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HomeMy WebLinkAbout10230 (5) � � � CITY OF DIAMOND BAR � COMMUNITY DEVELOPMENT DEPARTMENT � :,,.,� . 21660 E.Copley DrivcSuite 190 PRES+S ; (909)860-3195 Fax(909)R61-3117 � �'A^'� RUILDING PERMIT APPLICATION FIRMLY j Y JOBSITE �����I� � ��., APPLICATION ��;7 -�'+ NUMB R��Q'��#/C � o ADDRESS DATE_ ;' � , ISSUE 7YPE OCC APN LOT TRACT_ DATE_ _CONST. GROUP ' � OWNER �+- ZONING SETBACKS � � CDDRESS ��.�- Z�P� TEL._ _ FRONT RW ❑ APPLICANT _ ta� c�.<'�hc'` TEL.---- REAR CJ_._ � � _ — SIDE/SIDE STREET RW ❑ a � \..W_ SIDE Cl- m CONTRACTOR. Y`��'��'��'-`�I S "�+� � ADDRESS ��� �i �``�� �-''^- , � Q CITY C C''""3,'�,��''.�:_- ZIP i��� TEL.7`r���'C'��� PROPOSED USE--- j w ARCH/ENG! _ _ � Z DESIGNER — NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY _ ZIP_._,.__ TEL. _` ; � DESCRIPTIQN SQ.FT. FACTOR PSF ADJ.AREANALUATION � p� ONRJER-BI;ILDER DECLARATION SFR/ADD/REM � O 0� I HEflEBV AFFIRM UNDEN PENALTV OF PERJURY THAT I AM F.XElAPT FROM THE CANTHACTOqS ll- G8f0gB/C81POfI l W. CENSELAWFOFTHEFOLI.OWINGREASON(SFG'/o31.58USINE5SAN�PROFE5510N5CADE:ANYCITYOR (n U COUNIVWHICHRE�UIRESAPERMITTOCONSTFUCT,ALTER,IMPROVE,OEMOLISH,ORREPAIRANYSTqUC- W PafiO/OeCk � W TUNE,PRIOH TO ITS ISSl1ANCE.AL50 REQUINES THE APPLICANT FOR SUGH PEFiMIT TO FILE A 51GNE0 W �� STATEMENT THAY HE OR SHE IS LICENSE�PURSUANT TO THE PROV1310N5 OF THE CONTRACTORS I.L q O� CENSE LAW(CHAPTEH 9(CDIIJMENCINC WI7H SECTION 7C00)Of UIVISION 7 OF THE 9USINE55 ANO PRO- LL' P��VSpB FE5910NSCODE)OR THAT HE OR SHE IS EXEMPT THEfl[FROM AN�THE BA515 FOR 1'HEALLEGF.D EXEMP� (� � U TION.ANVVIOLA710NOFSFCTION7o31.5BVANYAPPLICANTFORAPERMITSU&IECTSTHEAPDLICANTTO Z Re-Roof ACIVIL PENALTY OF NOT MOHE THAN FIVE NUNDRED DOLLAflS(i500).): ' Z ❑I,ASOWNEROFTHEPROPERTV,ORAIYEMOLOYF.LSWITHWAGESASTHF.IRSDLECOMPENSAT'AN, � � COfPIffI0fC18I �� WIIL DD THE WORK,PND THE STRUCT�RE IS NOT INTENOED OR OFFERED FOF SALE(SEC.7046,BUSI- . J NESS AND PHOFESSIONS CADE:THE CANTRACTORS LIC[NSE L4W DOES NOT APPLY TO AN OWNER OF ' � PROPERTYWHOBUILOSORIMPflOVESTMEREON,ANDN770U0ES5UCNWOPKHIMSELFORHERSELFOq m S ��, THROUGHHISORHEROWNEMPLOYEES,OHOVIOEDTHATSUCHIMVqOVEMENTSARENOTINTENDE00q 7 W' OFFEREDFORSALE.IF,HOWEVEF.iMEBUIL�INGO'rIIMPROVEMENTI550�.DWITHINONEYEAROFCOMPLE 4 ��' TION,7H[OWNER BUIL�ER WILL NAVE THE 9URDEN OF PHOVINC.THAT HE OP SHE DID NOT BUILO Oq � = IAIPROY[FORTHEPURPOSEOFSALE). � ,W; ❑I,ASOWNEROFTHEPflOPERN,AME%CLUSIVELVCONTfiACTINO,WITHLICENSEDCONTRACTORS - ---_ �,. TO CONSTfYUCT THE PRQIECT(SEC.7044,BUSINE55 qN0 PflOFESSIONS CODE:THE CANTMCTORS Lb V811J81i0Y1 _ ADJ.AREA �W, CENSELAWOOESNOTAPPLYTOANOWNfROFAPFOPEftTVWHOBUIIOSORIMPROVESTHEREON,AND '�� WHOCONTRACTSFORSUCHVROJECTSWITHACONTflACTOR(S�LICENSEDPURSUANTTOTHECIXYTRAG QUANTITY DESCRIPTION FEE � TOfl3 UCENSE LAWJ. Y; � �� ('I IAM IXEMPi UNDER SEC.._. _.______..__ B.&P.C.FOq iHIS flEASON �': � �.: --,_ _._-. '_"' _"—_.. � DATE OWNER__._„_ Z% ; �' LICENSED CONTRACTORS DECLARATION � a ' W . �: I NEREBV AFFIRM UNOER P[NALTY OF PERJURY 7Hf.1'I AM LICENSEO UNOER PFiOVI51ONS OF CHAPTEfl i^ � � ..�J. Q 'd`.� 9{COMMENCING WITH SECTION 7000)Of OIVISION 30F THE BUSINESS AND VFOFESSIONS CADE.AND ,� z - K-`�`L '��...J X� 1AY LICEVSE i5 IN FULL FORCE AND EFFEC. � /� ,� J � m �� i �� O� L."'_ ::3�' LS-`��-�Ci��r�� " � s�... �; UCENSE CLASS ____._LIG.NO._._._ �;__ _ -j- �. � V��. DATE__ ____ CONTRACTOR "�'�JC1t�.� �C�=1h.� y d� W. z . � ��; WORKERS'COMPENSATION DECLARATIDN /��� � ��_ ` �-' I HEAFBY AFFIRM UNDER PENALTV OF DERJURY ONE OFhIF FOLLOWING DECLARATIONS: N' i d,, __I NAVE AND WILL MAINIAIN A CEf1TIFlCATE OF CONSENT TO SEIF-INSURE FOP WOHKERE' � Q COMPENSATION,ASPROVIOEDDYSECTION37000FTHE�ARUqCOOE,FORTHEPEHFORMANCE _ _ �// OF THE WOflI(FOR WHIGH 7HI5 PEM11T IS ISSUE�. � W y[ -{� I HAVE AND WILL MAINTAIN WORNERS'(:OMPENSATION INSURANCE,AS RE�l11RED BY SECTION � Q / 9700 OF THE LABOR CODE.FOq THE PERFORMANCE OF THE WORK FOR WHICH THIS PEFiM1T IS —_—i-- �', ISSUED.MY WORKERS' MPENSATION INSURANCE CARRIE AND POLICV NUM6ERARE: CONSTRUCTION ! j: �t2-� �bt v q _„_ PLAN REVIEW �; cannieR.— � - ----------- ':! � POLICVNUM�E���a._-�• � �' �..._. '� ' ELECTRIC __�_ ,'. j. � a w, i � 0 (IHISSLCTANkE�NOTBEQN.1Rt7EDaFTHEPEWNfISFORONEHUPUiEDDOt1?RS(Eiao)ORLESS} PLUMBING ._ __. W I CERTIFY THAT IN THE PERFONMANCf OF THE WORK FOR WHICH THIS PERMIT IS ISSIIfC),I MECHANICAL : j ...C7.. SHALLNOTEMPI.OYANVPERSONINANYMANNERSOAST06ECOMESUBJCCTTOTHE -- � -- d � WORNERS'COMPENSATIONIAWSOFCALIFORNIA,ANDAGREETHATIFISHIXILDOECOME INSPECTIONFEE � SU&IECT TO TNE WOFKEftS'fAMVFNSPTION PROVISIONS OF SECTION 1/0o OF THE LABOR � -r ~ CODE, SHALI�ORTHWITH COMPLV WITHTFIOSE ISSUANCE i� � �. � + O: /,J�` SMIP ��: --- � p �ATE:_.. � .__ APPLICANT: _.(_ ..� �._ .'.. -.---__-___ ' • W� � ENERGY P/C WARNING:FAp.UFE TO SECURE WOHKEPS'COMPENSATION CAVEHA6E IS UNLA L.AN�SHALL 6E ' �R �r SU&IEGTANEMPLOVEqTOCRIMINRLPENALTIESANDCIVILFINESUPTOONE N�REDTHOUSAND ENERGYPERMIT '�"'� e '�' � k ' DOLLARS(5100,0001.�N ADDITION TO THE COST OF CAMPENSATION.DAMA .AS PROVIDEO FOR IN Xt- -�- q '•��' � � � J� SECTION37080F7HELA90RCA�E,INTERFST,FNDATTORNEYSFEES, RETENTIONFEE: � � ' _— _—" _— �; CONSTRUCTION LENDING,B.GENCY PRE-ALT FEE: �' 1 MEREBY PFFIPM UNDEfl PENALTY UF PERJURV iHAT TNERE IS ACONSTRUCTION LENDING AGFNCV FOR TNF.OERFORMPNCE OF THE WORK FOR WH�CH THIS PEFMIT IS ISSUED(SEC.309�,CN.CJ. W' __ - LENUER'SNAME�__,_ _._..__ _._.-_ �: IENDER'SAD�flE55_„_ ___ ..__—.._.. �� ICERTIFYTHATIHAVEPEADTHISAPPLICATIONANDSTATETNATTHEA60VEINFORMATIONISCORRECT. TOTA�FEES �' ��' I AGREE TO CAMPLY WITii RLL CIiV FND COUNTY OROINANCESAND STATE LAWS fiF.IATING TO 9UILOING CANSTRUCTION,AND HEREBY AUTHOPIZE REPFESENTATIVES OF THIS COUNTV TO ENTEF UPON THE ABOVE-MENTIIXJED PHOPERTY FOR INSPECTION PURVOSES. � Z.� � ._„�.^ COMMEN7S__.._ 0 _� C'r_:a —C�`('-��`�'� ---- � m� PERMII?EENAMEIPHINT) '- ���� —... .'-- - ja —__ _. � (,/� ��(� � �1�� __ �y. �/j SIGNATUiiEOFPERMITTEE�' OATE �/J"'�(�/ � ` l RECPT._-NGl✓"' `v�D BY �-�VALIDATION � ~' WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—AppllcanPs Copy � -:,_� e I� �� �. ;i zr -r��s l?��� cn�;n�cn Q t� g m�crs�as -o�a� -� xi�� -a�c��� m ,� cn ��i1� � �j I z z�z Z D m,m m x t-i D � =40I0�0 t3 � O:� m � r -! � �-:,4 . : y yi�lausm v � < r- r Oc i a .� � �n m 7 -i � � r Irlr y v 1 ��'�2 z � � � G�IG? �'s ��ml'ol� o � !n i � `-'�t � ��-�i��� ��� -�-�i �;� � z � ��zl=��Ic� � vr���vl5;.z � T a P D! !'[': �G. tn�y,����r r .Cn.IS.I� 'o,fTi Z�lO L� SIEn�O 7J�UI— G t7 � ��C- 1 r r-�� .[ rtl I 171�ti D C) S7 � C�� ;I � � � �-�i�-{�Cl�'.�llil'- � Z 7 G� C���RtlD:ppi� y�� � � a(� �:��`�. ��: -i a 2 -�i� ; �I A c �. � ' �� -a "' -+ � "' ,� . �� � w � �.z � c � U; z c� �� �- -i i I ���- � _!- �:,� � I' � � � n ���a��l�;� ��+ �� � o � mN i � �I I ' iG7 -i z�Gy���z i7 z�m co c � fi? . � ; O i ``��n; � D �, � � m II I I ! �;. 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