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HomeMy WebLinkAbout12798 � � � ^ �� CITY OF DIAMOND BAR ' }(� j DEPARTMENT OF COMMUNITY&DEVEL S t �Q ' _� � 21660 E.Copley Drive Suite 190 � (909)86Q3195 Fax(909)861-3117 1 3 Z�Q�j RESS �4��9�' � BUILDING PERMIT APPLICATION 1`IRMLY � � JOBSITE j g ,� -- � a ADDRESS_ i���+ CLo�fK41� i� � APPLICATIO ��.-'�.,� PERMtT � P!C OATE � NUMBE # ISSUE 7YPE OCC I � APN lOT TRACT DATE CONST. GROUP � p OWNER �^^„ 4ny�,�c+'1-i "' ADDRESS ZONING SETBACKS I Z CITY ZIP TEL ,��1y4^L2-1� FRQNT RW ❑ APPLICANT TEL. REAR ❑ � � SIDE/SIDE STREET RW � � CONTRACTOR �'`�+ ��S'�"` SIDE ❑ � � ADORESS ��� L�' �tr.o �'< <. �-- ° � CITY �� ZIP� TEl.�3)`133� ��lt� PROPOSEDUSE �����.Ga..����S-�-is , ow ARCH/ENG! Z DESIGNER w NO.DWEL NO. NO. a ADDRESS � :CITY ZIP TEL UNI7S STORIES � BEDROOMS �' tn. DESCRIPTION S�.F7. FACTOR PSF ADJ.AREANALUATION .-�,. OWNER-BUILDEA�ECLARATION- SFR/ADD/REM O: []_ i HEp�Y AFFlRM UNDEfl PENALTY OF PERJURY lHAT 1 AM EXEMPT FROM THE COMMCTOHS LI� . Gflf89B/COfPDII :i W'-. CENSEUWWR7HEFOLLOWMGNEASON(SEG7a3t.58U51tdE55ANOPROFESSiONSCADE:ANYCITYOR �(f� � --U_ �OUryTyWNICHREQUIRESAPERMRTOCONSTRUCT,pLTEf�IMPROVE,OEMAU3H2ORREPpIpANYSTRUC _W PatiolDeck - � Z=- TUFE,PRIOR TO ITS ISSUANCE.ALSO REOUIRES 7HE APPLICANT FOp SUCH PEPMIT YO FILE A SIGNED - -j- -��- STATEMENT THAT HE OR SHE IS IJCENSEO PURSUANT TO 7HE PROVISIONS OF THE CONTRACTORS LI� '�� - j -�f. CENSE LAW(CHAPTER 6(COMIAENCINO`MTH SECTIDN 7o0oJ OF DIVISION 30FTHE BUSINESSAND PRO� ' u' PWVSPB - FESSIONSCODE)OR7FUTNEORSHEISE%EMPTiHEREFROMANDTHEBA5ISFORTHEALLEGEOEXEMP� iTION.ANYVKKATbNOFSECT10N7031.58YANYAPGLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO ,�� Re-Roof � � -- ACML PENPLTV OF NOT MORE THAN FNE HUNDFE��OLI.ARS(55oa).�: ' �� ❑I,ASOWNEROFTHEPROPERtt.ORMVEMPLOYEESWITNWAGESASTMEIN50LECAMPENSA710N . COfilrtlBfCldl ' } .�s; WILL00 iHE WOHK,AN�THE STHUCNFE IS NOT INTENDED OR OPFERED FOR SAIE(SEC.�049,BUSI� �� '� :&;�� NESS AND PROFESSIONS COOE:h1E COMTRACTORS LICENSE L1W�OES NOT APPLY TO AN OWNER OF :_�_.? . :PHOPEfffY NTIO&lILDS OR IMPPOVES TNEflEON,M`D WHO DOES SUCH WORK HIMSELF OR HER5ELf OR �:{ �.��- -•TNROUGHNISOPHEHOWNEAIPLOYEES,PqOV10EUTHAT5t1CHIMPROVEMENTSARENOTINTEN�EDOR '-� ---W: -pFFEqEDFOR3ALEIF,HOWEVER,TIEBUIl01NGOFIMPROVEMENT1590tDWITHINONEYEAflOFCOMPIE-_ �- - � -��..Z,�--TION,iHE OWNER$UILDER WILL HAVE THE BUPDEN OF PROYINO THAT HE OA SHE OID NOT BUILD OR IMPflOVE f-0R 7HE PURPOSE OF SRLE). j -_! t--= ❑I.ASONMEHOFTHEPROPERTV.MIEXCLUSIVELVCOUTRACTMGWRHLICENSEOCONTMCTORS ! 3 ��, --TO CONS7RUCT TME PROJECT(SEC.7a4,9USWESS AND PROFESSIONS CO�E:THE CqNTRpCTORS U V81U8tion ADJ.AREA �W, --CENSEIAWDOESkOTAPPLYTOANOWNEqOFAPROPERTVWFIOBUItDSOPIMPROVESTHEFEON,AND �� '-� ''_�_ -.VYFIOCONTRACTSWRSUpiPHOJECTSWiIMACONTRACTOq(S)LICENSEDPURSUPNTTOTMECONTHAG _ QUANTITY DESCRIPTION FEE - '70RS UCEAlSE IAW.). __0�- -. ❑IAM IXEMPTUNOERSEC. B.8 P.C.FORTHIS REASON �: Q . :--��.. . - < �: U LL�- UATE OWNEF -���� . � ti W - .FQ .__ � �ICENSED CONTRACTORS�EC'�ARRTION * W -� --0C IHEflEBYRFFIRMt1NOERPENAI.TYOFPERJURYTHATIAMLiCENSEOUNDERPROVISIONSOFCNAPTER +_ � :p_� 9(LOMMENQNGWI7HSECTION7000)OFDIYISION30FTHE8USINESSAN�PROFESSiONSCODF.ANO ; Z X: MY�ICENSE IS�N FULI FOftCE ANO EFFECT. � .W" —7 � m -� ��- L�CENSE CLASS ,1 � LIC.NO. � .1�-� � !� -_�,_ OA7E - l�' �T � CONTRACT � �, . .WORKERS'COMPENSAT�ON DECLARATION ��✓� � -� 6 _� ,��: IHEREBVAFFlRMUNOEHPENRL7YOFPERJURYONEOFTHEFOLLONfINGD[CLARATIONS: ¢ ` _,�' ___IHAVeANDW14lMAMTARVACERTIRCA7EOFCON5ENT705ELF�INSUREFOAWORK'cR5' _ .- :-� Q COMPENSATION,ASPft�VI�W8Y5ECTION9�ooOFTHEIABORC6��,i'OR7HEPEflFORMMiCE 'U ._� - OF7HE WORN FOR WHICHTHIS PEHAIIT IS ISSUED. � 0 W _I HAVE AND WILLMAINTAIN WOHKERS'COMPENSATIO�IN6UMNCE,AS REQl11RED BYSECTION - - �� �g �:Q-- 37aoOFTNELA80RCl�E,FOP7HEPEPFOqMANCEOFTHEWORKFORWHICHTHISPERMITIS -. 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ENERGY P/C � f _ J WAFNM�:FAILUFlE TO SECUflE NIORKEflS'COMPENSATION CAVERAGE IS UNLAWFUL,AND SHALL 6E /�p� � . � '.�'LL: SU&IECTANEMPLOY[flTOCRIMINALPENALTIESANOCIVILFINESUPTOONEHUN�REDTHOVSANO �ERGYPEFiM1T �� �1lL� OOLLARS(S1a0,000),IN FD�ITION TO THE COST OF COMPENSATION,�AMAGES AS PHOVIDED FOp IN I -�J- SECT�ON37aeOFTHELABOFiCODE.INTEREST,ANDATTORNEI^SFEES. RETENTIO�� - Q-. Ay,y ! :�- CANSTRUCTION LENDING AGENCY PRE-ALT PE{� Cpii�d71g�O,ND � - �- -:�:�: IHEREBYAFFIRMUNOEqPENALNOFPERJURVTHATTHEREISACONSTRUCTIONLEN�INGAGENCY �ya�� t]lyjJ�A +�r�,��'(i ' �- FOHTMEPERFOHMANCEOFTHEWORKWRWHICHTHISPERMITISISSUEO(SEC.3o97,CN.GJ. 'E t . Z W -_'�� LENDEWSNAME . - F'- LENDER'SADDRESS �.:_.W ICERTIFYTHATIHRVEREADTHISAPPLICATIONAtJD3TATETMATTNEABOVEINFOfiMATION�SCOflRECT. � TOTAL FEES � ` _ _ p IAGRFETOCAMPLVWITHALLCITYANDCOUNTVOROINANCESANDSTATEIAWSRELqTINGTOBUIL�WG � --� CONSTflUCT10N,ANDHEREBYAUTMOflREREPflESENTA71VE50FTHISCOUNTYTOENTERUPONTHE _ . 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