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HomeMy WebLinkAbout13210 (14) � � ,�, . � _ �� CITY OF DIAMOND BAR �'�j DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � �,� 21660 E.Copiey Drive Suite 190 (909)860-3195 Fax{9D9)867-31t7 PRESS �""""�� � BUILDING PERMIT APPLICATION FIRMLY � JOBSITE ���J�L� /'� f �j ��y Q ADdRESS�__ L.�'L �l��'� DATE CA710N� �G� NUMBER_��`- t1/ � iSSUE TYPE OCC APN LOT TRACT DATE_ CONST. GRQUP _ p OWNER � ��_�ll,�. _ o ADDRESS_7�_ Z(�NING SETBACKS � CITY ZIP TEL. FRONT RW !I_,__ g APPLICAN7 �� �� TE�`�)�.��j REAR _, n----- SIDFJSIDE STREET _ RW ❑ � CONTRACTOR C,� �ryt�L- ` ��• _ SIDE ❑_ � Q ADDAESS S� _E}►/� _���✓���� O CIN_.��v, _ �E ziP jlzz'^ 7EL. ` pROPOSED USE ��'�- `�J' w- ARCH/ENGI �; �ESIGNER � -C "C�.�1�,� ___, NO,DWEL. NO. NO. a: ADDRESS_ N; CITY , ZIP TEL. y UNITS _ STORIES _BEDROOMS �; '-" DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREA/VALUATI�N �.` OWNER•BUILDER DECLARATION SFWADD/REM O� p:.' i HEREBY AFFIRM UNDER PENALTY OF PERIURY 7H11i 1 AM E%FMPT FROM 7HE[:oNTFnCTORS LI. 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CWMVWr11CNREWIRESAPERMITiUCANSTRUC'f,ALTCF,IMPROVE,D[MOUSH,ORflEPAIRAYY3TflUC- ' pytiO/DBCk W1' TUHE,Pfl10R TO I7S ISSUANCE,AL50 REOUIPES TNE APPLICrWT Fpq SUCH PFRMIT TO FILE A SIGNED W � STATEMENi TrIAY HE Ofl SHE IS LICENSE�PUASUMlT TO T71E AROVISIONS OF THE CONTRACTORS LI- S CENSE UW(CHMTER 9(COMMENCRIG WITH SEC710N 700D)OF DIVISION 3 OF TME dU5MES5 ANI7 PRO. �'1' POOUSpa � FESSpNSCODE�OHTHA7HEORSHEI6[XEMPT7HEREFROMANUiHEBASISFOIiTHEP1L[GF.DE%EMP- (� � ;�� TKKJ.ANYVIDLATIONOFSEC710N709�.SBYANVAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANfT(J Z Rg-Appf �: ACIVIL VENALiV OF NOT MORETHAN FIVE HUNORF.D[70LLARS�5500).); -- . ❑I,A30WNEROFTHEPHOPERIY.ORMYEMPLOYEESWITHWAGESASTHEIfl50LECOMPENSATION, COrtImBfCiel �'r,:� WILL DO TME WORN,AND THE STflilC7URE IS NOT INTENDED UR OFFEflED FOR SALE(SEC.1044.BU51� � _ _ �.;�:NESS AND PROFESSIONS WUE:TNE CONTPAC70R5 LICENSF LAW DOES kOi ACP�V 70 AN OWNEp OF . � � � � PpOPEHiYYAi08UilD30RIMPROVESTHEHEON,ANDWFi0U0E55UCHWORNHIMSELI�OqHERSELFOH ' aj; THflOWHHI50RNFROWNEMPLOYEES,PRO4IDE0THAT5Up71MPROVEN.EHTSqRENOTIN7ENDE�Oq �� m —�— — W�„OffEFlED�OR3ALE.IF,HOWEVERTtEBUILDINGOq!MPROVEMENtI550IDWtTHINONEYEAROFCOMPLE- � ��� .TpN,THE OWNER-BUILOEH WILL HAVE TH[6URDEN Of PROVING h{A7 HE OR SHE DIO NOT BUILU OR ' — Z`: IMPf�VE FOR hIE PUAFOSE OF SALE� W;� ❑I.ASOVYNEROF.THEpflOpERtY,AMEXCLUSIVELYCAN7RIC?iNGWiTaUCE45tDCANTRACTORS a TO CDNSfRUCT THE PflOJECi(SEC.7olc,BlI51NE35 AND PROFESSID;JS CCUE'h!E CONTRACTORS L-. � V81138ti0fl ADJ.AREA.___ LL7i CENSEUWDOESNOTAPPLY70ANOWNE.ROFAPflOPERTYWFIOHUILO50RIMPP.OV[51'HEFfON.,4ND �: - `T' -- - -- -------- �''� WVIOCONTqACTSFORSUCHPR0.IECTSWIT:lACONTRACTOH(S�LICENSEDPURSUAM'TOTHECONTPAG ,�: � QUANTITY OESCRIPTION rEE �TOfl51JCEN5ELAW). _ �' -� G - D 0.;:� (:IIAME%EMP7UNDERSEC.________., _B.SP.C.FOR'fMt�SflEASON ;' Q �'.:_ ,' �?�— � � , �. — - - � � DATE OWNEN___ F-�-- � LICENSED CONTRAGTORS DECLARATION !.� �W I �� y � ` , IHEREBYAFFIRMIINDERPENAI.'iYOfPERIUflVTtlpTl/MUC'eNS�DUN�ENPROV�5lON5CFCHAP�q � p.','. 9�COFAMENCINOWITHSECTION70W)OFDIVISION30FTHEBUS:NEuSANDPROIk5577�5COUE,AND �:' Z _____�___ _ X'. A/VLICENSEISINFULLFORCEANOEFFECY. - �, m ' r � � - LLJ yy �y�.��s j .1. ��� LICENSECLASS � !�__LIC.NO. ls____�.J_.� �;: � t � I~��--- 9�. p -J.�/�_�_ an.; J V DA7E -� � CON7qACTOH_„��_,{,6�y,- t•. ll. ' W ',Ozb��"'._� �� YJORKFRS'COMPENSP.TION DECLARATION ll/� � � a - �� � 1 MEREBYAFFIRM UNDEH PENA:TV Of PE0.iURY ONE OFYME FOLLOYIING DECLAflnT10N$ '� � � .A �: _._._IHAYEANDWILLMAINYAINAC[HTIFICATEOFC0.4'3cN7�OSELFiNdUREfOqWO9KER9' �t � . _ ' _ ' rTy — . COARPET1Sh7'KJN,hSP4iOVI0k.08Y5EC710N370oC�FTNELM180RCODE,FOFIT4EPEHfOR.NAMCE `U`_ � OFTHE WOFX FOR WHICH THIS PEFiM1T IS ISSUE�. � �I W _,__IHAVEANUWILlMAll.ffAINWORKERS'COMPEN&ATIONMSURANCE,ASNEUi11NE�BYSECYION ' � �'� Q� 37oa Of THE LA80R CODE,FOF THE PEAFORMANCE OFTHE WORK fOR l'�N�CH THIS PER!AIT IG � ���// - ISStJED.MY N'OPKERS'COAIPENSATKKJ INSURANCE CAHRIER A:VO 7(lLlc:'/NUMBSRAPE: :� CONSTRUC7ION ' ,_.__ , ��� .._"'_'..._.. J l.� d y � � cnARieFl_�-�.-"'- - _ _ PLANREVIEW ���.. •� _. __._ -- ' - z aaicvNUMeEN l`�� �� ELECTRIC r`�N '�°' ---- — .. Q � - ---------�:�.�--------��3_� 0 (nuss�rt.x�NE�raisea��oFhr_FEarovruwaon�Er,ura�qE000u.a? rxiw� �Ess� . PLUMBING _• _ ------.......—.._.__ .._.__.._. W RKFORWH!CNTIiISPERMIT151SSUt:U,I MECHANICAL • �� Z 1 CEFTIFY THAT IN THE PEHFOpMANCE OF TIiE Vf0 __..-.._---_'_ . _ ._ �__"'—" ' ' (�J Sh1AL1NOT[MPLOYANVPERSONINANYMANNERSOP.STT1BECqMESUBJECfT()Tl+c �`— <'- � SUBJECT TO THE N17RKERS'COlAPENSATION Pq0 ANU AGREE 7HAT IF I SHOULp BECOM[ . INSPECTION FEE , !Z a�� t_���� _ WORNEFS'COMPENSATIUY lAWS Gf CFLIFORYIp �.� � '� ' 'lISIONSOFSFCT10Y37aoOFTH[LA�OR _ � � �4 � � COOF,ISHALLFOr�HWITHCOMPLYWITHTHO V OVISIONS. �SSUANCE ��ri'" � �__� I�'� , �' "�!s. .�� 5 ��..�� p � DATE:����_ APPLIGANP. �__. ' SMIP �� . ..... �� 7.� �. � --- �' ---- ��..s,�- ,�-�--a---^�•— —��. ' w WARNINGFAILURETOSECUREWbNKERS'COMPENSATIONCOVERAGEISVNLAN'FUL,ANDSHA4LUE ENERGYP/C .. .�.�i�� '~ �� � ' `• _— -"_— '_ "" ___'_ ',' � �SU&IECTpN EMPIOVER T0 CRIMINAL PENALTIESANO CIVIL FMES t1P TD ONE HUNDflED THOUSAND ENERGY PERMIT .._....... � DOLLARS(flao,000),INADDITIONTOTHECOSTOFCOMPENSAiION,DANAGESASPqOVIDEDFORIN �� -�— � —. �^ �- � � J ' SECTION91a90FTHELABORQ7DE,INTERF:ST.ANUAROHN[Y'SFI:ES_ RETENTIONFEE: �g_ �v(J_ Q . _.. -_. -.V._.. �7�/ J _�_ � O CONSTRUCTION I_[NDING AGENCY PRE-ALT FEE: •" '�" _ ' .-_.._ ___ . -` ---... ; � � I MEREBV AFFIRM UNUER P[NqLTY O�PLRJURY THAT TH[HF IS A CONSTRUCTION LENDING ACiENCY ___ __ _ FOfl THE PERF6RMPNCE OFTHE WORK FUH�h'HICH THIS PEflMIT IS�55UED(SEC.3a9�,CIV,C.). - --'"-�- —'-""'— '--"' w y � ; � _.- _"-__ ,... _ . , LENDER'SNAME_'___ ___" '_"" —'_"._ X ' .. � �� � .1. .__. ..-"" _"'�"_ � F-- LENUEH'SADURESS„_._,,,_._ n /y � � ICERTIFYTHATIHAVERF.ADTHISAPPLICA7IONANOSTATETHATTHEABOVEWFORMATIONISCOHFlECT. TOTAL FEE�J( 1� l � ;CJ �`� �l , -� � I AGREE TO COMPLY WITH ALL CITY AND COU4TY ORDINANCES AND STATE LAWS HFLATING TO DUIL�INC � CANSTRUCTION,qN�HEREUYAUTHORIZEREPRESENTATIVESOFTNISCOUNTYTOENTERUPONTHE � ��`]7 , Z �90VEMENTIONEOPROPERIYFORINSPL-CTIONPURPOSEB � COMMENTS����y_'� ; � �-` c`-s__���.�� I�C�N_N �--�N ---- - ---�.__—_..__ - QPF MITT NP.ME(PRINT) �. . �f. �j1 __'_'_ '_".. ._"' ' "__-'_ / N '__� •f^ �.L �_—_._- —_—' _ -- (n 5 ATUREOFP��—ERMI� DATE '_' = f�ECPT.NO._._--- ..__PAIDBY ---._ .... VAL�PATION-_-,-_ - __— ~ WHITE-Department Copy,YELLOW-Finence Copy,PINK--Assessor Copy, OLDENROD-File Copy,GREEN-ApplicanCs Copy ��. _.._ .. __; .. _. , ._ - , , _�...;. � :� ; .. _ � � r , , - � � ,:��€a � �� ,� " y � �-V �ag'�� i:: i ' � � � � °� �r�''r s,a. . l ', ��� � � } ' �.� _ ; �� `+' k � ....r �` F ' t ,; i _ .. i �� ' i � - . : . . .� I , `�� .., . �.,.... � ���T��-.. 1 ��' ; ' � 6 .. i � r - I 3 j � a r - . i , � i � ' ' ; � - i � ". � • ,. � � , I�� �l � �. , . � � ,a.�� � r� � '� . rs , , , , � , � i�� --� � , , , �,� ` i ' ! i � ,-�' � I � � � � i { T�i ',1," � E I F � « �� � � i � � � # _ I , �}!' �5� "''� .�` � ��. i � � ; �i- ] � S � � � �L.`� , I { � 1 ' ' ;�f � I � � � �'Z�� I � � _ � I � � °" � 1 ' % � ,- .i I `'.. � i . " � z ,. � i ' - � ; I � � � � � , . i t ,�.. ,,.._i....-- l i . ' � � , ; � i �rr �: , r � ; , : � + r' r 1 y ' �, � .,. , ,.. 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