HomeMy WebLinkAbout18039 CITY OF LIIAMOND BAR f""�
-""-`�'�'-" DEPARTMENT OF COMMtJNITY dz DEVELdPMENT SERVICES
2i65t)E.Copiey Drivo Suite t90 j�/�� �f
(909�86Q-3195 Faz(909)$61-3117 �//F'T-����� L�- � PRESS
�'„" BUILDING PERMIT APPLICATION FIRMLY
QJOBSITE �"7 w�����,� a yG�, / �S j�}- G' DATE ��� � NUMBER �7�_�,L #� U �
7.- APPLICATIO pERMIT � P/ �
"� ADDRESS��- r'��✓ YV'
� " ��- 15SUE (,! PE OCC
APN L47 TRACT ,,,7 �,�-�� DATE � � � CONST. CaROUP
� owNER�'ULTE E�
� ADORESS^�_4 4 VON RAR,MEN STE.�O O ZONING SETBACKS
� GfTY �'�jj�N,� � ZlP��1 '� TEI. ��—"�Q'�—t� REART RW (-pj
APPLICANT _ TEL. SIDElS1QE STREET RW ❑
� CONTRACTOR_ S},�MF. _ SIDE �
q� ADDRESS
Q GITY Z!P T l. PRQPOSED USE__..��z�l/ �/��/,.�,i�,1j�//��.-''�f�',�'j'
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� CtTY �'L ZIP ry EL.; — —O � Z�NITS STORIES BEDROOMS
ca
vs DESCRiPTIdN S4.FT. FACTOR PSF ADJ.AREANALUATION
dWNEH-BUILDER DECLARATIpN
� OiREM j�J I r �-� _`�� l
[] I HEREBY AFFIRM UNDER PENAISY OF pEfU,IRV TNAT I AM EXEMPT FpOM THE CONiRACTORS ll• Gafe e/CB �I � \
Li/ CEN58UWFOR7HEFOl1JJWNCeREASON(SfiC.703tS9uSIMESSANDPRQFESSIDNSCOpE:ANYCITY4R {f) 9 � ��� � ��/'J L,�-j�l.).t�-5��.`
G�.��7 COtX!'tYXNICNAEOtI1RESAPERM(TTOc�NSTRUCT,ALTER,iMPftOVE,bEM04ISN.ORflEPAIRANVSTRUG W PdSiO/D6Gk
TURE,PRqp TO ITS ISSUANCE,AL50 REW11RE5 TME APpLICAlJT FOR SUCH PERMR TO FILE A 51GNEQ
� STATEMENT FHAT HE Oft WE IS LtCEN3ED PURSUANT TO TtiE PROVIS�+'S OF THE{X7NTRACTQRS!.i- �
CENSE LAW(CNApTER 9(C'AMMENGMG WITN SECTpN 70001 OF DIVISION 3 OF THE BUSMESS ANO PRO- POOUSp&
FESSIl7NSC9DE�OqTHAT�HEOR5HEI5EXEMP7THEREFFOMANDTHEBA51SFOHTHEALLEGEDEXEMP� �
TlON.hNYYIOLATpNOF5ECTtON7IXi1.68YANYAPP�H;ANTr'4RAPERAiiTSU&tELTSTHEAPPIiCAN7t0 Z Re�Rooi
� A CtVl4 PENAL7V oF NOT MOfiE THAN FIVE HUNDRE��OLLARS(Sboo�.),
� CII,AS(?YMEflOFTHF:PROPERN,OflMYEMPLOYEE9WITNWAGE5ASTHEfRSOtECpMPEMSAS70N, `�mme�Cidl � .
Wllt 00 THE YK}i�C,AhID TF�STRUCTURE!S NOt tNTENpED QP OFFERED FOR SALE(SEC.7o4t,BUSI� �
� NESS AND PROFESSIONS OODE:THE CONTqACTOR5 LICENSE I.AW D4E5 NOT APPLY TO AN OWNER OF � +'Z � �r �� ♦i � .—� �-
PROPERTYYhiD8U1lDSONlAfPpOVESTkEREON,ANDW,iODOE55i1CHWt}F{K1iiMSEIFOflNEfiSELFOR � � �
� THHOt,X�i HISOq MERON7lI EMPl.OYEES,PROVIDEO iMAT SUCM IMPqOVEMEN?SAqE NOT INTENpED OR m `
OFFERED F4R SALE.IF,110WEVEI�7HE BUIIDM�OR IMPROVEMENT IS SOID WITHIN ONE YEAROFCOMPLF.�
� T10N,THE OWNER$UtiDEfi Wit.t.MAYE 7ME 6U�EN Of PROVtMG 7HAT 3�Oft SHE D�NOT BUILD OR
� IMPROVE FQR THE PURPOSE OF SALE).
W ❑I.AS bVMER OF THE:PRUPERTY,AM E?(CLUSNELV CONTR�CTM�WITN LICENSED CtlNiHACTOp9
('� TO CONSTftUCT THE PRp.lEGT(5EC.JOst,BUSiNESS AND PROFESSpNS�CSE:THE CONTRACTORS I.i• V8�U8f1011 �DJ.AREA
� CENSE UW pOES NO7APPLY TOAN OWNER OF A PpoPER7v WHO eU14D5 oq IMPnCrVES THEREON,AND
NT�OCONTMCTSfQRSUp�PqOJECT5WITF+ACONTRACTOR(5)IICENBEDPUqSUANTTOTNEGpNTRAG QUAPITITY DESCRIPTI6N FE�,
� TORS UCENSE UW.}. �
("11;1M EXE#4PT UNOEFi SEC. 8,d P.C.F6R TH)5 REA56N Q L�C'1 �� . ` ��
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� rt 1 a. ri,�� `� , ��`i_
OATE „OWNER i— '�` '
� __.... . W V �<` . /1'r
� �iGE1VSED CONTRACT6fiS DECIARATiON W �1 - � 1
i�v 1 t
c� 1 MEREBYAFFIFM UNOER PEiNALTY OF PERIURY THAT IAAt LICEN&ED UNpER Pt�VISlONS QF GMAPTEfl � � j \
A(COMMENCW(3 WtTii SECTiON 76W}t�O1YtSiON 8 OF THE BUSINESS AND PRI:FES5pN5(:40E,AND Z
AAY LICENSE IS RI KULL FOR�' AND EFFECT.
a LICENSfi, � ���.No. 517 5 9 3 j � � � "" -�� �+r'� � _.)� ...
� J��=�-� .Lr'1L" �- �^ '�� �?T *II
� OAFE ,,,_ „_ CQN7RACTflR, n. ,.
C � J � •�� �
� WCFRKERS'COMPENSATION DECIARATIQN a , �.�-�� ` ,
� I NEA£ AFFIWA UNDEA PENN.tt OF pERtUftY ONE OF7NE iOLl4WlNG OECLARAT�NS: Z � (xT. f 1 \, `y, i
V V 1 7� .r.
� �IHAVEANDWILLMAINTAINACERTIFICATEOFCANSENTTOSELF�INSUREFOpWoqKERS' _ ] � i ��1 �J
CONPENSJITION,AS PflOVfDED BYSECTtQ`1 tiou QFTNE 4A80p GODE.FOR TNE PERFORMANCE C.7 � ►'\f
� ( /q�-F THE WppK FOR VVHICN THI5 PEPMI7ISlS5UEp. �
A1/._..,I HAVE fND WILL MNNTAIN WORKER5'eOMPENSATION INSUNANCE,AS REOUIRED BY SECTION
p T�� 3�Do OF THE LABOfi�X1DE,FOq iHE PfiRFORMANCE OF THE WORK FOR WHICH THIS PEFMIT 45 �1'�''1 j ,P'T'1
iSSUEp.MY WOR ERS PENSAT iHSUAANCE CARp�ER AN6 POiiCY NUMBER ARE: CONSTRUCTION t„�� ��-• '��l�
} �Y�GIFI� EMP. INS. CO ��'"�(_�_s�'�� —�-�.
CARqIER_......_.� � q PIAN REVIEW _ V _,
� POLIC7 NUMBER,___
L�t�RL_ ��O��,L7A F.�P ,.�_�2 ELECTRIC
1 T�_.
� (MSBEct%1NNEFAM�r6ECalYElEboFniEFEw�/TISFORONEFf.x`OFtEDoa.I.AAS(5leoloRtEssl. PLUMBING �`:'^,�T�-- � ��1
Ll.l ( �.+�
� i CEfliiFY TNA7 iFf THE PERFDRMAMCE�TNE WORK FCIR WHICN THIS PE4iMit 75 iSSUED,i FJfECHANICAL i � �� + �-P � � , ) �� (
�ry SW,LL NOT EMPLpY 4NY PERSCNJ IN ANV MANNEq SO AS TO BECOME SUBJEC7 TO 7HE s 4 i .t"
(�/j� WORKERS'COMPENSATIONIkWROFCALiFpRNlA,AN�AGflEETHAT!FISHOU�DBECOME �NSPEGTIONFEE Y� _ � �1 1 i � t_S : 7 �""
H S CT T THE 4'/aRKERS'COMC6NSAT70N PROViSiON9 Of$ECTION 31000f TiE LqBpfl
� CO[�1 L$F�I,IF�'Y�WI7HCOMPLYWITNiA.'�'11+t�'}i0N�30MES ISSUANCE __�� �r�
� SMIP ��'��• .a..) o
p qATE:.,�., _ APPIIGANT: ^�.___ S .._ [ � �
J WARNIM(i:GAl1.URETO SfGURE WORKERS'CAMPENSATION COV£RAGE�S UNLAWFVL,AND Sh1AlL 8E ENERGY PIC ----<ij��-��_.. .. a V
W SU&IEC7AN EMPItlVER TO CPIMINAL P6NALTIES ANb CIVIL FlNES UP Tp ONE NUNOFEO 7HOUSANU ENERGY PERMIT � �
WLUfiS(f190,�ODl,M ADDtT10fJ TO THE COST OF WMPENSATION,�AMAGES AS PftOYIOEQ FOft IN
J SEC7ION3�680FTHEU80RfAtlE.INTEt1E3T,ANDA7TORNEV'SFEES. � \
p� RETENTIQN FEE: „_ "�S .�,�.�
4 CON57RUGTION�ENDING AGENCY PRE-ALT FEE: �
.^ .......—_�
� I NEREBYAFFIflM UNOER PENALTY OF pERJURY THAT i}+EAE i5a40ti5TRUCTfqN LENO�NG A6ENL;Y _^
FOR TFiE PERFOflMANCE OF THE WORK GOR NiCN THtS PEFMIT IS ISSUEO(SEC.3oe�,CIV.C.).
W IVONE �PULTE) � � �
� IENDER'SNAAiE�_.._._ .._ .,._.„,�
t— l.ENDER'SADQRESS
� _ _. �_ TC?7AL FEES � �� `��`�I
� ICERTIFYTHATIHAVEREPD'HISAPPIICATIONAN�STATETHATTNEA80VEiNfORMATHh413CQRpEG7.
� i AGREE TO Ci.kAPCY WtiH Alt ClTY AND COt1NTr oROtNAiJCfiS AM6 STATE UWS RELhT�NG TO BUILpING �
� i;bNSTRUCTIpN.AND HEREBY'AUTHORIZE REPRESENTATIVES OF THIS COUNTYTO ENTER VPON THE
�,�. A80YE�MENTN7NE�PROPERTYFORlNSPEGTK1NaVMOSES.
d COMMENTS ,
� JERRY INES
�
� PERM17'TEE NAME(PRINT) �
N '�o ' �:— 5=/5..=�' t
� SIGNATU OF PEfiMITTEE � DATF
� RECPT.NO. PAiD BY VALIDATIQN
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111A,110 M)BAR
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117[�-
BUILDING PERMIT APPLICATION f
PRESS
FIRMLY
ADDRIESS/5-/-*-C'
APN LOT TRACT 2L247
OWNER PULTE H E
ADDRESS 1804 VON KARMEN STE 2 0 0
CITY IRVINE ZIPO 2 61 2 TEL.949_797_4
APPLICANT TEL.
CONTRACTOR-SAME
ADDRESS
CITY ZIP T L.
ARCH/ENG/
lr
DESIGNER E rAT,iS� [�I'TER DRIVE
ADDRESS Q
IP92605,
CITY 1V�WPORT.1-11
Z
EL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQUIRESA PERMIT TO CONSTRUCT,ALTER IMPROVE, DEMOLISH. OR REPAIR ANY STRUC-
TURE. PRIOR TO ITS ISSUANCE.ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).):
^ I,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044,BUSI-
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF,HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF C OMPLE-
TI ON.THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
^ I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7041, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI.
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHOCONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
^ I AM EXEMPT UNDER SEC. B. &P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FOR(AND EFFECT. 517593
LICENSEC LIC. N0.
==1)fi
A,i;_,
PU
DATE
CONTRACTOR
WORKERS'COMPENSATION DECLARATION
I HERE AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
r fDF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
/
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE LABOR'CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ARRI
OLICY NUMBER ARE:
ISSUED'MV WORTS F
IN
EMP�
AC Ii'I C
INS.
CARRIER�7 C
POLICY NUMBER WORL 4301187A EXP 5-02
(THIS SECTION NEED NTT BE COMPLETEDOF THE PERMIT IS FOR CNE HU DRED DOLLARS ($100)OR LESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE LSF4LLFOOTjWITH COMPLY WITH PVDTIEON.OME S
DATE: -APPLICANT:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS($100,000),IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE. INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF
E NRK FOR HI ULTE IT IS ISSUED(SEC. 3097,CIV.C.),
�
P
N
LENDER'S NAME �
t
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION.AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
JERRY INES
PERMITTED NAME(PRINT)
SIGNATU OF PERMITTEE DATE
APPLICATIO PERMIT P/
DATE NUMBER
ISSUE U PE OCC
�
DATE
CONST.GROUP
ZONING SETBACKS
FRONT RW^
REAR^
1 SIDE/SIDE STREET RW^
t
SIDE^
PROPOSED USE
,r. 5 i� lY�
N0. DWEL. N0. N0.
2JNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREA/VALUATION
11-6414WREM L j � C(I
U) Garage/Carport
LLI
Patio/Deck
W
LL PooVSpa
Z Re-Roof
Commercial
CO
Valuation +"j +-ADJ.AREA
QUANTITY DESCRIPTION FEE
U
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CONSTRUCTION
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PLAN REVIEW
ELECTRIC
PLUMBING-es-�;%,� L ' �•,�,��r
MECHANICAL .
INSPECTION FEE
ISSUANCE
SMIP��• , )')
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES
COMMENTS
RECPT N0. PAID BY VALIDATION
1
WHITE-Department Copy,YELLOW-Finance Copy,PINK-Assessor Copy,GOLDENROD--File Copy,GREEN-Applicant's Copy
CITY OF BAR
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