HomeMy WebLinkAbout16166 �_��
/�1,,�,,,` CITY OF DIAMOND BAR �
• DEPARTMENT QF COMMiJNI"i'Y&DEVELOPMENT SERVICES
22664 E.Copley Lhive Suite 190
"` (909}860-3195 Fau(909)861-3117 PRESS
"''�', BUII,DING PERMiT APPLICATION ��y i,�_� Pi��,' 'Z��,, FIRMLY
� JO$SITE ^� ,n APPLICATION {\` PERMIT ! p/C j"�{ �"y ���
Q ADDRESS_. �?F'C'�S� [..��'��t4J 1r�i.S'� DATE ���r'`�t NUMBER '"�lJ�' � g J{ � '..l�;,t�
� APN LOT �.'3��"�13 TRACT_'�Z�-� ISSUE TYPE OCC
p OWNER F:/}� 7 DATE CONST. GROUP
��P Lc:!'P
o ADDRESS J��((R1 Llt�r"1 ��,.r�,sti./1 ZONING SETBACKS
� CITY �!"✓;r1Er �!P��_TE�.����'� G� RE�ART RW C� ,
APPLICANT "'ii t rT C°. TEL. �i��''__. g�pE/SIQE STREET qW �l
� CONTRACTQR �c� P SIDE �
� ADDRESS r..r' a..rl r- PROPf?SEQ USE S�;^-
� cirv !ru f n ' z�p�°..i�.1.� t'ei. r��t-�5�--;!`�t� �--
� ARCHlENG/
� QESI�NEFt.,_�ut'� S �` �:i��t. NO.DWEL. NO. NO.
�DDRESS `—�'-Z�P�_,,�0,� TEl.�ilY����.�1•�',�, �N�S _ STORtES BEDRO(?MS__,
� DESCRIPTION SQ.FT. CTOR PSF ADJ.AREANALUATION
p� OWNER-BUILDERDECLARATIQN gFRtAD61REM L tJ �
L� r�
Q 1 NEREBY AFFIRM UNDER PEN,LL7Y OF PEKIURV THAT I AA1 E%EMPT FROM THE CONTRACTORS 41- � Garage/Carpor! '� �� �� �
W CENSEUWfOHTNEFOLLOWINCiREASON(SEC.l43l.58USINESSANDPPOFESSqN5fADE:ANYCtTYOfl
Z CWFtTYYrt�fYiRE9U�iESAPEFiMtt7TOCGJ5THUCT,ALTER.iiAPiiOVE,pEMOUSH,ORREPAIRANVSTRUG- W P3�i0/DBCk
�� TURE,PRIDR TO ITS ISSl1ANCE,ALS4 REWIRES THE APFLICANT FOR SUCM PERMIT TO FILE A SIGNEp W
57ATEMENT TXAT HE Oq SHE fS ItCENSE6 PuflSUANT TO T»'e PROViSK)NS OF T!1E�i7RACT4RS�i-
� CENSE UW i�PTER c(C6MM6NCINp WITH SECTION�q0o)OF DIVISN7N 3 QF THE BUSMESS AN�PRO� LL' POOUSpB
PESSM?N517WE)bRTHATHEtlRSHE�SEXEMPThVEREfFOMANDTHEBASISFORTHEAL4.EGE0EXEMP- (!S
TION.ANYVIOtATIQMOFSECTIt#27at.56x,4NYAPPLlCANTr4RAPEf�1iTSU8.tECTSTHEAPPilCANTTO Z Re�Root
r ACML PENAI.TV OF NOT MORE TMAN FIYE MUNDREO DOLl,qRS(SSao�.)�
� [11,ASOWNEFlOF7MEPqpPERTY,ORMVEMPLOYEE5WITHWAGESASTNFIP50LECOMPENSATpN, Goittm9�CidI
W�IL 06 7ttE WOF#C,AND THE STRUCTURE IS NOt INTENOED 6A OFFERW FOR ShLE iSEG.�OM,BU54 �
� NESS MD PROFESSIONS(:ODE:THE CONTpAC70RS LIC6NSE LAW DOES NOT AVPLY TO AN OWNER pF // jy
PRDPERTYYfFpBUILDSORIMpFialESTHEREON,ANpW��IqppESSUCHWORKHkdSEI�ORtiERSElF4R � �"�i�'^" � � ��,�
� TNRQUtiFtHiSORHEROWNEMRIOYEES,GROViDE[STHA7SUCHIMPR4VEMENTSARENO7INTENpEDOR m
OFFERED FOR 5016,IF,FIOWEV6R TME BUILDING OR IMPROVEMEN715 SOLU WITHIN ONE YEAR OF COMRE-
� TION.7HE OWMEREU1tDER WIU.MAYE 7HE 9UR6EN 4F PROYK�lo 7HAT tiE QR SHE OW NOT sUitD OA
1MDR?YE FOR TNE PURPPSE OF SALE).
G71.AS ONTlER OF THE PROPERTy,µ��XCLUSNELV CONTflACTING WRN t ICEN5ED CAMRACTORS
� 'O CAtJSTRVC7 TFfE FF�JECT(SEC.?9tf,BUSitiESS}ryp p��SSIONS CCH7E:THE pJN7RACTORS li� Vd�U0110f1 �' ADJ.AREA
W CENSELAWDOESNOTAPPLY7pANOWNERt}FAPROPERTVWHU9UILb50RIMPROVESTHEREON,AND � -- -
� WYIOCONTMCTSFORSUpiPRQ1ECTSWITHACONTRACTOF{S�4ICENSEDPURSUANTTOTNECONTRAG QUANTITY DESCRIPTION FEE
� TORStlCENSELAW.). --
❑1 AM EXEMPT UNpEN SEC. .,,`8.&P.C_�DR TF115 flEASOM Q
U �' '`�
� QATE 04YNfR ` �� � / Ld-r�' �iJ
� UCENSED C6NTRACTORS DECLARATlON W •` �� x Y1 , � �_.
� \ ' �.-.S, �'
I HEREBYAFFIRM UNDEfl PENAL7Y OF PERIURY 7HAT I AM UCENSED vNREft PROVi9lpNs OF GktAA'fEfi ^ /}
� D(WAIMIENCN'7(I WITH SECTiOh17W0y OF OIVISiOk 30F THE BV9�NES5 ANO PROFESSIONS CODE.AND Z y VL..�
u� MY LICENSE IS IN FU4L F�RCE ANb EFF6c7. m �
Q L�CENSECLA55 f„_��___. LIC.NO_ � � �✓ !� � � � �
� QATE I ^G��( ` LZF .__GONTRACTflR �1' �.. �t�Y� 6�. � r- C
� WLTRKERS'COMPENSATIdN dECi.ARATiON Q �' �
� U � <
� I HERE6Y AFFIRM UNDER DENALTY OF PERfURY ONE OFTHE FOI�OWlYG OECt.AAATIONS: Z � � t
� ^,IHAVEANDWILLMAWTAINACEFTIFICATEOFCON5ENT1`QSELF�INSL1pEFPAWORKERS' '('J • ��
WMPENSATiOF7,ASPROViDEDBYSEGi'idN97WOFTMEI,ABORC06E,FORTNEPEAF6RMANGE U L vt t
Q OF THE WORK FOR WHICH THIS PER4.11T IS ISSUED. � �
w _�ii,4VEANDWILLMAINTAINWORNERS'COMPENSATIUNINSURANCE,ASREQUIREDBYSEC710N �
Q� 3700 pF THE LABOR LOOE,FOR THE PERFORMANCE OF THE WORK FOA WHICH TH1S PEflMiT IS t { {.i y (`,�; �,�i+ � -
` �SSUED.MY KEflS'COMPENSATiON INSURAriCF.CARRIER AM1HJ AOUCv NUMBEfi ARE: CONSTRUCTIQN t�� � �. I 1 v I ,1 1 1 eJ��`_
� � �^ .��_Y
y c�wnieA GGiC l't,�-!j{ -y,� A�d-�T•Jt�_^}� �l1S. 4CC? PtANREVIEW
d POLICYNUM6ER W���_. 1�.. GJ/,j�,��� • • � � � . ..--
Z^ ELECTRIC .
Q -- --�.—..._ \ _
d (iHssEci%7MtJE�No76EC�APiErEooFT1EPEw.tr�SFOF1oNE10.NLNiEJDoll.NiSlLtWlattEss} PLUM8ING �_ ,�,
W � �
Z' i CERTlFYTMAT IN TryE FERFORMANCE OF THE W6RK F4R WHICN THIS FEAMiT IS I59UED,� MECNANIGAL _,_���"„�y�_
C�'} SMAI,L NOT EMPLdY ANY PERSpIV IN ANV MANNFR SO AS TO BECOME SUBJECT TO THE ' -
(/J YIORKERS'COMPENSATK}N UWS OF CILL1fOflN1A,AN0AGqEE T}{qT tF i SHOU4,D BECOtdE INSPEGTION FEE
� St38JECT 70 THE WORKERS'CO{AP<NSATION PROV�S{ONS OF SECTION J7060f THE LA90R � '-�
� CADE,ISHAI.LFOpTHWI7NCOMPLYWITHT�pSEV%ovI5K1N5. ISSUANCE � �� 1 �� �^'"'
�' _,L„n-t .. _.�C�'_{i:_�b. — �� .. .
p 6ATE: L' APPLICANT. m� C-�I,[�+ SMIP _._.. _�. -_ �}
—� t ENERGYPIC •� � �7`'
J WXflNiNG:FAI�VftETOSECUREWORKERS'CAMPENSATi6NCOVERAGE16UNi.AWFVL,AND9NALLBk . ...,__�����( __,._ _ �l
� Sl!&IECTAN EMPLOVEH TO CRIMINAL PENALTIES AN6 CIVI1.FMES UP i0 ONE HUNDREp THOUSANp ENERC�Y PERMIT i^ �`-t(�_ f }+
JOW.LARS(5700.000).IN dDOITION TQTHE COST OF CCNtPENSATKNI,DAMAC�ESAS PflQYII}ED FQR IN -�
SECTION3Rf80FTNELABqRCOC1E.INTEREST,ANDATTORNEY'SFEES. �� �,w��
� HETENTION FEE: i
_...._—_... .^--
a C4NSTRUGTION�ENDING AGENCY ""��
pRE-ALTFEE� _, _, _,_
� IHEAEBYAFFIftMUNpERPENAITYQFPERJUpYTNATTHEREISACONSTPUG7tONLENDItJC.AGENCY ^ � r
FOR THE PEAFpRMANCE OF THE WORK �R WFiiCii TH{S pERMiT�S ISSUE�(SEG.3a6J, V.G.j. '— � ,��--� � -
Wj j y` n� � y
� IENDEflSNAME�K/.����i i.i�. .�.7�_��_.. _..�__�
t- IENDEA'SA�pftE55
� ICERTIFYTHAT'IHAVEREAOTHISAPPLICATIONANQSTATETNATTMEABQYElNFORMAtbN15(7JRRECT. TO�A���ES � �t �� .•`��
� i AGAEE TO CQMPlY WtTH AI.L CI1Y AFA COUNTY ORDINANCES NJD STATE UWS REUTING 7q BVILDING I � � v
� CONSTRUCTICNJ,ANpHEREBVAUTHORIZEREpRESENTATIVE50FTHI5COUNTYTOENiEHUFlONTHE €"`�[j <�' � j(}(j�
Z 119QVE-MENTIOt7ED PflOPEPTY FtlR�NSPECTIbN PURPOSES. COMMEI�ITS ��� �� �' t Lt U
� � �
� '
m .�...... �
¢ pERMITTEE NAME(PqINT)
�
y S�GNA7UREOFPERMI7TEE DATE
� RECPT.NO._ PAID BY � � VALIpATION__
WHITE---Clepartmen!Copy,YELLQW-Finence Copy,PlNK-Assessor Gopy,G41.DENR06-File Copy,GREEN--Appiicarrt's C�
,�
�d$"'� ,& � ���h¶$^pi F����� �X.'S,k'T.P.
$§�y�„,v�,.s�.��� t���c� ��.`�.a�,a��"1 X�.r� .
.e..� ,: a „ - .' _ .
� ,
q��,'' 2,� � g.
.
_
��, � - � ��r�` ��
�_ o �. � „��� n � � � �
�, � �
� � � � . ', � � °
���'�� � ,� � �-� � � •� �
,��.����.� ,�� , . � �
� � , �_- - _ _ _. . _ �
�- �y �c � _
w�
_
��`�� � �� � � �
.
�� _ _—
, � — � _ _
� :. � _ a
� z�i�� _ _
::�� _ _ . _
.. . . .,.�Y � � � .... .. ._ ... . . . . ...
��-r 7� ,�...�:�.; _
� _ _
: , __
� r��� � � �x �� _ _
s�- _ _ r� ��M�����u�
,. .._ ,������ -
- '1-l3 2i1 �' c�-�Z i� raC,-��-� _ _
_
. _ _ __ _
�. �r, � us� ��� ��,� . _ _
� `���_�^ �� � _ _ __ _ _
��x� � ����t��� _
� � �'� � �
g ;. _
� � � �s�l�`�'���� .'._. �._. _ __ _ _ _ _
a �: � ��� �
�'�� ��a, a �
�r a.�`" �a.'aP�AW�� ,�3 . .. . _. ... .. _ -
w � �s;E , �,y , __. . ... — -
� x � `�`�, �. �.". . -�- ' _. . ..
r s,����? �� r
} ��� ��� �' � �,'
� � � �� n
,� "� '��'�'�.,�# . .. .. ...
` � �� � �a��'� i ' . ..._ ... . ... .. . . . ... ...... . ... . .. . ... .. .._ ... . � � .
g 'I k�i� �'�� . ....,..�..__ ... ._..
� ������` ���� .. .. . . _ .. �� �� . ... " _. �.
-" b e; ... , _. ... .....
i.4�� ` � .... .. ..
...,..��....�..,�..n.....,...��........�......�.
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
JOBSITE
ADDRESS 23&67&I pn-d-V w
APN LOT 3-UC'TRACT<Z2-b-7
OWNER-Li-14�)tIP- �crcP
ADDRESS If 1�-LJ.Q 1 (1 on i 14'll
CITY_ lI'V; it*,ZIP �)?t-2_TEL � : "-7 17-E'(
APPLICANT 5,e-TEL.J�ai'-lIV
CONTRACTOR Ile jh20AC P
ADDRESS r�Y earl
CITY J rv I n f ZIP'i L61 TEL C1-(C1_jell-410
ARCH/ENG/
DESIGNER L,4.r S'&>C, .
ADDRESS
CITY ZIP 6�TEL.s- ' 1 "
OWNER-BUILDER DECLARATION
1 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 CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).):
D 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 COMPLE-
TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
D I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTlNG WITHLICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TOAN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A OONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
D I AM EXEMPT UNDER SEC. i B. 8 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 FORCE AND EFFECT.
LICENSE CLASS f 1 LIC. N0.4-r)
DATE,r � U F_CONTRACTOR i/I' #7r Yf
WORKERS'COMPENSATION DECLARATION
I HEREBY 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
OF 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
ISSUED. MY
KERS'C
0
MPENSAT INSURANCE CARRIER AND POLICY NUMBER ARE:
Wy
M
/
t
cc-��
CARRIER CLL t S
L�
)
POLICY NUMBER�+fJcc �•C F Z
(THIS SECTION NEED NOT BE OCI PLETEDOF THE PERMIT IS FOR ONE HUNDRED DOLLARS($lOD)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.I SHALL FORTHWITH COMPLY WITH T E PROVI
SIONS..
IS
DATE: II 1 -a APPLICANT:/f7 C.Q
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 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK. R WHICH THIS PERMIT IS
ISSUED(SEC. 3097,V.C.).
LENDER'S NAME, 1 �t-fHI 1 3 CAC-(Q}q
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.
PERMITTEE NAME(PRINT)
SIGNATURE OF PERMITTEE DATE
APPLICATION P/C
/C
NUMB R" 1 I. i�° #
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ^
REAR ^
SIDE/SIDE STREET RW ^
SIDE ^
PROPOSED USE I�1
IJSFI'L
N0. DWEL. N0. N0.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. fiiACTOR PSF ADJ.AREAIVALUATION
SFR/ADD/REM L ;, 1 J L
U) Garage/Carport
I Patio/Deck
LL Pool/Spa
Z Re-Roof
Commercial
Valuation I ADJ.AREA
QUANTITY DESCRIPTION FEE
LIJ c Y1 .
w on�
G3
G3 y
U
Z
� V V
� 1
Irk,I
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE IJ-c�
SMIP
ENERGY P/C
ENERGY PERMIT lt
f
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES
F
FFBO ?001
COMMENTS
Wy:
RECPT N0._ PAID BY fr VALIDATION
a
WHITE-Department Copy,YELLOW-Finance Copy,PINK-Assessor Copy,GOLDENROD--File Copy,GREEN-Applicant's Copy
PRESS
LA-s'y&t_.5 Arc; 'Z1?R FIRMLY