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HomeMy WebLinkAbout12756 � CITY OF DIAMOND BAR -- �"'�' DEPARTMENT.fJF COMMUNITY&DEVELOPMENT SERVICES �,� 21660 E.Copley Drive 5uite 190 (909)B60-3195 Fax(909)861-3117 PRESS �'^�°� BUILDING PERMIT APPLICATION FIRMLY o DDR'ESS�-I �}/ ` APPLICATI�N /� �'��� PERMIT h� P!C � DATE�_(J� NUMBER <' # � � APN L07 TRACT _._ DA EE l�."`�'"��� NPE OCC p OWNER sQ �S T CONST. _ GROl1P " ADDRES� C���i ZONING SETBACKS � CITY ��/1'j�M1�.�2 P�/�TEL�>3"77 " p( FRONT RW ❑ _ p APPLICANT _ TEL. SIDE/SICE STREET RW ;.] z �a CONTflACTOR �/ �. � SIDE __ ❑_..._.___._ ADDRESS 5'! �����;rt]n1L B��f�L. S'/�iTt � p J��� p,, �j�cj 1� PROPOSED U��- �7. CfTY� rV ��y/L ZIP� D 7EL.� L� �rRl ��._ � w ARCH/ENG/ � z DESIGNER _ �, ' � G--�+�'�-�f. � ADDRESS NO.DWEL, � NO. - NO. � CITY 7_IP TEL. UNiTS STORIES BEDROOMS � v� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION O. OWNER-BUILDER DECLARATION SFR/ADD/REM I HEREBV AFFIRM UNDER PENFLN Of PENURY THAT I AM EXEMPT FROM THE CON7RACTORS LI� � � Garage/Carporl � W CBISEUWFOAhIEFOLIOWINGREASON(SEC.7o31.50USINESSANDPFOFES510NSCA�L�ANYqTYOA (n U CIXINTYNRiICXREO111RE5APERMITTOCANSTRl1CT,ALTFR,IMPROV[.IIEMOLISH,ORREVAIRANYSTRUG w TURE,PRqH TO IT&IS&UANCE,AL50 REQUIRES THE APPLICPNT FOR SUCH PERMIT TO FILE A SIGNEO W PdiIO/DBCk STATEMENT THAT HE Ofl 517E IS UCENSE�PUFSlJM7T TO 1'HE PROVISIONS OF Th1E CONTRACTORS LI� � CENSE L!W(CHAPTER 9(COMMENCINO WITH SECTION 7000)OF OIVISIDN 3 OF THE BUSINESSAND PRD� � POOVSpB `j FESSIONSCOD�ORTHATHEORSHCIS[XEMPTTHEFEFROMMJDTHF.BASISFORTNEALI.EG[DEXEMP- (� V TION.ANYVpLATIONOFSECTION703t.50YAMYAPPLICANTFORAPFfiMiYSU&1ECT57HEAPPIICANTTO Z Re-RooP r. ACMLPENALTYOFNOTMORETHANFNEHUNDREDDOLLARS(SSOOI.): � L'JI,ASOWNEROFh1EPROPFRTY,ORMYf.MPLOVEESWITNWAGESASTHF.IqSOLECAMPENSATION,; CI Commercial � Wlll DO THE WORK,AND T11E 5YRUCTURE IS NOT INTENOED OR OFfEPED FOR SALE(SEC.7044,BU51� J � NESS AND PHOFESSIONS CADE:TME CANTRACTORS LICENSE LAW OOES NOTAPPLY TO AN OWNER OF� � ONOPERTY WFIO BUILDS OR IMPROVES YHENEON,ANU WHO DOES Sl1CH WORK HIlASFLF Ofl HERSELF Oq' �� THflOUGHHI50RHERONTIEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTENDEDOR m ,O OFFEREOFORSALEIF,HOWEYER7TiE0L'ILDINGORIMPROVEMENTIS50lAWITHINONEYEAROFCOMPLE- � TIQV,iHE OWNER�UIL�ER WILL HAYE THE BUR�F.N OF GqOVING 7HAT HF OH SNE OID NOT BUII.D ON � IMPflOVE FORTHE PURPOSE OF SALE). W L]I,ASOWNEROFTHEPROPER7V,AMEXCI_USIVELVCONTRRCTINGWITHLICENSEDCONTRACTOflS � TO�NSTRIICT THE PRQIECT(SEC.70<d,BIISINESS AN�GROFES51045 fADE THF.CON7RACTORS LI� V9I112210f1 ADJ.AREA W CEN&ELAWDOESNOTAPPLVTOANOWNEROFAPFOPERT'WHUBUIWSOHIMPNOVESTHEflEON,PN�" �'" -"----"""""-'"""'-- �� WIIOCONTRACTSPORSUCMPROJ[CTSWITY.ACONTRRCTOR(S�L�CENSEDPURSUANTTOTNECONiRRG� QUANTITY �ESCRIPTION FEE � � TORS LICENSE LAW.�. �0 ❑IAMEXFMP7lIN�ERS�C._'_"'__'..__.._._.— Q . B.8 P.C.FOF THIS REA54N � U LL � DAT� OWNER _--__'_..-__ ' _"_..__.-.__.—._- � ;Z. ., .. W ��,F-�-_- LICENSED CONTRACTORS DE(;L4RATION W �.�. I HEHEBYAFFIRM UN�ER PENALN OF PERJl1RY THAT i AM LICEYSED IJNDEA PFOVISiONS OF CHAPTER � � � �p,,. 8(COMMENCINpWITHSECTION70W)OF�IVIS!ON90FTHEBl1SINESSANUPHOFESSiONS(:ODE,AND Z MY LICENSE IS!N FULL FORCE AND EFFECT. � ��O LICENSE CLASS_� �" ___ LIC.NO. ����O+�"'��/ ,�� j � � �:.�� �ATE � CONTRAC70fi..,Gf..L�/���rF.,�.'_'-. n- J W �.� WORKERS'COMPENSA710N DECLAHA710N Q ,� U . ,,y. I HEREBV AFFIRM UN�ER PENALTY OF PERJURY ONE OF TH'e FOLL9WING U�GLAFl0.TIO4S: Z Q .�O IHAYEANDWILLMAINTAiNACERTIr•ICATEOFGONSENTTOSEIF�INSJR[FOPWOftK[fi;' $ �.��. COMPENSATION,AS PROVIDED BY SECTION 37ooOF THF U90F CODE,FOH TNE PF.HFORMMCE W __ OF THE WOflK POR WHICH THIS PFRMI715 ISSUED. � �' — _ � `W' _IHAYEANDWILLMAIMAINWORKERS'COMPENSATIONINSURANCF.,AfiREWIRf:DBYSF.CTIQN p yyy ��-Q, 3700 OFTHF.I.AROR COOE,FOR THE PERFORMAftCE OF THE WORN FOF WHICH THIS PEHMIT IS � -- - - ��h� ' ISSUED.MV WORKEHS'COMPENSATKKJ INSURANC RIEN AND PULICV NUTABER ARF.: ONSTRU ! ��' I :j- cnRRiER__ _b��� -. - PLAN REVIEW -.--------------- -- �-jT (/� .Z POLICYNUMBER_F„�-��t--',----�--� ELECTRIC .._.-._......'.'_-_ .__.'.______........._._.______- 'Q, ��� (fHISSEf,'RJNNE�NOTDE00.UfiL7EDOFTHEPEAMTISFORONEHUMfieDDJUARS(5100)ORLESS). PLUM8ING ___....___._____ .. _'....___._....._._...._......_....'_ �,Z i CER7IFVTHnT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PEflMIT IS ISSUED.I MECHANICAL _.._._._______.._____ :(�'y SHALLNOTEMPLOYANYPERSONINANYMANNEHSbASTnRC:CAMfSU9JECTTOTHE '� WOfiK[RS'COMPENSATIONLAWSOFCAUFORNIA.ANDAGHEEThIATIFISHaULUt1E1:0!.4L INSPECTIONFEE ...._................�A �� SUBJECT TO TFIE WORNERS'CAMPENSATIO�PROVISIONSOF SEC710N 37000F THE L0.80R �_��. � /�j.� �� CODE,ISHALIFORTHWITHCOMPLVWITXTHOSEPROVISIONS. SUANVC ..-------...._.........-_ �'�✓ _.."" '� IP `,p DATE: �Y' 'APPLICANT: ...._.-_ __'.-. __..._._.__.__- .�- ENERGV P/C �t w r. n R �4R�. ,J WAPNINGFAIWR[70SFCUNEWORKERS'COMPENSAT:ONCOVERAGEISUNLAWFUL.ANUSHPLLBE '�------ --��-��------- `LL� S110.1ECTANEMPLOYERTOCRIMINALPENAI.TIFSANOCIVILFINFSUPTOONLHUNDFEDTNOUSAND ENERGYPERMIT • OOLLAfiS(51co,000),INPDDITIONTOTHEGOSTOFCOMPENSATION. AMAG ��J SECTpN3�OeOFTHELABOFCODE.INTEREST.ANDATTOFWCY'SFEF.S. ,� RETENTION FE[: �! ' I A�MT�ND ______._ �O CONSTRUCTION LENDING AGENCY PRE-ALT FEE: ._��,����1tlD SA_ { ��� I HEREBYAFFIRM UNDE(i PENALTY OF PERJURY THAT THERE IS AGONSTFiUCTION LENDING AGENCY �a- FOR 7HE PERfORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED(S[C.3097,CIV.C.�. Z -��.._���/' _�w'� r ------..___.--- *: ' LENDEWSNAME _ ._.__ __ � ��� LENDER'SADDRESS��I���2L�_�../LVCY'�`r-. —'_""""'_"-__-"--- ._..__.__........_...."_'_"__...—___ -'—Y_ � � ¢�� ICERTIFYTHATIHAVEREADTHISAPP�IGITIONANDSTATETHATTHEABOVEINFORMATIONISCORFECT. TOTAL FEES � �� �� / 4�, �W� I AGREE 70 CUMPLY WITH AI.L CITY AND COUNTYORDINANCES AND STATE lAWS RELATING TO BUILUING � �� CONSTflUCTION.AN�HEREBVAUTHOPIZEREPR[SENTATIVESOFTHISCWNTVTOEMERl1PONTHE ) � : Z� ABOVE-MENTIONEDPPOVEflTYFORINSPECTIONPURPOSES. COMMENTS ____.__....__— �� � _-�. .f�,�-��� - � �� PEfiMITTEE NAMEe(P-flllfn �/A�/ ��� SIG EOFPERMIT�EE � DA���� " _' J ' '__' _._ ..Z RECPT.NO.____ _ —PAID BY _ � VALIDATION_„_'..�LI�_ � ~' WHITE--Department Copy,YELLOW�inance Copy,PINK-Assessor Copy,GOL�ENROD-File Copy,GREEN-ApplicanPs Copy � . ...�_, _ ., T_....._� (-. p � .` � r�- --; ..m{ s4 .� ��'�� ��_.d�+�y.� z"�."n - � � � i ' i :i � 9 � _ � � ( � t�i J �" _ tr� �� i 3 � � � � i { � i I� � � ,�1`49 a��. J 1 1 ! I . 4 { d _ � ��� � 1 7 I fi'��' 3'��'at� ?+,t � � �. i � ii .-� � �C � p '. J� ��� t � � i �� n+'�#'�. � � � z t� � � e 7 � .� °'� � ; � � � ��C'� -� � f �� ,4 S5¢ : a �''�"'�7 C"8 1 � I . , � � ' ' I P I 5 I �Y 7 � I-- � �}#ti���°��'�€��l�� ��,��'�a °� ', 7s � , � � s i I t j ' ; _ I � ,�� I y I �; � :� ,�ei,rb��i �' j � tit , k 7 � I i � -� I I j �r ,� � a t�' x s w � �:�o '� ; ��� �4 �7�7r�'�.5 �,: y f � I f ,. _ _{ _' ' _ ' . { i I � �� � v� � ,.. , �� ;._ i �... ,�, I 1 +�' �k\ . 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