � ADD ESS ( 02L. yy�ak �WY N�.DWEL. NO. NO. N CITY��'� ZIP����1.(�����f UNI7S STORIES BEDRODMS � v� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADD/REM �Q i�A�r�ar urroeA v�ur oF aeauar nu7 i ua exFrner�aa rne eonrnncroas u- Garage/Carport Lll CETLSEUWFORTHEFqlOM'1NfiPEAuON�SEG.�031.5BUSINE53ANDPROFESSiONSGODE:ANYC�TYOR (n 4� COl1MfYM�NIRIHFW1i1E8APERNITTOCONSTflUCf,PLiEfLIMPpOVE,DENOLISH,ORREPAIRNiYSTRUG W PdflO/D9Ck `Z TIJy��pppq TO I73 ISSUANCE,A180 P[OUMES THE APPLICANT FOR SUCH PERMIT TO FlLE A SICNED w ST�T9ffNT TF/hT HE Op SME IS LICENSED PURSUANf TO 7HE VPOVISIONS OF THE COPITMCTORS LI- 7� ` � �LMY(CHAPTER Y(fAY►FNCINO WITH$ECTqN 7000)OF�MSION 3 OF THE BUSINE55 AN�PRO- �'�' POOVS(78 �(p � Y� .��LI FESSIDNSOODE)Oflh1ATHEORSHEISE%EMP7TMEREFAOMANOTMEBASISFORTHEALLEGEDE%EMP• (� TK7N.AMYVIOLATqNOFSECTION70.)1.6BYANYMPLICANTFOHAPERMITSUBIECTSYMEAPPLIGANTTO � RQ-F7pp� � ACML PDlN.TY Of NOT NORE THAN FNE HUNDREO�OLUqS(1500).): � �I,A40NNEFOFiHEPROPERT',ORMVEMPLOYEESWITHWAGESASTMEIHSOLECOMPENSRTpH, O CORIrt1BfCifll WRA 00 iHE WOHI(.NJD T11E STRUCTURE IS NOT INTEMbED OR OFFERED fOR SALE(SEC.7o/{,BU51- J � AESS AN�PRDFESSIONS COOE TNE CONTRACTOqS LICENSE UW DOES NOTAPPLY TO AN OWNER OF � PROPfiRTY W!p BUIIDS OR MIPqOVESTHEAEON,ANO NM110 DOES St1CM WORK HIMSELF OR NEflSELF OR CC iHROIkiMXISORMERONMEWLOYEES,PROVIDE�THATSUCii1MGflOVEMENTSRRENOTINTENDEDOq � OOFF91EDFdi5AlElF,iIOYYEIlER1NEBULDINOORIMPFlOVEMEMISSOIDWITHINONEYEAROFCOYPL& Z TK711,THE ONMERSUILDER NALL MAVE THE BURDEN OF PROVINO TH�i HE OR SHE D�D NbT BUILD OR � W?IqVEWF7HEPURPO5EOF3�V.EA W ❑I,A40MTIEHOFTFIEPPOPENTY.AME)lCLUSIYEIYCON'MCTINGWIiHLICFry���qpCTORS Q 70 CONSTRUCT TNE Pfl0.1ECT(SEC.70M.BUSINESS ANO PROFESSIONS CODE:1 HE CONTMCTORS LI• V8IU8tifN1 AD.I.AREA W CElLSELAY/DOESNOTAPPLY70ANOYMEROFAPROPERiYW!iO6UttD50NIMPROVESTNEREON.AN� � WHOCONfMCTSFORSUCHPROJEC�SWITH�CONTMCTOR(3�LiCENSEDPUR9U/�NT?OTHECONTiUG pUANTITY DESCRIPTION ' FEE � TGi15l10EN5£UW.). — ' � } ❑IAN IXEMpf LINDER SEC. B.a P.C.FOfl 7HIS REASON Q �j.' +,��--CI�/L U wt � Q � � t0 wre owriER V , � LICENSED CONTRACTORS DECLARATICN W t' J � W 1 NEREBYAFF7R4 UNDEq PENIL7V OF CERIURY TMAT I AM L�CENSED UNDER PflOVI510N5 OF GHAPTER i(OONMENCHO NMTN SECTKKi 7000)OF DIVI510N 9 0F THE BVS7NE55AND PAOFE55lONS CODE,ANU Z ��'� .�---C� W IICEN3E IS�N Ml FORCEAND EFFECT. �1 �� ('� .� � _ .--� f '� � LICENSE CUSS ►'7\�v.�Y�_/.C)iCIC_NO O � '>•� t� oa�� � corrraacro� ��/_�_T�Jx1Crr�-,_+ a �Ti t � WORKERS'COMPENSAT�ON OECLARATION -� 4 � INEREBVAFFl UNDERPENALNOFPEiUURYONEOFTHE�OLLOWINGDECUAAT10N5: U (� Z � _IH►VEMIDWII,LMAINTAINACEHlIFlCATEOfCONSENTTOSELF�INSUHEFORWORKERS' _ - �-I 4- T � � � - ' COMOENSATION.ASPf'.OYAEDB'ISECTION31ooOFTHEU90ACODE,FCP7HEPEpWRMANCE U OF TiE WORK iOR NMIOI THIS PEAMIi IS ISSUED. S ��, C] W _IWWEMIDNILLMAINTAINXKJFKEPS'OOkPENSATIONINSURANCE,ASREdUIREDBYSECTION O 9Teo OF7HELABOR COOE,PoRiHE PEflFORMANCE OF THE WORK FOR Wh!ICH TMIS PEHM17�5 ' � I.iSUE�.MYVAJRKERS'CAMPENSATIOLMIN URANCECA RIEHAN�POLICYNUMBFRaliE: NSTRUCTION � CApF1ER S�TR.;_ � PLANFEVIEW � � -� � POLICYNtJIUBER "� ^ � . E� L�r�� ��G' � V + � q���ECIpNNF�N0T8E001.RE'fH10Fh£PERMT�SFDRONEItMXi[DD7.USS am1ORLESSF PLUMBING -'�7'� � �r rJ�,�y-(� Z � FY 1TiAT MTNE PERFORMANCE OF THE VlORK FOR WHICN THIS PEPMIIT iS�S�ED,t v 9-t'j'��.�*f���T `7 � t t� (,'J SHP1lNOTEMPLOYPNYPERSONIMANYMANNERSOAS708ECOMESUBJECTT �T� q ������� " y WORKERS'COMPENSATKKJ UWS OF CALIFORNIA NdDAGREE iMAT IF I S1i�AD � ��� 1 '� �s � 5�18JECTTO 7NE IM1ORREFS'COAIPENSATItNJ PilOV1510NS OF SECTKKi 3700 OF THE LABOR ,�p ? � cooE,�sHu,i c in�ca.+v�r wini na vaov�srorvs. ISSUANCE � L' w ^�� � 0 �n��_�__��� SMIP � ��� p DATE;•��APPLICAN7 V �/Q L"!',L__!_ � � ENERGY P/C WARNING:FAILUqE TO SECURE YV�FKEPS'COMPENSAtIOM COVEqAGE IS UNUWFUI.�ND SHALLBE LLSUBJECTANEMPLOVERTOCRIMINRLPENALTIESANDCMLFINESUPTOONEHUNDREDTNOUSAND ENERGYPEiiM1T `� � pOLUflS(i1a0.OM).INADDITION TO THE COSTOf COMPENSATION,DAMAGES AS PflOVIpFO f-0R IN � SECT10N37oe0fTMELABORCODE,INTEREST,ANOATTORNEY'SFEES. r �fir�; RETENTION FEE: G, d CONS7Rl1CTION LENDING AGENCY PRE-ALT FEE: •� O � 1 MEREBYAFFIRM UNOEH PENALIY OF FERNRY THATTNERE�S A CONSTRUCTION LENDING R6ENCY FOq THE PER W RMANCE Of THE WORK FOR WMiqi 7HIS PERMIT IS ISSUE�(SEC.309],CIV.CJ. � LENDER'SNAME �{, } � LEN�EflSADDRE53 � ICERTIFYTHATIfLWEREADTHI3APPLICATIONANOSTATETHATTNEABOYEINFORMATqNISCORRECT. TOTAL FEES 0. I AGflEE TO WMPLY N7TH ALL CITY AND COUNTY ORDINANCES ANO STATE UWS REUTNJG TO BUILOING � CON9TRUCTION,ANDHEREBYM1TFiOFREREPRESENTATIVF50GTHISCOUNTYTOENTERUGONTHE ABOVE�MENTqNE�PHOPERTY FOR INSPECTION OURGOSES. COMMENTS � �-��i�� `���? � 4 7EMJITTEE NN.1E(PRINn � ,ti?a, h ���� � SH3NATUREOFPERMITTEE , �ATE � ' � � RECPT.N0. PAID BY VAUDATION � WHITE--DepaAment Copy,YELLOW—finence Copy,P�NK—Asseaso�Copy.GOID�NRO�File Copy,GREEN—ApplicanPs Copy � � w w., ������� ���� , �;ti'� ,_,, �t°� �'� ����`� �i�����.: ��. . �� �� � �_,, EF ��. �a � _� ��_._ i_ _._. _���°� �_-____ - .._..- �__._ �-. 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