HomeMy WebLinkAbout15489 I
t/ J�
Y
CITY OF DIAMOND BAR
" DEPARTMENT OF COMMUNITY&D$VELOPMENT SERVICES
�' � . e' 2i�oE.cop��y���s�c�i90 PRESS �
(909)860-3195 Fax{909)861-3117
� �'A^''� BUII.DING PERMiT APPLICATION FIRMLY
oN JOBSITE .� ��� ��S tL� /'�OG I.�, DA�CATION � NUMB R'�� R�
ADDRESS
� iSSUE TYPE OCC
APN LOT TRACT DATB CONST. GROUP .
p OWNER
"' A�DRESS .3��2 Cr° 97'LG c� ZONING SETHACKS
u' CfTY D/t3 rt�an D bJflJ.ZIP�l/�'eS�TEL�.rUrl'��N�+ REAR RW p
� APPLICANT TEL SIDE/SIDE STREET RW �
� CONTRACTOR �f SIDE O
g A�DRESS �' PROPOSEDUSE A�('A�I�- TA .(i-�,air � A�-F
CITY��A Ye[/�14- ZIP `/G/ TEL�e�G"�f 3.�— - '�N P
� ARCHIENG/ . /dy� �.
DES�GNER NO.DWEL NO. � NO.
ADDRESS l UNRS STORIES BEDROOMS
� CITY ZIP TEL
y DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
� ONRVER-BUILpER DECLARATION SFR/ADOiREM �
O
i�aEer�uv�u+oEn rEriKn oc vE�umr nur i u+ezEuoT�aoM n+e cor+nuctoRs u� GaragelCarpat
8 COiSEUWFOHTMEPol10M/MOREASON(SEQ7a77.SBU5WE55INOPROfE5510N5000EMlYCRYOR (n
� CQJNTYMR1101REOUFE411iEPA1RIDQONSTRUCT./LTE0.IAAVAOVEOE40lI5M.ORREPAIAANYSTRUG W PatidDeCk
TURE,ppqq TO(TS IS$U�NCE,ILLSO REWIRES 7HE APGIICMlT WR SUCM PEPo.11T TO FRE A SiGNED
� 6TATFYENT TWIT HE Oq SHE 13 l/CENSED Pu0.5UAHf TD THE PIqV1510N5 OF iHE CONTRACTORS L4
LEIAELAW(OUVTER��COMMENCQJ(1 WITH SEGTION 7000)OF OMS�ON l OF iME BUS�NESS M!P PRP �' PooUSPe
FESSD119 000�OR TMAT NE OR SME I9 EXEIApT iHEREFROM ANO iHE BA515 Fd1T/1E ALIECED EItEMR
TqN.ANYVIOLATIONOFSECTI0N7o]f.6BYANYADCLICMRiORAPEMAtTSUBJECT4TMEMPUCANTTO Z R0-R001
� 11GV4 VE77AL7Y OF NOT MOfiE TM/VI FNE MUNDRED DOLIARS(Ssoo).Y.
� �I,ASONRIEROFTHEOROPfRiV,OR4YEMPLOYEESN'IIHWAOESA57HEIRSOIECOMPFN4ATI0N, ❑ (`,pmmBfC�a1 '
WILL DO THE NORK,IVA T1�E STRUCTl1XE IS NOT IMElIDEO DR OFfERED FOR SF1E(SEG 70!!.BU51• _!
NEE!MO PROFESSIONS OOOE T1E CONTMCTORS LICENSE UW DOES NOT AFPIY TO AN dM�ER OF
N CiqD�ATYMI1qBUlD$OqYPRT'ESTNEREp1,MAW110DOE55UL1iWlMKNIMSELFOFHfRSELFOR =
2 T/1HOUGHM30RMEHtrWpEYPLDYEES,DROYDEDTUTSVCMOAPqDVEA1EMgARENOTMENDEDOl1 m
� OFFEREDFORSALEIF,FqwEVE0.7HEBULDSMOR�daROVEA7EHTI55OLDw�TMNONEYEAROiCOMRE-
L 7pN.7NE OwNER-&1RDEA MAIL IUYE T1E BUNOEN OF PROVMO TNAT ME OR SHE DiD NOT BURD OR
= IMViqVEfORTVEPUHPO5EOF5ALE1
W O�AS OMMER OF THE VNO�ERfY,A4 E7�ClUSNE1Y LOMRACTNA MrtT1/LICENSED CONTMCTORS
� TO COHSTRUCT 7ME iR0.1ECT(SEG)OM.BUSIHES3 M1D PROFESSION�COOE iME WNTMCTORS LF Valuatlan ��''� ADJ.AREA
� CENSEUWDOESNOTMPLYTOINOWNEROFAPROPERTYWM0�ILDSORMCROVESTHEREOlI,µp
MH�ODHTMCfSFOR5UOIPRD.IECTSW1iNAfbMMGTOR{SJLICENSEDRIRSUM7TTOTMECOMTMG pUANTITY OESCRIPT70N FEE
� Taa uCENSE Uw.} . ,
O 1 M�IXE7,IPT UNDER SEG 8.t V.G.FON TMIS RE/�4pN U
I�L �
DATE OMMER V
� J
UCENSED CONTAACTORS DECLAFlATION W
� IHfREBYAFTRtlAUNDERPENKTYOfPER1UF1YTiAT1iUALICENSEDUNOEqPROVIS10N90FCNAPTER �
�(OOMYENCNOWIiNSEGTqN700D)OFOMSqN]OFTMEBUSINESSANOVROFESSIONSCOOE,ANO Z
W LICENSE IS N FULL FORCE AND EFFECf. . m _ . _ . _ _ __
� �
� LI�SE«A55�' L1C.NO. � ` " � 3 '
v �� �=�c{—o0 co�rtA�cma '-13 C'r.s�9 j— a
a6 , WORKERS'COMPENSATIONDECLARATION ' , a . , . ,
� '. � U
N I HEREBY AFFlN.�UNDER iENAITV OF 7E0.1UN'/ONE OF NE FOLLOWINO D£CLAMTqMS: �
y W - Z _
Q
0 �I/UVE MrD V�RL M1�MiTAM1 A CERTIFIGTE OF CONSENT TO SEtF•INSURE FOR YRMKERS =
� CpAYEN5AT10N,A]PROVIDEDBYSECTONITOOOFTNEt1�BORCOOE,FOAMEVERFORMANCE W
Of THE WORK FOR NMidl TNIS PERMR IS ISSVED. ; � � � .
Q . . . ' . ' � �1 ,
d �1 HME ANO WRI4AIHTAN MRNiKER3'COMiENSRTION MSURAIICE AS REOUIRED BY SECTIDN
77ppOF1NEUBOqOppE,FORTHEPERiORMANCEOFTNEY/OR1(PoRIMHICF�TFtlSPERAlrt15 �
� �suen.ur�odaPErisAraNlr�suwwcEuaniERumra�cvaur�eER�wE CONSTAl1CTION �jc/
? CARAtEN R r��,� R T PL4N REVIEW
� aa�crruraeER J��11 �����f'�s EIECTAIC + ��
� (TNSSECRqNt{�/qTBECQiiFiIDOc7FEPEiwtiswHWEHlUiEDDOlUit56t0%OFILRu� PLUMBING
Z ICENTIN7HATINh1EPERFONMM10EOfTNEWONCFOl1wInCHTHISPEW.�?ISISSUED,1 MECHANICAL rt��` -
Po
- � SMfll NOT Er.!PLOY M/Y iEPSON N IINV YANNER SOAS 70 BECOIAE SUaIECi TO TME '-. ` I.:Il J _ _ - . --_ - -_--_ -
y WOPo(ER5COAIVENSATIONUWSOFGWFORM�I��GREETHATIF15110UlDBECOME INSPECT�ONFEE
S SUBJECTTOTHENUFIKEHSCWPEN4ATpNPROVI5qN50FSfCTqN77000iiHEUBOR f'I
CO�F.ISHALLWHTMMTNC047LVWITHIHOSFPilON510N3. ISSUANCE" TY QF�1;��r1�!/��Tn�. �}
y�' - -- - 1ir • 2�T=�jStll\ ���
� {�� ^lY�-�C� �7�C�J�'�.eC�i� SMIP `3TJet.Di� � T� �'t,.�;• — '�-�--�—
� DATE � APPLICANT: `--i--'_'�i�-S��. •"_
WARNIN�3:iAllUHEM5EQIREWORKER5CO/dPEN5AT10NCOVENhGEISUNUWFU..IWOSHALLBE ENERGYP/C
�y SUBIECTMIEMPLOYERIOCNMwALVENALTIE9/�NDCNiLFMESUPTOONEIMAFEDTH0U5AND ENERGYPERMIT
pp�(/�FIS p100,000),IN/�DDITION TO TXE COST OF Cd.1cEN5�710N.DIVA�OES AS VROVIDED FOR IN
¢ SECT/JN]7oeOF711El.AeOR[a�EMEREST.ANDATfORNEY5FEE5. RETENTIONFEE:
a CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� IHEpEBVAFFlW�11rAENVENt1TYOFVENUR'ITMATTXERE�SACONSTiiUCT10NLENOM0A0ENCY '
Z FOq TME PERW R�IMICE DF iHE WOaC F�p WMK]I tM�S 7EM11T IS ISSUEO(SEG]ov7,CIV.C.).
W
� LENDEFtS tUME
� IENDER'SAODRE53
� I CERTIFY 1MI.T 1 HAVE REID TH13 A00.1GTqN MA STA7E TFUT THEli80VE INFORM�TpN i5 CORRECT. TOTAL FE ES � �O1�'
p_ 1 ACREE TO Cq.�RY MrtfH ALL GRY AND COl1NTY ORDMANCES AND S1�TE Uw4 REUTk70 TO BV4DINO
CONSTRUCTION.A/A HEREBV AlliHORQE REPRESEMATNEY OF TNi4 COUNTY TO EHfER 11PON TNE
�, �00VE�MENT%7NEO VNDPERTY iOR INSVECiqN PURPp5E5. COMMENTS
9 /yt�-R X �'1 ��,����
_
¢ FERMRTFErUA�E arrt� G �"'DZ O
N
� KiNANREOFPERMI7TEE DATE
� RECPT.NO. PAID BY . VAUDATION
WHITE-Department Copy.YELLOW-fv�ence Copy,PINK-Asseuor CopY.GOLDENROD--File Copy,GFiEEN-ApplieanCa Copy
: �_� -- — _ Q - � TT -n � cntnmoC� � mrn7i7i �o � �ri � g -+ vi Gim in
'� m m � 't)' -r -> -, z r m m m 3� m y x z p O O O � O T. m 7� r � r
' IT'D fi" > 2� D �D � m 'D � r r 'i O C C C Q D O -i � � p tTl L� � ` �..
� . ...I 'D-i ;'S r r r r p '� -i Rt � � � L� G) L� 'n � T m � � C n � W
��} ,+. . , 'oc� . � � i� � mSc� p -oc» n � � � nsxxnzcn � � � � o � ��
, ' .. r r �r- v �i -i � � cn � ro m T O ,S� x cn O o
� "I C D �' ' � Z � � C� -D�-1 � vmi 'rr- Z � Z � C in C c m D m 1 n � rn � � f+�� � 'T• t�•''S�I . i
ri3. �'i z � � � .� m � z -i -� . � n c � o m � r� _+ z� z = <_ � 'T' c p v' ".`�
'� �� V7 T` - �a q (n � z L� � r �- Z � m -� Z -t c) 's O v� ,�, �
� . �. �� �:i N U] . f�, n ' Z -3'{ O m Z � G) r' 7 m U7 C -I • �;
. , . • ;.:� _ �
'.. � . .. .I m N �." i y ; , �, ., � O Z L� � � n n � z D m ._
{ m l� ,�^I `� -i L� � —f
�_ �QiB ' �...� ' � � � � o�?
� I - - � �, � �,.
� � � �'� ��
� - - - ��l
o �� �
_ �, � a � �
e N �
= � �, �: mo
"� _ � c� -n
�, ��1 �"n'9 m o x � � p � -n D O v �a v �n � m v �n co � -n � c C � -n 1 j -� �
Q L �:r zmm � z -- Zm -n000zom � z � � � Zz = � O
- -� ,zn m� < D� rtt y ln Z y o T O O O c Z m y o m m o p y O �, �
� r" r � r n [n r r r = � C"l � r m 2 � v m m 7J � �� � �
, � '� fTi 2 � N m n fil A -1 T T fn 2 2 � m Q � f' 3J 31 m A�,,��,��{i �
' .�� { m � -p O — y � _� m z z m � � z D.O z m n n � rT-- �z p �.l�l m Z
.,.s _ cnm ;-� Zs � L� O D DG� ozoOmm00 i""k
� � � r (] C� D
(�' ' � �-o v -n z � � ' z � -i p n z � m Z m -n o o u�i -�i x� � Q
�,.� oTac� � � � �, zn o � a� m � oo � � 'm�; � W
� ��
�1 . i � r � � � � � � � � Do � �� � �
� � . ` � � Z � �`�
- � .�
,
� rtU f�� � .-
6 - m��
- . � ���
_ � n � !
,
-- � � � �i
� �i. �.
_ I � � � � , .
' � � l._ _ . -' . : I � ,
. E_._�. . i � � � {._ I_. I ,� _ . - _, i
� � � i I ; I � i _�