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HomeMy WebLinkAbout16241 (9) A CITY OF DIAMOND BAR -- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 2166Q E.Copley Drive Suite 19U `�" t�os)s6o-siss����>s�i-��i� PRESS os �...'��''f BUII.DING PERMIT APPLICATIOIV 4� �� FIRMLY � .�oBsiT� _� ��1� rn � l'r� G` -�-� Q ADDRESS � � � / .r�,� APPLICATIdN d PERMIT ! _ �f P/C r, -- -�-Zstbw f�--r°iY./�-. DATE � �t NUMBER V'� t # � —""� ISSUE TYPE OCG APN Lt�T TftACT `'�3 �2� J DATE � '� _�. GONST. GROUP � p OWNER �v/1''� __�'r �_ � ADDRESS /d"�`��1� a�i�AT_�L��¢j�f � ZONING SETBACKS �� CiTY ZiP TEL FRQNT Ry�r� �}_ APPt�iCANT TEL. REAR �— l,� � SIDE1SiDE STREET RW ❑_ � CONTFSACTOR� SI6E t� ADDRE5S A Q CITY ZIP TEI. F�QPOSEp USE rL G �� ARCH(ENG! DESIGNER NO.DWEL. NO. NO. ADDRESS cn UMTS STORIES BEDROOWtS � CITY ZIP TEL. � DESCRIPT1pN SQ.FC FACTOR PSF ADJ.AREANALUATION � {7WNER-BUlLDER DECLARA710N SFRIADDtREM G7 � 1 MERE6Y AFFlRM UNUER PENAITY OF PERri�RV THAT I AM EXEMPT Fp9M THE CONTRACTORS LI� �gfflae/CdryOft 447 CENSEUWFORlHEFOLICM1YM7QREASONi$�C.]o3t.56USiNESSANOPPAFESSt6NSW0E:ANYCiTY6R (f� S.7 COUNTYWHICHREQUIHESAPEiiMITTOGONSTRUC7,KT�R,IMPROVE,DEMO�JSH,ORREPAIRANYSTRUG � 7Ufl�,PRIOR TO ITS ISSUANCE,/LLSp qE0U1RES TNE APPUCPNT F4ft SUCH PERMIT TO RLE A SIGN�D W PatiolDeck w� S7ATEMENT 7HAT HE�R S4E IS LICENSED M1RSLlANT 7q 7HE PPOViSiONS qF THE CONTRACTORs L!� � CENSE LAW(qiApTER 9(CYJMMENCINq WITN SECTION 7000)OF OIVISION 3 OF THE BUSINE55 AND PRO- � POOUSPB FESSiONSCX?OE}ORFtUQNEQRSHEtSE7(EMPTTNEfiEfftOMANDTHE8A5tSFOftTNEALlEGEOEXEMP� (� TqN.ANYVqLATqNOF3ECTIDF17031.5BYANYAPPLICANTFORAPERMiTSU&lECTSTHEAPPLICANTTO Z Re-Rooi � A CIVI4 FENAI.N OF NOT ANJRE 1}IAN FNE HUNDRED DOI.I.ARS(SSoO�J: � U6eiSOWNEt{OFhtEPfl6PERTY#iMYENPCOYEESN1TFiWAGESASTHE�RSOLECbMPENSAT�Pl. � �bltime�Ciel VALL IXS TFIE WORK,AND THE 9TRUGTUflE IS NOT INTENOED qR OfFEHED FOR SALE(SEC.7041,BUSI. J � NESS AND PNOFESSIONS C�DE:THE CONiRACTOR9 LICENSE l.AW DOES NOT APRL�TO AN OWNER OF � PRDPERTY WHO BUftRS pN IMPflOYES TtiEtiEON,AhD WN0 DOES SUCH v10flK H�MSEIF OR HERSELF OR (,� THROUQH HIS OR HER ONRI EMPIOVEES,7RfiVIDED THAT SUCH IMPROYEMENTS ARE NOT INTEN�E�pR m O UFFEHEDfORS/tE.iF,HOWEYEH,Tt1E8U4L01tiGORiMPROVEMEN7lSSl'RDWITM1NQfVEYEAROFGfJIMP��- � TION,TFIE OWNER�BUILDER W1U.HAVE TNE BURDEN OF PROVINa 7HAT HE OR 5NE Di0 NOT 6UiLD OR � IMPROVEFORTHEPl1RP0&EOFSALE). w �J6tSOW!#ER6fTHF_Ppff9EFTY.AtdFXGtUSiYElYCIN4TRAGT�i(`iW1THtiCENSEE}CXNlTRACT4flS {^t TO CONSTRUCT TME PRW ECT{SEC.76M,HIJSINESS AND PFOFESSIONS CQC1E:THE CONTFACTORS ll• VaIUBIlOf1 ADJ.AREA UJ CENSpLAWDOE5NO7ApClv70ANOWNEFOFAPFOPERTYWFIOBUI��SOR',MPpOVESTHEREbN,AND � macoriraacis�oasuc:H�aoaECTswrruaconiTrucrars�syucsvsEoa�asi;,wrro�r++F�far,o. pUANTITY DESCRSPTtON � TORS LICENSE UW,). FEE CI iAM EXEMPT UNDER SE[:. g.d P,C.FOR TH:S REASON Q � U U" OATE � OWNER_„___� � F � —�. — W � LiCENSED CONTRACTORS DECLARpTIpN -� � w I ttEREBY AFFIAM UNPER flENALTY c�F PER.lURY TNAT i AM LICENSE4 UNDEF PR4ViSbN5<.1F GtiAGTER � (� O�CLIMMENCIN(3WITMSE(:TION�000)OFDIVISION90FTHGBUuINES6ANDPFOFESSIONSCODE,AND Z .....�......_ _.. tj� MY LICENSE t5 tN GULL fOI�GE EffEGT. m r—^J Q LICEN3E CLASS„�j "_ LIC.NO._�l _ � U OA7E�","�i/�C�I � C4NTRACTOp_ d -- �� W � N�ORKEH5'COMPENSATION DECLAFATION Q � IHEFEBYAFFIRMUNDERPENA{,TYOfPEMipVOtJEOFTNEf61AOWtryGDECi.ARATiONS: Z � �ifiAYEAN6HqtLMAMTAM7ACERTtFiCA7E17fCAPi5ENTT4SEI.F-INSUREFORWQRKEHS ¢ ^� ��� � COMPENSATION,IIS PqOVIDEp 8V SECTION 3100 OF THE LPE30R COpE,FUR THF P'cRFORMANCE U OF THE W(?RN fOa iNMICH TMIS PEqM1T IS ISSUED. W w � 1 � _I MAVF ANfJ WILL 6AAINTAM WCSRKERS'COMPENSATqN INSURANCE,A5 RECNJIREU BY SECTION � 3TotrOF TH£GABt>R CQDE,F4R THE DERFCRMANCE OF THE W4RK FdR WN{CH TNSS PEftMiT 1S ISSUED.MV W ER"'(�MFENSATION�INS'U�RA�NCrE/CAHRIER AN�PQLICV Nl'�A/1��•p qqF� GONSTRUCTION j c�RRIEa_�f_,�ft/'�/AL�Lfk l - �1��. L.QJ .. PtAN REVIEW � . .� � POLICY NUMOER /r LY,V'[,L, ���Lt.."..__J_;✓�.; EIECTRIC �� �.��.u�t.4^ r Tfl -- - - ---.....� � (nusstcrnwNeeora'rsEa�7E6oFn�EpEre.vrsrtwor+EFUN[x�ou:,r.ws.stsioo�ot��ess�. PLUMBING . tu _.._ _ _ .'� I C�qTIFY THHi I��THE('ERFORMANCE OF THE WORK FOR WHICN THI5 PERMIT IS ISSUEp,I MECHAN�CAL (;f SHALL N07 EMPIOY ANY PERSON IN ANY MANNER SO 45 TO BECOM�SU6JECT TO THE �-- —'" —"-'-- (Jj KT?Po(ERS'GVMPENSAiiOti UWS Of CALiFOFiNtA,AND AGREE TNAT IF I SHOUta 3EGbMf. (NSPECTION FEE S SUB,IECTTOTHEVfORKERS't"AMP�NSRTI4NPRdY1510NSOFSECTIl7N3lp00FTHElA60R .���' GflUE,i SHALL FC)ftTHWiTH(:C1MP�Y W1TH ThtOSE PftOYi510NS. ISSUANCE Q �-_�_1 �.r�_��-_.� _ _ p DATE: —�� APPLICANT: 4"� - SMIP � —_.._— J"� WARNINO:FAIWrIE TO S[:GUflE WORKERS'COMFENSATIDN COVERAGE IS UNI.hWFl1L,AND SHA4L BE ENERGY P/C �_. — -... �.. __.... �y Stt8JEC7ANEMP(,OYEHT4GRiMiNN.7ENN.TiESANUCIViIFWESUP700NEHUkDREDTHOUSAND EWER6YPEFSMIT DOLlARS iS100,OW1.iN NJDITION TO T'HE CpST Oi'�COMP�NSATION,DAMAGES AS PROV�pG�FOR�h � SECTION 3]OB OF THE LABOR CODE,INTEREST.PNCI ATTOpNEY'S FEES, RETENTION FEE: �— ....�__ _ � CONSTRUCTION LEN�ING AGENCY PRE�ALT FEE: —....---..,___ —..� � 1 HEAEBYAFFIRM UNDER PENAI.TY QF PERJVPV THAT TNERE tS ACONSTRUCTiON LENDING AGENCY _� FOfl THE PERFORMANC[OF TNE WOHK FOR WHICH T VE�IT 1313SUED I$EC.�091,CIV C.). -----� W �(y� �j /J j+ � LENUEH'SNAME.�,,,,, �IV`�L v �t"r ��+. i— LENLIER'SA��RESS_,_„__ � W i GERTIGY 7NRT i NAVE flEAD TMIS APPtYGATiON AND SiAT£THAT TNE A80VE INFORMATqN FS CpAfiECT TC}TAL FEES {� "1 ��� �? � I AGREE TO COMpLV WI7N ALl GITY AND GOVNTY QRDINANCES AHD 5'GTE 4AWS R6LATING T09UILDING � CONSTftUCtfUN,ANDH[flE8YAV7H(7ftiZEREPRESENTATIVESOfTHfSCOUNTYTOENTEftU?ONTHE z ABOVE-MENT�ONEOPRC�PER7YFORINSPECTh'JNPURPC'SEb. 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R �w�t � '� � d��� � � � � _ , w," ` r', � ., � _ '�� _ _ _ _ �'. � � � � t � � � � � � � _ _ � . � ��� � fi �'�� � r ���f�`��� �1 ; � �����"��s9�����q+� ._ ._. .. ... .... .._ .. . . ... .. . . . �+ t � ..xa,�����vt�'�����":�;�^�����„t; ... UI,I�III�U U,lh 0 s 0 a w 0 0 w 0 0 w w 9 w 0 z w w ]C Q 0 3 z 0 �d a 0 U w cn rn 0 7d- 0 w 0 0 z 0 w z cs CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21660 E.Copley Drive Suite 190 (909)860-3195 Faz(909)861-3117,� BUILDING PERMIT APPLICATION PRESS FIRMLY WHITE-Department Copy,YELLOW-Finance Copy. PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy