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HomeMy WebLinkAbout12266 (11) �. CYTY OF DIAMOND BAR �;%'�'�� � DEPARTMENT OF COMMUNITY 8c DEVELOPMENT SERVICES ' /; 21660 E.Copley Drive 5uite 190 (909)860-3195 Fae(909)861-3117 � PR�SS �''A�' BUILDING PERMIT APPLICATION FIRMLY � JOBSITE r� APPLICATION PERMIT /' P/C Gj� o ADDRESS,✓`�.�.�'�`I l'""t��.r��P��f�y�._f DATE�lr7�� NUMBER I�2�`� � !�'-�� � APN LOT�_ TRACT���'P�I� �SSUE q_� TYPE OCC DATE_���'-19��"CONST. C.7ROUP p OWNER �,�Cil CAL.l�b��,%i p ADDRESS_� l�`Z�tl �GLD.S't�iilht(rS ZONING SETBACKS Z CITY�1siH�nJal� E�ltj2 ZIP TEL.��3 t'J_��I FRONT RW ❑—_-- o APPLICANT �j f�j N 1�.J.,�( TEL.��7_ REAR ❑_____ a SIDE/SIDE STREET RW_ f7_..__.,__ � CONTRACT R ��(rJ f'}�ifr%f-7S' SIDE ❑ ADDRESS�,�� G-r�FRQ�:�.�1 � CITY R�AI./i/�D�,�(�j,� TEL.�(�°7<<�}:�g3EJ PROPOSED USE �oU�J�I�T.� C/{�"Z'F_ �}cr1 N�' . w ARCH/ENG/ ����� ,` ''""' ��� -- z DESIGNER -- w - NO.DWEL. NO. NO. a ADDRESS � CITY ZIP 7EL. - UNITS_�__ STORIES �___BEDROOMS� � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER QECLARATION o SFR/ADD/REM [] I HEREBY AFFlPAI UNDEF PENALTY OF PERlUHV hIAT I AM L%EMPT FROM TFIE COMRqCTORS LI- G3f8gB/C9fp0lf A.0 CENSELAWFORTHEFOLLOWINGflEA$pN(SEC.�031.69USINESSANOPP.OFESSIONSCCDE:ANYCITYOft (/� U COUNTYWHICHFECKIIRESAPERMITTOCONSTRUCT,ALTER.IMPROVE.DEMOLISH,ORREPAIRANYSTAl1C- W p8f10/DBCk �� 7URE,PRIOR TO ITS ISSUMICE,AL30 qEQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROYISIONS OF THE CANTMCTOAS ll• �� GENSEUW(CHAPTEF9(COMMENCINGWITHSECTION7W0)OF[11VIS!ON30FTHEBUSINESSANDPRO- u' POOUSpfl FE3310NSCODE)ORTH.�THEORSHEISE%[MPTTHEREFROMANDTHEBASISFORTHEALLEGEDE%EMP- � V TION.ANYVIOLATIONOFSECTION7031.6�YANYAPPLICANTFOHAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Raof F, ACML PENALTV OF NOTMOflE 1HAN FIYE HUNORLD DOLURS({500).): � � L]I,ASOWNENOFTHEPROpERTV.ORMVEMPLOVEE5lV1THWAGESASTHEIRSOLECOMPENSATION, COR1ffIBfClel WIIL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFEFEO FOR SALE(SEC.7o4a,BU51� �J y NESSAND PROFESSIONS COOE:THE CONTPACTORS LICENSE LAW OOES NOT APP�Y TO AN OWNEH OF � PROPERTV NRIO BUILOS OR IMPROVES THEREON,AND WHO OOES 5UCH WORK HIMSELF OR HEPSELFOR ' 1x THHOU�HHISOHNEROYJMEMPLOVEES,PROVIDEDTHATSLICHIMPqOVCMENTSAi1EN651NTENDEUOR m -- W OFFEREDPoq$ALE.If,FIOWEVERTMEBUILDINGORIMPROVEMENTI550lDWITMiNONEYFAROFCOMPLE ��� TKN1,THE OWNER-BUIL�EH WILL HAVE THE BUROEN OF PROVINIi THA7 HE OP SHE DI�NOT RUILD OR � IMPROVE FOR iHE PURPOSE OF SALE7. W IJI,ASOWNEROFTHF.PROPERTV,AMFXCLUSIYf.I.YCONTfiACTINGWITMUGENSE�COMfl�CTORS [L 70 CONSTRUCT THE PR0.IECT(SEC,7004.6USINESS ANO PROFESSIONS CODE:THE CONTRACTOfiS LI- V21U8tiOf1 ____.,..,_._____ADJ,AREA � 'W CEN5ELAWDOESNOTAPPLY70PNONMEROFAPROPERNWH08UILDSORIMPROVESTHEHEON,A�D '--'---- � WFqCONTRACTSFORSUCHPROJECTSWITNACONTRACTOR�S)LICENSEOPURSUANTTOTHECONTRAP QUANTITY DESCRIPTION FEE � TOflSUCENSEUW.). "' o fJ1AMEXEMPTUNDERSEC.___________.._..._.____._______.._—B.&P.C.FOH7HISREASON Q /r �rv L C..+', �3 � `' ` {f � _—__ 'y—� / . LL" DATE _OWNER__ . � r �� ..I� IS'�./ �" / ' z. ______—_—_'_____'_.—____..".___ p LICENSED CONTRACTORS DECLARATIDN W � I HEREBYAFFIRM UND[R PENPLTV OF PERJURY THAT I pM LICENSED UNDER PROVISIONS OF CHA�TER :y: 9(COAIMENCINO WITH SECTIDN 7oD0)OF OIYISION 30F THE BUSINE55 AND PROFESSIONS CODE.AND Z ��� � -� ' ?C MYLICENSE IS IN FULL FOflCEAND F.FFECT. �' ��` , � n � LLI 2 f, ) ) � �. LICENSE CLqSS_�J `.� ___LIC.NO. "����.7 j._._______ L G•) �3�y /� L,, r pr, � �" ! ✓ La' ~�- �ATE�_r�+� /� CONTRACYOR�[=i.J �''FGIf9'�_IS__ d w, . C�G.✓�"./ � � d�� WORKERS'COMPENSATION DECLARA710N � � Q -�', IH[REBYAFFIRMUNOERPENALiYOFPERIURYONEOFTHEFOLLOWINGDECLARATIONS: Z M/9 ��� ' (,.�� /1 /") i ¢ ` "� ,� �'�? �- �� '��' IHAVEAN�WILLMAtNTAINACERTIFICATEOFCO45ENTTOSEIF-INSUREFORWORKERS' _ '�, COMPENSATION.AS PHOVIDED BYSECTION 370o OF THE LABOq CODE.FOR THE PERFORMANC[ I W __ ,Q: OFTHE WORK FOR WHICH7HI6 PF.RMI71S ISSUED. 3 � W IHAVEANDWILLAi0.1MAINWORKERS'COMPENSATIONINSURANCE,ASREWIREDBVSECTION Q 37ooOFTHELA80RCO0E.FORTY,EPEflFOPMANCEOFTHE1hORKFORWHICHTMiSPERMITIS ��� �f'y d' ISSUED.MV WORKEHS'COMPENSATION INSURANCE CAHflIEFAND POLICV NUMBER ARE CONSTRUCTION __ i 1� �r- _.. "__' �. �j�� CARRIER�T�E..--���' -------._._._......_. PLAN REVIEW I`a C�1 _...-.----- . --- � .�` POLICY NUMBER I.��qG ELECTRIC �� � 'Q' --------- ------ �j �q _. �� (t}IISSEGTIONNEBINOTBEODRWLEfFDOFhIEPERA4TISf-0fiONEHUrDF1EDOCtlAR5�E1W)ONLESS} PLUMBING __.____..__ � �"�7L/ . .,- ...__'..... ._�,.2_r�_ W' Z�. I CERTIFY THAT IN THE PEHFOfiM0.NCE OF THF.K'ORK FOR WMIGH 1 HIS PEHMIT IS ISSUE�,I MFCHANICAL ____ __,._______ �� : � ��(7�, SHALL NOT EMPLOY ANV PERSON INANY MANNEN SUAS TO BEf,OMF.SUFUECT To hIE �" "�� WORKERS'COMPENSATIOtiiAW3OFCALI�ORIVIA,ANDAGREETHAiIfISHOVLDO'cC/JME INSP[CTIONF[[ _ __ ---..--- ---'-- ,= SU&IECT70THEWOFKERS'COMPENSATIONPROVISIONSOFSFCTION3]ooOFTHCLA60R — -- /y���yyy �y/y E,ISHALLFORTMWITNCOMPLYW N OSE IONS. ISSUANCE __f(6�{.AL% �.. !�: �. � /y`�� � �. 'p.' DATE: APPLICAN ____'.'_'_...__"_ SMIP ��_. _ LV�1„� .. � � -.J: . � � ENERGYP/C � J; WARNING FAILURF.TO SECURF WOFlKE COMP[NSATION C ERACE IS UNLAWFUL,AND SHAL�BE --��--��-�-��-------�- ..�y, SUBJECTANEMPLOYERTOCRIMINA. ENAITIESANOCIVILFiNE5UP700NEHUNURFUTHOl1SANU ENERGYPERMIT ____.,...__.._.._____..._ � DOLLAR3(iloa.ao0).IN ADDITIOti TO THE COST OF COMPENSATqN,DAMAGES AS PHOVIUED FOR IN /� i�;. 9ECTION37oeOFlHELABOHCADE.INTEREST.ANDATTORNEY'SFEES. RETENTIONFEE: _. . _ L�l✓' �d�. CONSTRUCTION LENDINGAGENCY PRE-ALT FEE�- -„�� � �Q�. -- I�-- --- '---'--- � ,���� IHEREBYAFFIRMUNDEflP[NALTYOFPEflJURVTHATTHEflEISACONSTRUCTIONLENDINGhGENCY _____ _______ FORTHEPEflFORMANCEOFTH[WORK WHICHTHISPERMITISISSUE015EC.3D97,CIV.C.). — Z ~ ;W', .. __'_--"' ' � LENDER'S NAME � ' � : _._.—.....____---___ 't.�g' �, '_'—. ....._.__..— _. '.F--., LENDER'SADDRE55__.,_.. '�,��"�' TOTAL�6�72 ���r � / ' ICEFlTIFYTHATIHAVEREADTHISAPPUCATpNANDSTATETHATIHEABOVEMFORMATIONISCOFRECT. I AGHEE TO COMPLY WITM FLL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING �' CONSTRUCTION,ANDHEREBYAl1THORIZEREPHESENTATIVESOFTHISCOUNTVTOENTEflUPONTHE ��'+5'.Z ABOVE-MEMIONEO PROPERTV FORINSPECTION PURPOSES. 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