HomeMy WebLinkAbout14055 CITY OF DIAMOND BAR � �'�
--�� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190 �
(909)860-3195 Faa�(909)861-3117 PRESS
`�M^ BUII.DING PERMTI'APPLICATION FIRMLY
JOBSITE APPLICATION � PERMR � P/C a
o ADORESS � I • DATE ��__NUMBE �t �
$ ISSUE TYPE OCC
APN LOT TR T DATE CONST. GROUP
p OWNER
"" ADDRESS ZONING SETBACKS
� CITY � 21 TEL REAR Rw ❑
APPUCANT TEL. SIDE/SIDESTREET RW ❑
� CONTRACTOR SIDE ❑
� ADDRESS PROPOSED(1SE ' (�
CITY ZIP TEL
� ARCFVENG!
DESIGNER NO.DWEL NO. NO.
ADDRESS UNRS STORIES BEDROOMS
� CfTY ZIP TEL
� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
�
� OV'MER-BUILDER DECLARATION SFR/ADD/REM '
O
p 1 HE(iEHV AFFli9A U�DER FENALTY OF PEf WRN T1uT I uA E7CEUPT FROM ME CONfMC70R5 t} G82g9/C8rp0/I
W CENSEUWFORTHEFOLLOWINOREIl90N�5EC7671.58U5R1E55ANDVROFE551DN5CO�E:ANYCfTYOR (JJ
u OOIMttMR11p1PEOURE511PQWRTOCONSTRUCf.A1TER�P�'EDEMOLJSH.ORREPAIRANYSTAUG W PdfldDetk
6 tt1RE,7Rri1 TO RS ISSU�NCE IL50 REOUiPES THE APPIICANT FOR SLKH DERUIT 70 fKE A SIGNED W
� STATEMENT T1AT HE OR SNE IS UCENSEO PURSU�NT TO iNE Vi1OV7510N4 OF THE CONTMCTORS L4
! CENSEUN�(OUPTEq�(CdIMENCINOYATH5ECT10N70o0)OFDMSqNIOFTNEBU5nJE55ANUPFO �- PooVSpa
�E FESSqNSCODE)ORTW�TMEORSNE19E7fEMPTT1fEREFNOMANDTHEB�54FOqil�EhILEGEDEXEMP• (�]
V iqN.Ml'/VIOIATqNOF5ECT10N7W1.6BYMlVAPPIIC/J{iFOHl1PERMRSUBJECTBTHEAPPLIGVITTO Z Ra-Rool
� A[MVENALiI�aFNOTG1aHETWIFNEMINORED00LLAR4(Ssoo)1: .
� OL��'EROFtNEPROPENTY,DRMYEMPLOYEESW�T�wACE5A5TTiEtR50lECOUPEN5ATI0N, O Commercidl � ' -
WN.L DO THE WOR1(AND TNE STRUCTUAE IS NOT IMENDED OR OFFERED fOR SILE(SEG 70U,&154 J
N NE53 Al41 CROFESSIONS CODE THE COHTMCTON3 UCENSE Uw OOE9 NOT AVP�V TO M!OWNER Of ?
Gp00EqTY SNIOBU4D9 M I4PRT�E4 THEREON.M1D W110 DDES SlX]I WORK MA.ISELFOR HERSEIF Oq
•- Q iHR0U0MMISONMEROYMEMRO�'EE9,PROViDEDTHATSUd11MVqOVEM�JfT9MENOTMENOEDOR m
- Q ,OFFEPfDWHEALEIF,NOWEVEiITK_&JIDiNf70RNAGROVEMF71T13sOlDN�T1tlNONEVfAROFCd�AP1.E-
Z TION,TFIE ONMER�IM1.DER WILL H�VE TME BURDEN OF PqOVINO TMAT HE Ofi SHE D�NOT BUM1D OR
� IMPROVE FOR T1/E PURPOSE OF BIlE}
w O17�7'�WMEROFTNEVR07EHTl;IAIOIQUSNEIVWIYfR�CTNOYfITHUCENSEDCONiMCTORI
[L TOODNSTRUCTTHE PRO.IEM(SEC.7W,BUSiNE53 M1D PROFESSqNS CODE TME WNTIUCTORS U- V8IU8iI0f1 AOJ.AREA
LLJ GEN4EUWDOESWTMPLYTOIWOVA'EROFAOHOCER7YWHOBUIlD90RMPROVESTHEREON.IlNO
� N?qCOHfMCTSiORSUCJIVRO.tECiSVI,THACOYiMCTON(5)LICEHSEDPURSU�NTTOiHEmMfMP pUANTtTY DESCRiPT10N FEE
� lORSUCENSEUIW). }y�'- , I
O I I1.1 E%E�7i UNDFR 6EG B.t P.C,fOsi TN!S REASW U � f�VS S�lt O�nE 1
� �
LLZ- o�re ovmea V - .
o LICENSED CONTRACTORS DECLARATION -�
� w
�HEREBY�FflRYUAERPENKT/OFiER1UH1'TM+.TIAMLICENSEDUHDERPROVISlONSOFCHAPTER Vr
�(001.IMENCMN3 WITH SECTqN 700�)OF DM510N 7 0F TNE 8U5INE53 M'D 7FiOFE55�M'S CODE,AND Z
W LICENSE IS N ML iDfICE M.9 EFFECT. m � �rwti
� uc�secuss LS-1 ��c.r,o. 2��—�=ll$ � - .��
v o,�re�—17—q 9 cor+rrucroq M�Dp�►7c!a!!�'C_ a. ,
w /� ���
� WORKERS'COMPENSATIONDECLAW+TION �\/I�� Q � '� ( IJ:lJ -
N I NENEBYItFFIMA UNOEN PEN1ITV OF VERRIRI'ONE OF THE FOLLOW'N6 DECLAP4T 5: U C .�.•� R/�7
Z \Frl�1
Q
� _IFLNEIUVDW�L.LMAIHTAINACEiRiFlCATEOFCONSENTTOSELFaNSUREFORWOPoCER5 S ��r` �w�]'l,^�--^-^�r
� COMPENSMqN.ASPFIONDEDBYSECTKN17/000FTMELABONCOOE.�ORTMEDEFFOtNANCE W �UILDII�ll Y�'�'.,l.1��; �' 1 _
ocn+e woac Fon wH�nns vEar,m rs iswm. � -,
� _I HAVE IHD VALL MAMTAN NOi1KER4'C04PENSATION MSUMA`CE�A9 REOUIPEU BY SECTIOH
�7pp pFtHE LA9pq COpE,f'Oq THE DEAFORIIANCE OF TME WON%iOR WH1C11 T1115 PERMR IS
� ��SSUED.AIYWORKERS'CWVEN4ATK)yMSURM�CECARR�ERN+OPOIICTNUMOERME CONSTRUCTION �
> 'l
��Eq STA'�'E l=uND PLANREVIEW n ��,�.
o �(v' nun+aen z2��99 o��'Z � � ELECTAIC `
� ��;,�qy�rar�Q,.At�[ppcnfp[ss.�rswqo�Nrc�np7i,�nsMoo�oa� PWMBING
Z ICEHTiFYTMATNiHEiERFORMM7CEOFiHEWORKFOqWHICHiH15PERMRI515SUED,1 MECHANICAL
(�j SWLLL MOt ElA0.0Y ANY VEASON N AM'N�NNE(i 50115 TO BECOME SU3IELT 70 TNE -
� NORRERSCOMPENSATIONUI'/SOFCAL�FOqMA11NDAGREETFUT�F151qULOBECOME INSPECTIONFEE
S SUBIECTTONENtlA1:ER5C01ApCN5ATqN0 ''IOY FSECTION370DOFT UBOR ISSUANCE 9 - L
ppp��yiFll WqT}/MilICOMRY WI ..e VRON51 5
� SMIP
� `p DATE 9�I I�� APF'LIC • .
� ENERGY P!C
WARMNhFAiLURETOSECUREWORKEHSCOMPEN5A710NCOVEMGEIS r1UK ANDSMNIBE
� SUBJECfANEMROYENTOCNM7U�PFNtLT�E4/JdOCMlFN1ESU7TOONEM/NDREDTNOUSANO ENERGYPEHMIT '
OOlUR9(f 1m,00a�IN ADOITION TO iHE COST OF COMPENSATION,01�MAGE3 AS PROYDED FOfl IN
f,• ¢ SECTqN770lOf7HEL�80RCO0E�pE5T,ANDl1TTON.'EY'SFEE4. RETENTIONFEE: �
~d CONSTAUCTION LENDING AGENCY PR6ALT PEE:
' O
t�� INEREBYAiFlPAIUNDERPENALTVOFCEfWRYTHAThIFREISACON$TRUCTIONLEN�MGAGENLY
iOR TNE OERFONMM'CE Oi ME Y10RIC fOR WH�G1?M�4 PEPoA�T IS ISSUED�SEG�oY7.CIV.C.�.
Z
W
� �FNDEq'SNUAE
� lEN0ER5ADORE55
� ICERTIFYiHA71FUVERE/D7N�5M0.�CATIONANDSTATETN�TTIEABOVENFORMATIONISCORRECT. TOfAL FEES �
� I�GREETOCDMPLYN77N11LLCfiY/NDCOU'RV�AD�NANCESANDSTATEUWSREUTINUTOBUILDiNO L i V
CONSliM1JCT101�7.ANDMEREBYAUlF1�FQEREPRESENTA7NESOFTNISCIXINTYTOEMERU�ONTNE �a �� C
Z �BOVE�MEHTIONEOVROPEHiYFORINSiECT10NM1NGO5E5. COMMEMS - - -- - -
� J� � �
_
vcm+rttc6 r+�(��u�+il
�, � 9-1�-99 2y► 1 /
� OFPE rEE oaE RECPT,NO. � PAIDBY �'J VAUDATION
� WHITE—Department Copy,YELLOW—Finence Cop�PINK—As�esSa Copy.GOLDENROD—File Copy.GREEN—ApplManYs Copy
-
-�r .,"_...' mm _ `.` t7 i--�� n � ' � n ni m � m D m i o 0 0 o A o D m � � � � �
�-..�. '; fil� - .O.. O �.� I, D A cn m � Z � r r � O C C C O � O -� � p] O n � � �
� ��,a "D-1 � S f r r C- y U � fTl { Z r r � L� L� [�i �1 T 37 � L� Z � T7 D .�'
. � ..� . "O�C� � '0 n T Cl y� 'o C7 17 ➢ ,n Z I� RI 2 2 S (� Z (A � 7J .
.. �. .11� �� .. r r m C7 17 � -i � [n = � 'o frt 2 O �, 2 � � D � C� D � �? _
rJa �-i . Cil Tmbz '� r n zc rrm < mm
'!�R cy Z ` � '� cncmi� i- z zm u' � cm > rT' m � < � ' � ;
�J� . "' =�; z � -{ � � z --� � . � � � om $ � _+ �oZ = � � � v�
a cnT L � � C � z --im � -{ � m � Oin ��I
-_y,. �. -i N(D �' G G� n z -i � C,) rtl Z Ll �. � z m m c -i r�J �
' . � . � ; Ri N r.� � Q Z C/� � C7 :D G7� ' Z Z m '..,;��I
� �� . fn z "� _i G) � r . '.f . �,
� - p � � �
ffl-,l6 1,` Z — _ . . _
_�_��__.. �.,,__�.. ^I � ' y
� " �c� � � ' � �
W �'�� a-
� i `�' � C' � s''
:a l !���� ..
- � � I 2
- � -- ?' �- " s l
- - � � � ��� ` � � � - �
�-� ` I z � ._
. _Q �
(' 111 m o -
i — n 'Ti
m o � � � o � � o O � v v �„ � m -o � m � �n ,� c c -n � � -� �
� - . .,y� m m 7� z Z Z m T O O O Z O m 7� Z A � Z z = � 0 .
=q� Cil C D m p j Z q O �1 O O O C Z m D � � frl fft-Q O D O ' �I D
37 � r � r (n r r r v' � n r T -p v m m � O �' �'S�
� . C - ;;:� � m = � O m n � � m Z m � G) = z j p � � D D -Dr� � p � ��� ?7 Q 'e
:� , •.i� cn � -{ _ ; � L� O � r�- n n D � L� Ci � � Z m m p p � � �l',�1 �I Z
� v -n � � � ' Z -a -i pa z oo m � 0 0 m -i ,ul n 0
1 ` s.� y � z � °7 9 mcn Z � � � mD � oo �o � F��; p �
h • _ " � -� � � � c� Gzi � r � m Z l c� o _ m i �
L�i n L� � . T_p� p p � - :�� 0 �
_ r ,m � o � �`^:
�. ' ?�'•j _� O � 'i
! Z 1
I , - __
i •
i?' - " i�
f i ��I i i��w .
.zr.,,
., I _ - �t�
; "` � - -- : - - 1
.,' I 1 _ t I _ I
j� - r� I - T' .
� { .�� �
� �°:
'� �{` I �' ' � �t �i
I ' I � ' l I I � ���
-+ ; ! � ( .f I __.