HomeMy WebLinkAbout12-1852 �� __ CITY OF DIAMOND BAR
� DEPARTMENT OF COMMUIVITY&DEVELOPMENT SERVICES �
. 21810 Copley Drive,Diamond Bar,CA 91765
(909)839-7020 Fax(909)861-3117 Building Inspection 13otline(909)839-7027 PRESS
'�"'. BUILDING PERMIT APPLICATION FIRMLY
¢ DDRESS 'r.�' �� G hQC W�i y�(;�QQ 1e �O APPLICATION `+ PERMIT i•7 ,��(�5� p/C
o DATE � ��O I I 7- NUMBER�L #
`r APN LOT TRACT DATE � i Zr TMPE �CC
p OWNER �Je O���eC CONST._� GROUP
� � ADDRESS �I� C�nwC M�r� 4 e ZONING SETBACKS
Z C�TY Dio.►Ma,nt� �70.� ZIP al1bS TEL�15-yI�3''Ilo�� FRONT qyy �
� APPLICANT GaC�o.S Go.S��1Ia TEL.a\�5'45�-�+�1"1`d REAR p
Qo � SIDE/SIDE STREET RW ❑
� CONTRACTOR Cl�^ rc��� C�M9 ��^�.' SIDE p
ADDRESS v� \ � O �^.
� CITY I...ds ZIP 00 TEL���'aa ���I� PROPOSEDUSE �e'"COO��� Wl"'�� Ca (e+e �-ea�-6 ,
w ARCH/ENG/ � ir�� ne�J C�'� e y'WOC� Jr �c`,J�O•
z DESIGNER ��`�^�,� � �Y'�ni.���G"�' G�'� ��'L'a,fe�
w NO.DWEL. NO. NO.-(�-
a ADDRESS
cn UNITS ` STORIES a BEDROOMS
, � CITY ZIP TEL.
�
� DESCAIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
p� OWNER-BUILDER DECLARATION SFR/ADO/REM
O
p 1 HEREBY AFFIRM UNDER PENALiY OF PERIURY THAT I AIA E%EMPT FROM 7HE CONTRACTORS LI- G0fa90/CefPOR
W CENSEUWFORhIEFOILOWINOREASON(SEC.7a77.5BUSINESSAND7ROFE5510N5CO0E:ANYCfTYOR (n
U LOUNNNTiICHREWIRESAPERMI7TOCONSTRUCT,ALTEROdPROVE.OEMOLISH,ORREPAIRANY57RUG
w TURE.PRIOR TO RS ISSUANCE,ALSO REOUIRES THE APPLICANf FOR SUCH PEFMIT TO Fl�E A SIGNED W Patio/Deck
� STATENENT 7HAT HE OR SHE IS LICENSED VURSUANT TO THE PROYISIONS OF 7HE CONTMCTORS LL
� CENSE LAW(CNAPTER Y(COMMENCING MAhi SECTION 7000)OF DIVISION 7 OF THE BUSINESS AND PRO- � POOVSP3
� fESSpNSCOO�ORiHATHEORSHEISEXEMPT7HEREFROMANDTHEBA515FON7HEALLEGEDEXEMP- C7
V TION.ANYVIOUTIONOFSECTION7031.59YANYAPPLICANTFORAPERMITSUBJECTSTHEAVPLICANTTO Z RaRoaf a�OD
A CMLVENALTY OF NOT MOFE THAN FIVE HUNDRED DOLLARS(i5oo).):
Q ❑I,ASOWNEROFTHE7ROPERTY,OPMYEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, � COrtIf110fCi81
Z VALL 00 THE WORKµD THE STRUCTURE IS NOT INTENDED OR OFFEREO FOR SALE(SEC.70a4,BU51- J
� NESS ANO PHOFESSIONS CODE:THE CON7RACTORS ItCENSE UW DOES NOT AVPLY TO AN OWNER OF �
— PROPERiYWl1OBUILOSOfi1MPROVESTHEREON,ANONMODOESSUCHWORKHIMSELFORHEFSELFOR
Q THROUGHHISORHEROWNEMVIOVEES,PROVIDEDTHATSUCHIMPROVEMEMSARENOTINTENDEDOR m
� OFFEREDPDRSPLEIF,FiOWEVEqTHEBUIIDINGORIMPROVEMEMU^SOLDWfTHINONEYEAROFCOM7LE-
Z TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF FROVING THA7 HE OR SHE DID NOT BUILD OR
� IMPROVE FOR THE PURPOSE OF SALE}
w ❑I,ASOWNEROF7HEPROPEHT`/,AME%CLUSNELYCAN7RACTW6WfTT1UCENSEDCOHTRACTORS
� TO CONSTRUCT THE PRQIECT(SEC.70N,BUSINE55 AND PROFESSIONS CODE:THE COMMC70R5 LI- V81Udl1011 ADJ.AREA
W CENSE UW DOES NO7MVLY 70AN OWNER OFA PHOPERTV WHO BUILDS OR IMPROVES hIEREON,ANO
� WHOCOMRACTSFORSUCHVRQIECTSWlTHACONTMCTOR(S)LICENSEDPURSUANTTOhiECONTMG OUANTITY DESCRIPl10N FEE -
TORS LICENSE UW.).
� ❑I AM E%EMPT UNDER SEC. B.!V.C.FOR THIS REASON Q
7� U
� DATE OWtJEA F
Z U
� LICENSED CONTRACTORS DECLARATION W
� I HEREBY AFFlRM UNDER PENALTY OF�ERNRV THAT I AM LICENSED UNDER PROVISbNS OF CNAPTEH �
d Y(COMMFNCW(i WfT}I SECfION 7000)OF DIVI510N 30F h1E BU51NE5S AND PROFESSIONS CODE,M1D Z
�X 1/Y LICENSE IS W FULL FORCE AND EFFECT. m
� UCENSE CUSS ��� LIC.NO._D,��"""� j
V DATE CONTRACTOR d
W
� WORKERS'COMPENSATION DECLARATION a � �
� 1 HEREBV AFfIRM UNDER PENAL7Y OF VERJUM ONE OF TiE FOLLOW WG OECIAqATIONS: Z
Q
� _I MAVE AND WILL M/JNTNN A CERTIFiCATE OF CONSENT TO SELF-INSURE FOR WORKERS =
� COMPENSATION,AS VROVIDED BY SECTON J7oo OF 7HE UBOR CODE,FOR 7HE PERFORMANCE W
Q OF THE WORK iOR NM1iICN 7HI5 PERMIT IS ISSUED. � -
w � 1 HAVE AND WILL MAIMAIN WORNERS'COMPENSA710N INSUMNCE,AS REOt11HED BY SECTION
� Q �70o OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK iOR WHItl1 iH15 PERMR IS '��.D
• ¢ �`
ISSUED.MY WORNERS'COMPENSATION INSURANCE CARRIERAND POLICY NUMBERARE: CONSTRUCTION
� CAFRIER QA�L G�CF PLAN REVIEW
0 VOLICY NUMBER
Z ELECTRIC
¢
� (fHISSECTICNNFIDNOTBENNPLEfIDOFhEPFAAff6FOqOrIEMR�R�Op1AiL5�5100)ORLE551 PLUMBING
W
Z I CERiIFY THAT IN THE PEiiFORMANCE OF 7HE WORK FOR WHICH THIS VERMIT IS LSSUED.1 MECHANICAL �
C,�J SHALL NOT EMPLOV ANY PERSON IN ANY MANNER 50 AS TO BECOME SUBJECT TO TiE
� WORKERS'CAMPENSATION UWS OF CAUFORN10..4ND AGREE THAT IF I SHOuID BECA e INSPECTION FEE �
� SU&IECT TO TNE WOHKERS'COM➢ENSATION PROVIS OF SECTION 9700 Of T � �
f.ODE.I S LL 50frIHWITN COMPLY WITH THO PROVI N5. � ISSUANCE
p DATE�� APPLICANT�� -SMIP �,.•��
J WARNIN6:FAIWRE TO SECURE WORKERS'CAMPENSATION COVERAGE IS UNUWFUL,AND SHALL BE ENERGY P/C
� SU&IECTAN EMPLOYER TO CHIMINAL PENALTIES AND CIVIL FINES UP TOONE HUN�HED T10USAND ENERGY PERMIT
DOLLARS(S10o.000),IN ADDI710N TO7HE COuT OF COMPENSATION,DMAAGES AS PROVIDED FOH IN
J SECTION]7oe OF 7HE LABOR CODE,IMEREST.ANO ATTORNEI"5 FEES. �
[C RETENTION FEE:
OCONSTRUCTION LENDING AGENCY � PRE-ALT FEE:
� I HEqEBY AFFIRM UNDER PENALTY OF PERIURY THAT THERE IS A LONSTRUC710N LENOWO AGENCY
a- FOR THE PERFORMANCE OF 7HE WORK FOR WHICH 7HIS PERMIT IS ISSUEO(SEC.30W,CIV,C.�.
W �
� LENDER'S NM1E �.
F— LENDER'SAODRESS ) �
w ICERTIFYiHATIHMEREADTHISAPPLICATIONANDSTATETUTh1EABOVEINFORMAT10NI5CORRECT. TOTALFEES ZD�•�7
� I AGREE TO COMPIY VATH ALL CITV M!D CAUNiV ORDINANCES AND STATE LAWS REU71N6 TO BUILDING
� CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATNES OF hIIS COUNiY TO ENTER UPON iHE
Z ABOVE-MEMIONED PROPERiY FOR INSPECTION VURPOSES.
o G0.C`Oc �Qb�l 1'� COMMENTS
J �
� J
PERM E NAM RINf)
� �11� I ��
Uj SIGNANRE OF PERMITTEE DATE
= RECPT.NO. � PAID BY VALIDATION
~ WHITE--Department Copy,YELLOW—Fnance Copy,PINK—Assessor Copy,GOLDENflOD—Flle Copy,GREEN—Appticant's Copy
�:3a�'e �� ���6�ta�;�� ��`'��
��:i��"�.��V���'�9 ���i.�6��R�F
�.�; ..-..
a ,".;�`,�='�o` "� ' -"".�.`,',���r# "rk�J,i�cR''F�'^'c�f�� �.'��� .��.,;� R z--�..t�-rr`5�—�±.. _�'�.t�`r.:^�a� �.'�;�.;..'C".,F�--�.� �"�Tj �` ._"e�"—�'�'�-aF
��`�'',�,�'��A l�1 �.., ,R. _ R�'t.!�'k�':n ��� �� ����'e�?.. .. .�Y�ar��`~ � �1J rs km T�'7E��x:����fi�f'`-w{U�fli�4�f'L,F.�-r��� ��a�r5�o � '�. q q ' m ,�,r r
.i,�s`N3-�`;����� _ z�� �� . "� '� "t��r.a,r-= �� a .-es. 'L. � .-f`+,its;�'a� � �,� 1 � ���l��-�:'°�'��--, :� `�.`.
�#�.::s_.. ,. .• _L.S:c`i'3,...: . �y: 'i ,s:� ��.c.��sar�'-.,�. .Kru°.,��.,}�ct'�:���:.'.._ � ^;�.--�LL.;�-t' ��� �i3:_:�.� y v,t':.,..
ET Br�CI' ___�__. �._ I r-LOOR 1GIS i _. - -
_ --- - - _._ ____ _ __ _. __. ----- __ __.�---- ------- --- -- ---
FTGS'`ORvtS/�fEEL ---. i ....___ ---�- ---- ----- ------ LI�HP REQ�vlTS '
---__------ --- �---— _.__.__. — -I- -- - -----1 ------------...------------.
�LFCI=RIC GROUND � ; i j UNDER FLOOR DUCl� j I
— ------,__._------;-------------i --------------------
GROUPdD FWi�1BING � � j �NDER FLOQR CONC�UiT �i �
--- ---------;------! --------� �- ----� ----I
SLAB uPADE i � J fIRFPLACE FUl!P,!DATIO�! ' '
-------------------...-------- ------------ ---- -------I-- — -
TEN1P POUVER � r I------------
'-------- I i FIREPLACE Ei(�JND BFAte%1 �---I_
--�----- __—. _ C
WATER SERVICE � � �;v11D HT.BOfdD f3EANi
_�-1-. -- —
ROOF SHEATHI�dG __1_1l .�] 3�— —� I$FT.BOND BEANi
FRAMING!VEMTILATIO�! i I �FINAL B�PJD E�ANI
----------------_.—..--- --------�------------------- �---------_-------------.._.------------
ROOF COVER � I --- -------------
PRE-GRADII�IG
-..------------------------'....--_------�------------------------ ------- --------....--------------.—_ _--------------------------
ROUGH HEATING � I I DENCH�hJG
------------- �----._—-- ------ — ' - -------- ---- --------
ROUGH ELECTRIC � I I ROUGH GRADING
ROUGI-I PLUM6ING _�_�— j FINISH GRADING
SHOV�/ER/TUD TEST ___ j _ I POOL ELECTRIC
EX7.LATH;SIDING , ; ;POOL FENCINv
bVALI INSULATIOM � I I POOL FINAL
CEIUPJG IPlSULATION � ! � I OFF SITE Ih�iPS.
DRYbVA!l_NAILING � DEDICA.TIONS
--------------------------------- ------------------ ----- � - -------- --------------------------
-
SEWER �FINAL CNG----- -------------
_..--------------------�----------�------------- �--------------
SEPTICTANK _ _{ LANDSCAPE/IRRIG. __ _
—�.----
SEEP PITiL.L. � � ON SITE IMPS.
GAS AIR T[ST -- � _ FIPJAL ZOPJING
FINAL�ONST. �i, \'L. i FIRE DEPT.FINAL � . .-.-
FINAL HEATING i rHE�,LTH DEPT.FINAL
FWf\L ELECTRIC � ;DEV.FEES PAID
FINAL PLUNiBING _ _� I ENERGY
FIIVAL PLANING �
- �---- ----- ------ --------------- -----
FIN�1L ENGINEERING----- - ------ -- i _9"`�._� .� ::.,,_ ��_,� .
� ,_ .
-------- ---�------� --- ----- -------- - ' u",.�,- = ------- ------------ --
COMMENTS _ _ ___ __________
---- --- — _-- -- ---- -
--
' ---- —.-----------1-1-- �--Z---�� --------------
—-------- ---------
SEPTICTANKSIZE
SEEP PIT/U SIZE ----- - -- ----------�--- -- --------------
's`� " -�'- --- — ------- -- --------
_��
�� �� �: - -------- ------
f ���`-� " �;.- ��'-: — ----- ---- ------ ----- --�--
� � �
- �
;�;_ � . --:
' sr "- .�...�i�„ � .
.'•'��'jy'' ...� � ^ �
. -.`. - --�------------------'---
.':� - ' -----' �---�--------'------ -'---------
- � -
,_
�=' . � - �� �------------------------------ ----
� - - _ '-- --------------------
��'� :� . - -- -----------------�------- — ------- -- --
- � �'-- --�'��
. . .4
, . �
, �� C v.
. ... .,�,- '�
. .
Attac,.hment A
Form for Non-Franchise Hae�lers for Construction and Demolition Debris
Company and Project Info:
Name of licensed demolition conttactor hauler or self hauling company Ad�G�c;e c� Roo�����s�e w�s���'
Address of Company 331� (rlc�c�a�e �1 �'2a`'6 City L� '
Zip Code �OO`�°y Fhone Number 3�3"aa�'��� �
Address and Name of Project Site
OaJ2 O1,J 2�
'�.��b ��QINn��Ap�CL�� �6
Type of recycleable material or waste material to be transported for this project
Report Information:
Please submit this information prior to final buiIding inspection.
A report reflecting the following infarmatian:
• The estimated volume or weight of construction and demolition debris,listed for each
material; �
� The estimated volume or weight of construction and demolition debris that can be
diverted listed for each material;
� The estimated volume or weight of consti-uction and demolition debris that will be
landfilled as waste; and � •
� Identification of the vendor or facility that will collect or receive the construction or
demolition debris.
AB 939 Fee Payment: �
- Pay AB939 fee of$12.00 per bin and$50 per roll off for all non-franchise hauler containers
Type of Container number of container
Paid date(office use only) (revenue code CD Waste)
Agreement and Signature:
The property owner agrees to submit documentation to demonstrate compliance with the 50%diversion
requirement for construction debris and shall indemnify and hold harn�less the Ciiy for damage and
liability, including any financial liability, fines and penalties, associated v✓ith using a non-City
franchised hauler and failing to satisfy diversion requirements.
Property Owner Signatur Print Name Date
G�� Cac1�s Ca�-'��k� �� I�I � � �
Self Hauler Signature Print Name Date '
Last updated June 26,2008