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HomeMy WebLinkAbout17818 (17) l . . . . . . ... . _ .�_....,_—._._._.. . ._ �..... ... .. _ _ _ _"'"_— ' _�` CITY OF DIAMOND BAR � DEPARTMENT OF CO[vII�fUN]TY&DEVELOPMENT SERVICES ,�T� ZisuE.copi�yn���o PRESS (909)860-3195 Fax(909)861-3117 , "-�� BUILDING PERMIT APPLICATION FIRMLY ¢ AD RESS • t 1 Q �� ATION r ��NU B R� k,C 0 $l�Q � APN LOT T ACT qtL�� ONST. GROUP p OWNER C� � "" ADDRESS i �C U I ZONING SEfBACKS gCITY 21P OD TEL. , 9 R�RT RW ❑❑ APPLICANT T SIDE/SIDE STREEY RW p � CONTRACTOR 0� V . SIDE ❑ Q A�DRESS Q� O ' ' � CITY � � TEL � PROPOSED USE ��w ARCH/ENG! • � ' ' C.�� DESIGNER � n. ADDRES 1 O r_ NO.DWEL NO. N0. a CfTY ZIP 1��� TEL. � )p UNITS STORIES BEDROOMS � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER•BUILDER DECLARATION SFR/ADD/REM O � 1 MERE87 AFGIRM UNOER PENAL7Y OF PEiWRY iHAT I AM E%EMPT FHOM TNE LOMMCTOHS U• G8f890/C0fp0II W CFNSEUWFORTMEFOLIOWWaREA50N(SEQ7o�1.SBU5INESSANOPROFE5SI0N5CODE:MIYC�TVOR (n C.J CWMlTYK711pIREIX1IRESAPEHMRTOCONSTRUCT,/LiERIMPROVE.0EA10L15H2ORREGAIRANY5n7UC• W PHtiO/DBCk u� IUPE,GRIOR TO RS ISSUINCE.AL50 REWIRES TNE APPUCANT FOR SUCF1 PERMIT TO iILE A SIGNED .� STATEMENT TN�T ME OH SHE IS UCENSEO PURSUAN7 TO iHE PilOVI510N5 OF THE CONTMCTORS L�• .� CENSE UW(p1AP1EA 7(CO�dMENCINQ YATH SECTION 70D0)OF DIVISION f OFTHE BUS WESS AND PRO- u' POOUSpe � fE55lONSCODE)ORTHATHEORSMEISExEUPTTMEREFROMIw�THE8a515iOR7HEALLEGE�E%EMP• (r} V TKKi.ANYVIOL�TIDNOFSEC'��ON7W1.fiBYANYAVPLICANTiOHAPERMITSUBJECTSTHEAPPIICANTTO Z Re-Root � ACML7ENALtYOFNOTMORETNANFNEMUNDNED00lUR5(t5a0).�: � � 04ASdMdEROFTHEPROPERTY.OR1IYElAPIOVEESYVITHWAGESASTHEIR50LECOMPENSATqN, 0 �mmerclal z YViLL DO TNE wOFK.IWD THE STRUC7URE IS NOT IMEN�EO OR OFfERED FOR SALE(SEG 7aa.BUSt� J NE53 AND FROFESSIONS CODE:THE CONTMCTORS UCENSE UW DOES NO7APPLV TO�N OWNER OF N VHOOEHTYVh10BU0.D50RIMPROVES711EREON.ANDNT1Q00E55UCHWOHKHIMSELFORHERSELFOR m � THflOUGMNI50RHEROVMEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTIN7EN0EDOR QOFiERWFORSALE1F.110WEVE0.IHEBULDINGORIMPFOVEAAENTIS50LDWITHiNdJEVEAROFCOM7lE� -" � z TqN,THE OWNER�BUILDER WILL NAVE THE BUPDEN OF VROVVJ6 TMAT NE OR SHE�ID NOT BVIID OR � IMPfiOVE FOR TME PUHP0.5E OF SALE4 O l AS OM�NER OF TNE PROPERTY,/�M E%CWSNELY CONiMCTING N7TM LICENSED CONTRACTORS � TO CONSTRUCT THE PqQ1ECT(SEG 70ta.B1151NE55 AND PROFESSIONS CO�E:THE CONiMCTOflS LI� V81U8110fl A0.1.AREA W CENSEUWDOESNOTAPPL�TO/NOWNEROFAPROPERTYIAR108UI(DSppMPROVESTHEREON.AND � WIIOCONTMCTSFOftSUCMFR0.7ECTSW�TNACONTMCTOR(5)LICENSEDOUIiSUANTTOiMECONTRAG pUANTITY' DESCRIFTION FEE X TORSLICENSEUw). � OIAMEXEMPTUNDERSEC. B.tP.C.FORTHISREASON U O � � � DATE OWNER � W �c[ LICENSED CONTRACTORS DECIARATION W CC I MEREBY AfFIRM UN�ER PENALTY OF PEfUURY TNAT IAM L�CENSED UNOER PROVISIONS OK�MA7TER' � p„ 9(COMMENdNOWI7H5ECTIONi0oC10FDNISION70FiHEBU5INE55�NOVROFESSIONSCOOE,AND Z X M'ILICENSE IS N FUI,L FORCE AND EFFECT. m liJ L, � UCENSE CUSS B'�I LIC.NO. 7�`-t��'� � � � r t.� �O V DATE 7�/�/1��-- CONTRACTOli�DON I-�ll Z/'C GV a . W � WORKERS'COMPENSAT�ON DECLARATION a � IMEREBVAFFIHMUNDERiEN�LTYOFPERM1IRYONEOfTHEfOLIOYnNCDECUMTIONS: U � Z a � �IHAVEANOWILI►IAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWOHKE0.5' 2 - -Rr�.'-"' '- COUPENSATI0N.A9PNOVIDEOBv5EGT10Na]ooOFTHEIABORCODE.FORTMEPERFORMANCE U �t OF TME YYORIf FOR WNICN iH15 PEAMIT IS ISSUED. � ` �4�� � � � ' �I HAVE ANO WiLL MAMTNN WORNERS'COA�PENSATqN INSURANCE,AS REOU�AED BY SECTION Q ]7000FTHEU�BORCODE.FO{iTNEGERFORIAMICEOFTHEWOfiKiORWN�LT17M�5PERMITiS J'� � ' _,15M���� ISSUED.MYWOHKERS'COMVENSATIONINSIIMNCECARRIERMlDVOLICYNUMBERME: CONSTAUCf�ON � f "_ j uwniEr+ SY�—T�� I—ti�CL PLANREVIEW ' - _ �.= � va�cYNUMeER ELECTRIC � (fHIS5ECf10NNEmNOTBE�mOF71EGER.R6faRONE11tMEDOQUfiS(5100)ORLE55} PLUMBING � ICENTIFYTHATINTHEPERFORMANCEOFTHEYJORKFORWHICHiHISPERMITI5155UED,l MECHANICAI � SHqLLNOTEMPLOYANVPERSONINANYIAANNERSOASTOBECOMESUBIECITOTHE � � � WORKERS'COMVENS�TIONUWSOFCILIFOFNIAANOAGREE7NATIfI5H0ULDBECOME INSPECTIONFEE SUBJELTTO TME WORKERS'C0IAGENSATION PROVISIONS OF SECTqN J7oo OF THE LABOR �SSUANCE v OCOOE,I SHALL FORTMWITI COMPLY WIT/THOSE PRONSIONS. ` d DATE: AFRICAM: 5M1P V- w ENERGY P/C � � WARNING:FMUflE TO SECURE WORKER5 COMPENSATION COVEMGE IS UNUWFU..ANO SWLLL BE SUOJECTANEMi'LOVERTOCRIMWALDENAL1�ESMDCMLFINESUDTOONEHUNONEDl�qU5M1D ENERGYPERMIT - � pOLWiS(1100,000),IN IDOITION TO 7ME COST OF COMPENSATpN.DNAAGES AS VflOVIDE�FOR W O ¢ SECTpN710lOF7NEUBORCOOE.NTEREST,ANDATiORNEY5FEE5. RETENTIONFEE' OCONSTRUCTION LENDING AGENCY pRE-ALT FEE: �/� CL INEREBV/FFiquUNOERFENAL7YOFPERJUFYTMATTHEREISACONSTRULTIONLENDIN6ACENCY � � FORTHEPEflFORMANCEOFiHEWOfiKFORWHIC}ITMISPfRMITI5155UE0(SEC.]o97,CIV.W. � LEN�EffSNAME C LENDER'SADDRE53 _ . WICEflTIFYTI/ATIHAVEREADTHISMPLICATIONANDSTATETHATTHEABOVEINFpiUAATqN�SCARRECi TOTAL FEES ��� ' d 1 AGREE TO fA��LV VATH ALl CT'11ND COUNTYOFOINANCES IWD STATE UWS REUTINO i0 BUIl01N0 i CONSTRUCTION.ANDMEREBYAUTlIOR2EREPRESENTATIVESOFTHISCWNTVTOEMERUPONTHE �� " � � � ABOVE�MEMqNE0VRo0ERTY WRPOSES. COMMENTS � I J � = I m CER1a A�AE �)/� � � / � �� vj 10 RMI A1E � RECPT.N0. PAID BY VALI�ATION j WHITE-0epaAment Copy,YELLOW—FinAnce Copg PINK—Assessor Copy,GOLDENROD—File Copy.GFEEN—ApplicanCs Co y � . .t: . . , � , . .. . . .. ... ., . . . .. . . ,... •� • �. ....._-__._.. . . .. � . . . _ . ... ... . . � .� ,. , . r.:! ��:' C'� �Jl��P�iCls�€� BIa� . lC�.'�r�'t=�f 10��' C;��.:Ofat7 ��E-�p,i_c �dCca►`I. �_ s)'��:i' i��F'�.+��c ���;�.._.__�....... 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