HomeMy WebLinkAbout12322 �� CITY OF DIAMOND BAR ^
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES ,+,
� 21660 E.Copley Drive Suite 190 ��
(909)860-3195 Fax(909)861-3117 PRESS
����'� BUII,DING PERMIT APPLICATION FIRML.Y
o ADDRESS�LO ! �!7 /11C�JON�Y DA�CATION q, � � NUMBER ��vtt�
c� ISSUE TYPE OCC
APN LOT TRACT � DATE CONST. GROUP
p OWNE�
" ADDRESS � � C ZONING SETBACKS
Z CITY 1��- ZIP � TEL REAR � ❑
g APPLICANT TE� SIDE/SIDESTREET RW ❑
� CONTRACT G O T' SIDE ❑
� ADDRESS PROPOSED USE l
� CITY - ZIP TEL D -
ARCWENG/
DESIGNER NO.DWEL NO. NO.
ADDRESS UNITS STORIES BEDROaMS
� C17Y ZIP TEL
uNi DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
� OWNER-BUILDER D�CLARATION SFWADDIREM
O -
p I HEREBY ItFFlR4 UNDER PEN�LTY OF VEFLIUltY THAT 1 M1 E%EMPT FROM THE CONTRACTORS LF GaragelCarport
LU CENSEUWFORTNEidlOwM(iREA50N(SEG7071.SBUSME53M107NOFESSIONSOOOEAN'/GTYOR (n
�.) COIMTYNtiIdiREWIRE9APEHt�IRTOCONSTNUCT,KTER�PR�VEDE1A0U5M.WiREPlURANYS7AUG W
�Z TURE VPoOR TO IT!RSU�NCE.ALSO PEOU�RES 7HE ADPUCINT FON Sl)pl VEMAR TO FlLE A SIdNED W PdtiO/D9Ck
STATEYEM 1HAT ME Oq SHE IS LICENSED PURSUMfT TO TNE PiqVI5�ON50F iME WNfMCfORS LF
� CENSEUW(CHAPTENO(C01.11lENCR10N1TiSECTON7000JOFDM5ION)OFiHEBV5tNE55ANDORO� � PooVSpa
FESSqt19 COOE10f1 TT41T HE OH SHE IS IXE1�PT 7MENEFROA/AND 7ME BA519 FORTME/�LLFOEO E%EA1P•
TION.N7YVIOLATIONOFSECTIOHTWt.6BYN�VAPPLIGNfFORAPEF9A1TSUeJECT57NEMP�ICufTTO Z Ro-Roof
� � AQVIL PENtiLT OF NOT MOFlE THN/i1VE 1MARE9 DOlUA5ltsaol.g .
� ❑1�30MMF1iOFTHEPf10PERTY,ORE�YEMPLOYEE5WITNWACESASiHEINSOIELOIAPENSATION, � CpmmBlClal '
WR�p0 iHE YAFlI(A!A THE STRl1Cil1RE�5 NOT MEPAED OR OFfERED PoH SILE(SEG TMt,BUSF J
N MESS AND FROFESSIONS CODE:THE COHTMCTORS LICENSE UW DOES NOT AVPIY TO MI OYmER OF ? �
7ROCEiffY 1M/D 8U1D4 OR IIIONOYES iHEREON.MA Wlq DOES SUC11 WORK HIMSELf OR NERSELF OR
� � iHA0l10H ie5 OII HEH OMM EMPLOYEES.PROVIDEO Tui SllGI MPROVEMQRS ARE NOT MENDEOOR m
OFKEPm PDR SALEIF,110M�EVER iME BULdNQOR MPROVEIAIXT IS SOLO WITMNONEYEAROFCOM0.E
� TION.ME OMiNEH�6UlDER WKL IUVE TME BURDEN OF PROVWO 1H�T HE OR SHE�m NOT BUttD OR
MPnWE iaR iME RJRPOSE OF SJJ.EI.
O 4 N�MMER OFT/1E VROPEHf'I.W EXCLUSNELY COMMCTNO WR11 LICENSED COHTMCTORS
� TO tONSTAUCT TiE PNOJECT(SEG tOt/.BUSINES4MA PROFESSIONS OODE 1HE CONTRACTOR9 L4 V91t19fW�1 ADJ.AREA -
W CEHSEUWDOESNOTIIPPLYT011N0'/1NEflOFAPROPERiYWMOBV4DSORM�R0YE5T1EREON,ANO
� wwcartrucrsronsra�ono�erswini�eartiucTonfs>i�r+seeauAswwrmnaEoxrrw�c. OVANTITY OESCPoPTION FEE
� TOR9t1CkN5EUW.�. ' J . .
O 1/JJ El(EL7T UNDER SEG 8.t P.0 FOR 7HI5 REASON Q
U
l� ¢
�ATE oWNEq V
� J
UCENSEO CONTRACTORS DECUAATION W
4d �r�uer�aa um�aer+xn oF rEnuAr n��r�w��c�r+seo urmen oaowsar+s ov cwwr[a � _. . ,,
d •(OOLIMEXCNOYrtIH5ECT10N7000�OiDM4iONlOF7MEBU51NE55ANDVROFE55i0NSCO0E�ND Z -
X YY IICETISE IS N FVLL FORCE MA EFF[CT. J1
� ��E«�s G— � �.�. 6 936 � �
�
� o�ts �—/ — corrrrucroa d 00 a
� WORKERS'COMPENSATION DECLARATION �
� 1 NEREPY/�FFlRM UNDER PENnLTY OF FERAIRY ONE OF iNE FOLLOwNa DECU�UTIDNS: . U
N Q
O �IlUVEANDWKLM���NACERTIFlCATEOFCONSEHi705ELFINSUREFORNVRRERS S
� COUPENSATION,ASPiIOVIDEDBY5ECT70NJ70oOFT1ElABOfICODEiOHtHEPERFOqMANCE �U
OF TIE WOAK FOH wMd1 MR PERRIIT IS ISSUED. �
� ��HAyE�WpWRLMAR7T11d1N'OPo(ERSCOMPENSATICN7MSURANCE,ASREWIREpBY5ECT10N
4� ]7ooOf THE LABOR ODOE FOqTME PERCORMNlCE OF iHEwOFK FOR YYHICH 7H14 PERMR 14
asuEo,uy w��cE��vcxs�T70N INSUiUNCE CARFIEA AND GOIICY NUMBER ARE CONSTRUCTION
� GWRIER �.. (:emP - P�w Ae,n�v
o� Paicr MneeEn `3'7�! �/�D')� ELE /'� y�
Q fM1i55ECTONtE�N0T�0U�lE1IDOFTVEPE1MTSiORaEM�F�001UR5�ftao�CAIFSS} PLUM IN IIJ� V
Z ICENTIFYTUTNiHEPERFORuhNCEOF7HEYVOHKFORWM�ditMSPERAttTi5155VE�,I NICAL
(,�} 9uLL1 NOT EMPLOV N1Y PER50N N N1Y A1FMIER SO AS TO BECOME SUB.IECT TO 7ME
N WOfp(ERSCOMPENSATION UwS Of GLLiFOfwihµD�GREE TUT IF I SNOUIOBECOME �N ON FEE
S SIAJECTTOTIENOFtl(ER5CO�.�PENSATIONPROVISiON50FSECT10N77000FTHEUBOq
�ooEisru�.coan+vnn�couvirvnn� PAo�ns 119. ISSUANC Z, �
O � yL�
p DATE:�dAPPLICANf: � � � ,
� WANNttK1:FAILURETOSECURE�'1�F1KER3�COMFENSATqNCOVEMGEISVNUwFUL.MAS'ULLBE ENEFiGYP/C
� $UBJECTANEMP�OYERTOCAIMM/LL�ENALTIESMIDCMlF1NE5U0TOpNE11lXJDRE01}IOUSAND EryERGYPERMIT - --
DOl1AR5(f10�.000�,M/�DDITIONTOIHECOSTOFCOMVEN4ATpN.DAMAdE5A5PROVWEDFORM .'_—_- _"-'---'_—___. _ . ...._____'___'__'__ _
J SECT�ON»oeOFtMEU80RC�DE,MTEREST,lVlOATTORNEYSFEES. q�NT10NFEE:
LC
p� CONSTRUCTION LENDING AGENCY pkE•ALT FEE:
� IHEREBYAFFlRAIUNDERPEN/�LTYOFPERNHM1NnTTHEREISACONSTRUC710NLENOMOAGENCY
FOfl TNE iERFORMINCE OF TNE WON1f FOH WNICN THi4 7ERIAIT IS ISSVED(SEG]097,pV.Q�.
�
� IElAER3 NAME �
F— IENDER'SADDRESS
� ICEqT�FYi1uTIHAVEREPDTHISAPPL�LATIONNASi�iET1UTMEA80VEINFO(WI1TqNI5CORRECL TOTAL FEES �`
� I��REE TO COMVLY WfTH N.l UTY/J7D COIRlTY ORD�NhNCES/JJD STATE U�`�5 REI.ATNO TO BVILDINO
CONSTPUCTIdJ.AND HEREB`/AUTiIOPoZE REPRESENTATIVE$OF THIS CQMit TO ENfER UPON iME .
� �BpYH,1EMpNEDFROVERIYFORINSPECTqNPUAPOSES. COMMENTS
`�-� �_ /Ld,�
m VE{MTTEE IPRINn/� � ' / /
fn In�I/!� !1 1 . 1 h � � � / �
y SqNA FEOFGEFwRTEE DATE
RFCPT NO. PAlD BY VALI�ATION
� WNITE—Department Copy,YELLOW—Finence Go[ry,PINK—Aasessa CoOy.GOLDENROD--Fib Copy,GREEN—ApplicanYs Copy
'� �'� I i (7 T TT � � m � � vn � m � � � � � � � � � m � m �
m m � Z Z Z n m m m � m y 2 p o O o � O a m 7� m � �
R7��"0 �� i ' � . _� D D y D (� m � � � r_ r � O C C C O D O -{ � � �
�-_i - � � .' r; r' r r- y 'O _i Rl Z f- 2 L7 G) fil 'il �� 'il ff1 'L7 � C n � � ��
-ac� � , �: vms � � vc» a � Z � mxxx � z �n � � c� z � -T, a
; �-I � _ , fTl � -•, c' m � � -i � y r Z c � � � � m O� G� m m � D a C� � � , '
r ..i'� C z -- ' Z �� _ � � _� � vmi i- Z Z cn m � c m y m m a 3l m o � G) � •
�,�.�Cn T� : —{. Z � � -i -{ • T. � C(- � p !p �.� -I 3J Z = � ]J m C 31 Cn 'r.
I;m� ; � � '� � z � Z ,� N Z � +� - r � m ' W Z m , � .
rv G� o � y ; z m
m z � -+ __ � or ..
� o
A1
z
� -_ � �. ^- o
- �. '.= � , -
� j _ � - - ;
_ - -_- - � .
; _ , _ � � � :
� ' - � m o
n �
_ - �,, 9zz zm -nooOz � cov -nm � -n -n c c � � O O
m ox � 'n0 "� v0 � 'o � '�
m � a z O m � Z p m m o o D O � _
mn � ao "'� 000 czmD � Z
. _ . ._ '• �° -n -ri � r- =t cOn r n tn r r r = � c� � r � 2�-n v m m � . � .
'n Rl 2 frl N rtl D � '?7 T rtl 2 2 � ;-i r 7] 7J m �7 �
� �.�:�� -G m � � p m y Z � m z m r � � Z D O � W D � -n �t 1J � :U Q
�.-.� fn � Z Z �rt C� C� r r O
m � vG� o � rA- c� C> � � � gzoOmm � � � ,m ,�
� m � 'D T Z � � . z 'Ll "� O D Z � W Z m T O O C�ll `-I , " � �0 .
1- �. o � a � r�, � �' a, . � � zz �' ma � oo �o � O' m
Z � . � � � � � nvZQa , � �p D
_ � � � D � � - �, �i
D 1 � �
� p C
Z '� �
` , , � '., .. ..
i
/
. . .` I ' �; {� .-
_� i
� i
•
. _ _ _.. . . ... . _.'. __. .. . ... __. ... .� .. _ _ � � �
� , ., ., ._.. - -� _. _. . . . _ _�._._ �__ • _ �