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HomeMy WebLinkAbout14165 (7) � CITY OF DIAMOND BAR ��� ��� ��A�n DEPARTMENT OF COMMUATiTY&DEVELOPMENT SERVICES Q�,jD `�C`Q 21660 E.Cc�ley Drive Suite 190 (909)86a3195 Fax(909)861-3117 3��nn PRESSB Bi)II.DIIYG AERMIT APPLICATI4N "�� FiRMLY o� JOBSITE � APPLICATION��--�„� � PERMR �L� �� P/C ADDRESS JATE � NUMBER N � APN LOT,�^ TRACT ISSUE TYPE OCC °C OWNER q} DATE CONST. GROUP O o ADDRESS W ZONING SEfBACKS � "'� cirr J.�,�►�a� ��✓ Z1P TEI� > 3 FRONT HW ❑ " � APPtICANT TEI r. REAR ❑ � � i S1DElS1DE STREET RW ❑ CONTRACTOR C �w fih.G SiDE ❑ � ¢ ADDRESS � " o CITY ZIP� TEL�'� — PROPOSED USE l� �-^ V4�t.. w ARCH� - - -r �� DESIGNER NO.DWEL. 'NO, � NO. AODHESS UNRS STORIES BEDROOMS � CITY ZIP TEL. cn DESCRIPTION SQ.FT. FACTOR PSF AOJ.AREANALUATION O OWNER-BUIIDER DECLARATION SFRJADDJREM � I I�I�BY AFRiIM IR�DER PEN�L.T'OF PEFiIURV THAT 1 AM EXEMPT fROM THE�ONfRACfOf15 l4 GfllBge)CaryOR CBBEU�YikYi'iNEFO1.LdNkNiREASON(6EQial1.58USINESSAN'�Pf10FE5510NSCODE:ANYCITVOp (� Ca1117VMFM]INEfY1WE4A7ERMfTTOCONST/iUCT.ALTERiUOROVE.DEMOLISH.ORPEB9INANNSTfAJG {,(J P8�10/�BC1C TUNE.PNUPI TO ITS IS9UNiCE.AL80 flEW NIES iHE APPLICANT FOH SIMYi PEiW IT TO HLE 1151GNE0 � � STATTiI£NT T1�T HE OR StiE IS LICENSED PUPSUMIT TO TFIE PPOYl510N5 OF THE WM1'lYCIORS L4 � CEILSE UW(CFiWTER Y(CdIMENCMXi WITH$ECfIpN 7000�OF�IVISION 30F THE BUSINESS M1D PRO• POOUSPB fESSCNSCUD�MiMA7HEORSN�ISEXENPT7HEREFROMANDTHEBA515FORTHEALLEOEDEXFJIP- (� YIOt7.7W'fVI0U1T%7NOFSECTqN7o91.6B�ANYAPPLM.ANTFOR�PER41T5UBJECiSTHEMPLICANTTO +� (�-R� � A GY�L PEN�LTV OF NOT NOPE 7HAN FNE 11UNDRED OOLIARS(S6oa).7: ^ ❑(.ASOWNEROFTHEPAOPERTY,ORMYENPLOVEFSWITHWAOESASTHEIRSOLECOMPENSATION, COR1111BfCIeI - � W�LL DO THE YiOFlK,AlK1 TNE STRUCNHE IS NOT IMENDEO OR OFFEPE�FOR SALE(SfiC.7044,BUSF �J MESS AND PilOFE5510N3 CODE:THE CONTRACTOFl4 UCENSE lAW DOES NOT APPLY TO AN ONYNFR OF � PRDPEMYW1108URDSORNIPflOVE57HEREON,ANDNRiOD4E5SUCMNOPKH�MSEIFORHEf�,SEIFOR � LL NROUDF1/9S OfdYiER OMM EYPLOYEE9,FROVIDED THAT SUCH YPROVEMENTS ARE NOT INTENDFO Oq m O ,O�OFOR6ALEIF,�qNIEVEq,iHEBUKDIMOORNIPlqVEl�EtffIS30lDN7T11NONEYEAROFCOMPLE Z 'TqN,TVE OMMEA.BURDER WlLL HAVE THE BUROEN OF PqOWJC THAT HE OR SHE DID NOT BUILD OR = MIPROYE WH�WPPOSE OF SAL�' w ❑I,A90WNFN�TNEPHOPEATI;IWEJ(CLUSNELYCOMMCTINOWITIiLICENSEDCONTRACTOqS ¢ TO CW7STRUCT Tff PROJECT(SEC.70M,BUSINESS AND PROFESSWNS CODE:THE COMTF4CTOAS LI- V81URticxf ADJ.AREA �1J CENSEUWDOE3NOTAPPLYTOA}001�MEROFAPROPERTYNTIOBURDSORIMPROVESiHEREON,ANO Z WIbOONIAACI5FOq5UC11PPOJECT5W1TH11C01'RAIICTOR(S�LICENSEDWRSU/WTTOlNECOPITRAG QUANTITY DESCRIPTION �E � 7a151Jcer+sEtAw.1. �p / ❑IAM E%ENPT lNl�ER SEC. B.6 P.C.FO{i THIS REASON q L' �� / � � ¢ �!di�7tti�/ �.�i � o�re ow�,EA � 1 / 3 CJ U � LICENSED CONTRACTORS DECLARATION -� � w 1 HEHEBY 4FF11W IRAEq PENKT!OF PERp7AY TTiAT 1 AM 11CFNSED UNDER PROVISlONS OF CHMTER /� S 0(OOWIENCRIliWITlISECTION70ro�OFDMSpN90FTHEBU5WE5SANDVROFESSIONSCODE,AND Z Z� l'V�+ �KJ YY LICENSE IS W Flll.l FORCE/IND EFFECL m 0 LICENSE qASS LIC.NO. � V�1 DA1E cor�7riAcroR 2� = WOR!(ERS'COMP£NSATION DECLAAATION � � 1 HEHE9V�FFIfbA IJNOER PEN�LTY OF PE0.IURY OME OF7HE fOLLONANG OECIARATIONS: Z � ,�_IHAVE�lANALLMAMTABIACEfiTIF'ICATE�CONSENTTOSELF-INSUREFORWONKEqS' _ CqAPFNS4T10N,A5PFiOVIDED9V3ECT10N37000FTHELAPORCO�E,FQRTHEPE0.FORµANCE W OF7NE WORK FOH WMlpi THIS PEPMIT IS ISSUED. � W �IHAVEANOWn,LMA1M�INW�DWf,ER500MPEN5�T10NINSVfUWCE,ASREWfAEflBY5ECT70N _ l�� /,� O J7aaOF7HEUBOROODE.FORT/E7ERFORMPNCEOFTMEWORKFORWHiqiT715oERMITIS � 53UED.MYN'OW(Efl5COM0EN3ATIONINSUMNCEGRRtERMIDPOLICYNUM9ERARE: CONSTRUCTION � CARRiER� K� PLAN REVIEW � POLICY NUAIBER -����],�g t EI.ECTRIC v Z�S . Q� ! (fFtlSSECf10MNE�N072EC0AFLETFDOF7IEPEMRfSR)RaNEMRDF7�DOtWLSR�aolaltESs} PLUM8ING � � Z ICERTIFYTHATM1iHEVERFORIAMICEOFhIEWORKFORWHICNTHISPERAIITISi55UED,i MECHANICAL � /(/�� � (� SXALLNOTEMVLOYANYPERSONMANYMANNERSORSTOBECOMESUBJECTTOTME � �', � NfORKERS'COMPENSAT%7N LAWS OF CPLIFOANI0.AND�GR£E THAT IF 7 SHOUID BECOME INSPECTION FEE S SU9JECTTOiHE�`�ORKENS'COMPENSATqNPF70VI5HRdSOFSECTION])o00FTHELABOR '1y�L�ryp� � `_ v� COOE,ISFN�LL�fO_pp��pnTHCpAP�vWITHTMJS�SIONS. L� ISSUANCE Y-� $� (�J � / �Q"�1( IijN SMIP p OATE:._�;_�_ APPLICANT:, J WAANMU iARURETO SEWflE WORKEHS'WM�ENSATqN COVERAGE IS UNLAYYFUL, 0 SHAlLBE ENERGY P/C �y SII�ECTAN[i1PLOVEHTOCRIMINM.PENALTIESANDGMIfINESUPTOONEMUNDREOTHWSANO ENERGYPERMIT DOILARB(f10o.OW),W MDI7ION TO THE COST OF COMPENSATION,DAM�pES�5 PROVIDE�WR IN J SECTpN9TOeOf7HEU80HCOUE,M7EflEST,PNDATTORNEY'SiEES. HETENTIONFEE: Q � CONSTRUCTIONLENDINGAGENCY PRE•ALTFEE ,��� � � � IHEREBYAFFIRMUNOERPENALTYOFPERRIRYTHATTi1EREISACONSTRVCTIONLENDINGAGENCY - ����;� FOR THE PERFORMANCE OF THE WORK Pofl WNICM TNIS PEfiMIT IS iSSU£O(SEG.309T,CIY.G). � � LEt&1EA'9 NAME F� LENDER'SADDRE55 Q ICER71FY7F1.4TIHhVERf�1DTH15MPLICATIONANOSiATETFUTTiEABOVEINPoRAA11TI0NI5CORRECT. TOTAL FEES d IAGREETO COMPLY M�IiNN.L Cf1V AN�COU17T'ORDINANCESAHD STATE UWS REUTIN�TO BIIILOINO CONSTRUCTION.M�D HEFEBY�U[410R�ZE REPRESENTATIVES OF TNIS COUNTY N ENTEqUPOry THE aABOVE-MENfIONED VROVERTY FOR INSPECTION PURPOSES. COMMENTS J � � PERMRfEENAME(PRII1� - cn �r- s.1/'C SY � R[iN�NREOFFERNITfEE 011TE � RECPT.N0. 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