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HomeMy WebLinkAbout17972 (19) �� CITY OF DIAMOND BAR � DEPARTMENT OF COIvIIvIUNITY&DEVELOPMENT SERVICES 21625 E.Copley Drive (909)860-3195 Fax(909)861-3117 PRESS �"%�«� BUILDING PERMIT APPLICATION FI R M LY o ADDRESS I���CHY�- �I V�G I �./� DATE CATION S-S-OJ_ NUMB R�� p'C � $ ISSUE TYPE OCC APN� LOT RACT DATE CONST. GROUP p OWNER _ � � .7 "' ADDRESS �- C � ZONING SEiBACKS c gCITY 4 b '. — ZIP TEL._����� L)'jJ��" REAR Rw p APPLICANT TEL. SIDE/SIDE STREET RW ❑ � CONTRACTOR�'�SC�/ �7.L��1R.( � . SIDE ❑ � ADDRESS �71EL1 !-Ilr�i� �� � ^ ���" p ,r _ � PROPOSED USE � UPG!4Wt TD L/1�1`T cin C�P�.r�s GA- ziP� TEL�i2- S —�I P �-41.�._ o ARCH/ENG/ � . C~ DESIGNER izii NO.DWEL NO. NO. n. ADDRESS � CITY ZIP TEL. UNITS STORIES BEDROOMS � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADD/REM O p 1 NEREBY AFFlRM UNOE0.PENALiY OF DERRIRV h1AT I AM E%EMM FROM THE CONTMCTORS LF Garage/Carport W CENSEUWFORTMEFOLLOwINOREA50N(SEG7091.6BUSINESSANUPROFESSIONSCODEANYCITYOR (n U COUNTYWHICHREOUIRESAPERAIRTOCONSTRUCT,QTERIMPROVE,DEMOLISH.ORREPAIRANYSiRUG W P01i0/D6Ck � TURE.PRqR TO ITS ISSUMICE.ALSO REW IRES THE APPIICANT FOR SUdi PERMIi TO FILE A S16NE� W � STATE4EM THAT HE OR SHE 15 UCENSEO PU1YSUu1T TD THE DNOViStONS OF 7HE CONTRACTORS ll- CENSE UW(CHMTER 0(COMMENCIN�VnTH SEC7ION 7000)OF OMSION�OF THE BUSINESS AND PRO- � POOUSpB � FESSIDNSCODE)OR7H�THEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTNEI1lLEGEDE%EMP- (� TqN.ANYV10UTqNOFSECTION70��.S8YANVAPPLICAh1TFORAiERMIiSVBJECT3TFIEAPPLICANTTO Z Re•Root A CML PENALTY OF NOT MORE TMAN i1VE MUNDRED DOLLARS�f5o0).): � 04�OWNEROF7HEVROPERTY,ORMYEMPIOYEE5KITNWAGESASTHEIR50LECOAIPENSATqN, 0 CpTmBfCi.31 Z WIIL DO THE WORK AND THE STRUCTURE IS NOT INTENDEO OR OFFERED iOR SALE 15EC.70��.BU51- J N NESS AND PROFESSIONS CODE:THE CANTMCTORS LICENSE UW DOES NOT APPLV TO AN OWNER OF ? PROPEHiY WIiO BUILDS OR M7ROVE5 TNEREON.AN�Mn10 OOES SUCH WOFK MIuSEIF OR HERSEIi OR Q TXROUGHMSOi1HEqONMEA�PIOYEES,OROVIDEDTIUTSUCHIMVROVEMENTSMENOTNTENDEDOR m � OFFFREDFORSALE.F,FIOWEVERTMEBUILDINOORIMPROVEMEMISSdDWRMNONEYEAROFCOMPLE- Z TqN.THE GtttJEH-BUILDER YALL HAYE ME BUiiDEN OF PROVW6 THA7 HE OR SME OID NOT BURD OR = WPROVEFORTMEPURPOSEOFSA�EI. w ❑4ASONMEROFTMEPROPEflTY,AMEXCLU51VElYCONTRACTN6WRHULENSE�CONTRACTOFiS � TO CONSTRUCf T1E PRQIECT(SEG 7a�I,BUSINESS AND PROFESSIONS CODE:THE CONTMCTORS ll- Ve�U0li0f1 ADJ.AREA W CENSEUWDDESNOTMPLYTOANOWNEROFAGROVEHiYWHOBVILD50RIMPROYESTHEREON,AND F WFiOCONfMCTSFOHSUCHVROJECTSWI7HACONTMCTOR�S)LICENSEDPURSUMIfTOTHECONTMG OUANTIN DESCRIPTION �E � T00.5 LICENSE LAW). �i p O IAM D(EMPT UNDER SEC. B.i P.Q fOR THIS REASON Q D � U li.. � DATE OWNEF V z W � I LICENSED CONTFiACTORS DECLARATION W � �HEREBY�FfIRMUNDERPENALTYOFPE0.IUMTNATIAMLICENSEDUNOERPROVI510NSOFCHAPTER V, p., 9�COMAIENp1MWITH5ECT10N70ooJOFDM510N�OFTHEBUSINE55ANDPROFESSIONSC00E.AND Z MY LICENSE IS W NLL FORCE AND EFFECT, m � C�w ���.No. G�d'�� 3 = � uccNsecuss - v on� 'i-b'^G�2 -- conTrucToa t-"7��Lf�-i�l G a _ w - � WORKERS'COMPENSATION DECLARATION a � IHEREFnGAFFIRMUNDERPENAITYOFYERJURYONEOFTHEFOLLOW:NGOECUMTqNS: Z / � � IHAVEANDW41MAiNTNNACERTIFICATEOFCANSENTTOSELF•INSUREFONWOfiCERS' S � COMPENSATqN,AS PROV10ED BY SECTION 7)OOOF THE LA[iOR CODE,FOR THE VERFORMANCE w /�OF TNE WORK FOR WHICH THIS 7ERMIT�S ISSUEO. � � v I HAVE AN�MALL NAINTAIN WORKERS'COMPENSATION INSt1RANCE,AS REOUIRED BY SECTION � Q �7000F THE UBOR CODE,FOR TNE PERFORMANCE OF 7NE WORK FOR WNICH THIS VERMIT 15 ISSUED.MYWORKERS'COMPENSATKKJrIN,S�UR,A,NC�ECARRIERANDPoLICYNUMOERARE: CONSTRUCTION j GANfUEN ��`� "�����''rl`� PLAN REVIEW � oa�errruMeea S� U.i 1� dO ELECTRIC v � (IHSSECiKYaNEmNOTBE�.W.ETmOFTE7ERA1T6iLRONE141�DREDOd1I�IftODJORLESS). PLUMBING _-- ��� 1 r 1 I �11 Z ICERTIFYTHATINTHEVERFORMRNCEOFTMEWORKFORWMIp17M15GERMITI51551/ED.I MECHANICAL U' SHALLNO7EMPLOYANYPE(t50NINANYMJWNER50A5TOBECOMESUBJECTT0T11E N WORNERS'COMPENSATpNtAW50FGLLIFOR , ACREETHATIFISMOULDBECOME INSPECTIONFEE S SU6IECTTOTHEY:ORNERS'COIAPENSATION NSOFSECTqN OFTHEUBOR cooE.�sw�uFoar�n�couv�vx�nrr E sbr+s. ISSUANCE � � C �S�'C Zr AVPLICANT: SMIP � p DATE:,J V W ( ENERGY P/C � WARNIN6:FAILURETOSEGUREWORKE 7L'4i�T N MGEISUNUWFUL.ANDSHALLBE � SUBJECTAN EIAPLOYER TO CRIMINAL NAlTIESANDT.IVIL FINES 117 TOONE HUNORED THIXISAND ENERGY PERMIT DOLURS�ftoo,0o0),IN AD��TIONTO TIIE COSTOF C0IAPENSATqN,DAMACES AS PROVIDE�FOR IN m � SECTION770lOFTHELABORCO�E,NTEREST,ANDATTORNEY5FEE5. RETENTIONFEE: � vO � CONSTRUCTION IENDING AGENCY PRE-ALT FEE: O ' � IMEREBVAFFIPAIUN�ERVENALT/OFPERttJRYTNATTHEREISA[ONSTRUCTIONLENDINGIGENCY Z FOR THE PERFORAIANLE OF 1HE WORN FOR WHICN THIS pERMIT IS ISSUED(SEC.�097,CIV.C.� W � LENOERS NM�E F_ LEN�ERSADDRE55 ' � ICER7iFYi/NTIFIAVEREADT1I5MVLIG1TqNAND57A7ETHATTHEAeOVE1NFORUA7qNISCARRECi. TOTAL FEES �6�SO w IAGREE TO COM�IV YATN ALL CRY AND COUNTV ORDINANCESAND STATE UWS REUTINa TO BUILDIN6 � CONSTRUCTION,ANDHE BYI1UTYfORREREPRESENTATIVE50FTHISCOUNTYTOFMERUPONTME ' ZABOYE�MENTqNEDVRO TYFORINSPECTION7URPOSES COMMENTS _ • �� � ER N (PR T) Q � y �G R 4i �ATE — RECPT.NO. PAID BY VALIDAT�ON �, WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessa Copy,GOLDENROD—File Copy,GREEN—ApplicanYs Copy _ . . . . , ,- -_ , . - „ -__.._ _ .. -�_, .,-. _ . . �� .., ,, . . . .. . , . , . . , � . .. • � . ., . . . ..�.. ., , „ . .. . , C!i'." 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SEPTIC TANK LANDSCAPE/IRRIG. � SEEP PIT/L.L. ON 51TE IMPS. GAS AIR TEST � � FIWA.L ZONING FINAL CONST. ' ! F DEPT. FINA! FINAL HEATING � � FIEALTH DEPT. FINAL FINAL ELECTRIC �(,-(��0�' � I I DEV. FcES FAID FINAL PLUMBING j j i, E�JERGY j __ I ��'. '_?'':�TY`'�'�"�� �.. ....�_��.____---- � �. -._--____.., . - COMMENTS -�/`�,� � m �Zcr� �G���S��C7.� `'�23�- —�.�r�`�7—� c l�S�v✓dz C,t�sJ Z'�L SZ c,►G�p—��— `�l'� �� SEPTIC TANK SIZE SEEP PIT/U SIZE ,��� _.�' ,y�,� ,a' I �� � �..,._____._..`-". .__.__..........;