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HomeMy WebLinkAbout16868 (42) �� CTfY OF DIAMOND BAR � DEPARTMENT OF COMMUNI7Y&DEVEL�PMENT SERVICES , ��� 21825 E.Copley Drive (909)860-3195 Fax(9Q9)861-3117 PRESS BUILDING PERMIT APPLICATION FI R M LY � JOBSITE � /� � APPLICATION I� �t�6 PERMIT 'I „ P/C o ADDRESS���D C�1 �✓� vt DATE ✓o�J I NUME3ER J �ll q � ISSUE TYPE OCC APN LOT TRACT J'�o���I DATE CONST. GROUP p OWNER � !; "-' ADDRES,S�LS, �I ' �= ZONING SETBACKS gCITY /tJ1'fZ�`l ZIP � TEL. Y " 7 FRONT RW ❑ APPLICANT TEL.�D REAR ❑ � SI�E/SIDE STFiEEi RW ❑ � CONTRACTOR � ' s��ns SIDE ❑ � ADDRESS � .� � ' � C(TY ' '�' ZIP � EL PROPOSED USE oARCH/ENG/ (c-�i r �z DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SO.FT. FACTOR PSF ADJ.AFiEANALUATION p� OWNER•BUILDER DECLARATION SFRlADD/REM O I HERCBV AFFIRM UNDER PEN�LTY OF GERIURY THAT�M1 E%EM7T FROA1 TX[COHTMCTORS L4 Garaga/Carpon W CENSEUWFORTMEiOLLOWINGHEA50N(SEG70]1.6B1751NE55AN'�CROFESSIONSCODE:ANYCITYOR (n U �p�JMyWMCHREOlnRESACENAARTOCONSTRUCT,ALTERIMPROVE,DEYOLISH.ORREPA�RANYSiRUG W Pa�idpeck Z TURL,PRpR i0 ITS ISSUANCE,A150 REOUIRES 7ME APPLICAN7 FOR SUpI PERAUT TO FILE A SiCNFD w S7ATEMENT THAT NE DR SNE IS UCENSEO PURSUIINT TO THE Pi10V1510NS OF TM[CONiMCi0i15 LI- w � CENSE LAW(p1MTEN Y(COMMENCING WITH SECTqN 7000)OF DM510N]OF 7HE BUSINE55 AND PRO� u' POOVSPa FESSqN5CO0E)ORiH�7MEORSnE15E%[MPTTNEREFROMANDTH[BASISFORTMEILLLEGCOExEMv V TION.ANVVIOLATqNOFSECT10N70]1.SBVANVAPPLICANTFORAVERAlIT5U8JECTSTH[APPLICANTTO Z R0�R001 � A CML VENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS If5001.1: � ❑I�OWNEROFTHE7ROPERTV.ORUYEMPLOVEESK'ITHWACESASiHEIFSOLECOM0EN5AT10N, � (�`pmfTlerCial Z WILL DO TH[WORI(ANO THG STRUCTURE IS NOT INTENDE7 00.OFFERED fOR SAIE(SEC.70N.8U51. NE551WD VROFESSIONS CODE:TNE CONTMCTORS LICENSE LAW DO[5 NOT APPIY TO AN OWNER OF N VROPERiYMAfOBURO50RIlAPROVESTHEREON.AI:DWMO�0E55UdIWORKHIMSELFORHERSELFpq � CL iHRDUGHM150RHEROWNEMPLOYEES,FROViDCDTHATSUCNY.IPROVEMEMSARENOTMENDEDOR m � O�FEREDFOFi51LLEIF,FqWEVERTNEBUID:NCORIMPFlOVEMENtI550LDWITTnNONEtEAROFCAMaLE• Z TION.THE 01NNEREUItDER YALL/I�VE THE BURDEN OF VROV�NQ THAT HE OR SHE�ID NOT BUILD OFi = IYPROYE FOR TH[DURPOSE OF SALE). O l AS OWNER OF TME 7ROVERTV.IUA E%CLUSNEIY COMRACTINC NnTH UCENSED CONTqACTORS Q TO CANSTRUCT THE PROJECT(SEC.7W�.BUSINESS ANO PROFESSIONS COOE:TME CONTRACTORS U� VdIUOliOt1 ADJ.AREA W CENSEUWDOESNOTMP�YTOANONTICHOFAPROPERTVWF10BUqDSORNPROVESTNFREON,AND � YrtqCONTMGTSFORSUCHiROJEGT3WIir�ACONtRACTOR(5)LICEKSEDPURSUANTTO7HECONTMC• QU DESCFi�PTION FEE Y TORS Uc[NSE uw). y � O I AM E%EIAPT UNDEH SEC. B.1 P.C.FOR THiS REASON U � /� '��4-I� � � � DA7E OwNER V W ¢ IICENSED CONTRACTORS DECLARATION W �C INERCBYIIFFIRMUNDERPENALTYOFPERIURYTHATIMIIICENSEDUNDERiROVI510N50FCHAV7ER � d Y�ODMMENCWONnTHSECTi0N7WolOFDMSiON70FTHEBU51NES5ANDVROFE55i0NSO00E,AVD Z X W LICENSE IS Pl FULL FORCE AND EFFECT. . Xe��� � � LICENS...E���C///USS ��� LIC.NO. � `� ✓�� � ~ DATE�(f O CONTMCTOfi �7•t�=% a W I ,�fi�I � WORKERS'COMPENSATION DECLAHATION a � � INEREBVAFFIWAUNDERPENAL7VOFPERIUW�ONEOFTMEFOLLOWIN00EGURA7lONS: Z Q 0 IHAVEANDW:LLMAiNT�INACERTIFICATEOFLONSENTiOSEIF•INSUREFORWORKERS' S � Cp1IOENSATION.AS DROVIDED BV 5ECT10N 77000F TME LABOR COOE.FOR TNE VERFORAIANCE W i OF TXE WORK FOR WHICH TNIS FERMIT IS ISSUED. � ' O W 1 HAYE AND WIIL IAAiNTA:N WORKERS'COMPENSATqN INSUR.WCE.AS REOUIRED BY SECTION Q � 'f�ooOFMEUBORCODE.FORiMECER�OfiMANCEOFTNEWORNFORWMICHiHISPERMITIS ' ISSUED.MY WORNERS'CO ENSATqN INSUM�CARqIER AND ICV NNAOERARE: CONSTRUCTION � GRflIER • �,� �`��� � PLAN F7EVIEW � POIICYNU48ER �..�� --- ELECTRIC 'r—�� •-• _ O•S ¢ ...�—/+"''�—�`i I L )� � (M55ECifONNEmwTB[K/.ctE7EDOFhEPEfIATBFOfiO1:EMADRED00LLNL56+m10R1E55I PLUMDING Z 1 CERTIFY iHl1T IN 1ME FERFORMANCE OF THE WORN fORY1111CH TNIS FEMdR IS ISSUED.1 MECHANICAL - (J' SHALL NOT EMPLOY ANY FERSON PI�N1'MIwNER 50 AS TD BECAME SU0.IECT 707HE � WORKERS'COMPENSATqNU'NSOFCALIFORNUlANOACREETHATIFIS BECOME INSPECTIONFEE S SU&IECTTOTHEWOfiKERS'COMPENSATqNPRO . NSOFSECTqN O i R _ � � coo is oar rHcour�v ;is s. ISSUANCE � � � �L Gl SMIP P�� � DATE:'�����APPIICAN . _ _ � W ENERGY P/C � -T-- � WARNING:FAdU ETOSECUREWOAKERS'COMVENSATIONLOVERACEISUNUWFUL,ANDSH�LLBE � � SUBJECTANEMPLOYERTOCRIuiNA�PENALTIE5M10CMLiWE5UPi00NEHUNDREDiMOUSAND ENERGYPERMIT DOlU�S(f 100.Ooo).N/�DD1710N TO i11E COST OF CO�IPENSATION.DAMAGES AS PROVIOED FOA IN � SEGTION7)OeOFiHELAFlORCODE,NTEREST,ANDATTORNEY5FEE5. RETENTIONFEE: a CONSTFiUCTION IEhDING AGENCY PRE-ALT FEE: , O � IHERCBVAFFIRMUNDERPENALTYOFPERIURVTMATTHEREISACCNSTRUCTIONIENDINGIG[NCY n- FOR THE PERFORUANGE OF TH[WORK FOF WHICH TXIS OERMIT IS ISSVED�SEC.700),CIV.C.). Z W �Z LEN�ERSNAME � F— LENDER'SAJDRESS w ICEflTIFYTHATIHAVEREADTHISAPPLIGATIONANDSTATETu7THEABOVENFORMAilONISCORRECT. TOTAL FEES � \,�b � I�GREETOCOMP�YN7THILLLCITYANDCOVNTYORDINAHCESANDSiATELAWSRCUTINCTOBUIDINC V CONSTFUCTION.Af:D MERCBYAUTMORIZE RCPRESENTATNES OF THIS COl1NTV TO ENTER UPON 7HE Z AWVE�MEHTIONED PROVER7Y f0 'SPECTION�UR E5. 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