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HomeMy WebLinkAbout10634 f q „`^ �//''-� , - CITY OF DIAMOND BAR COMMUNITY DEVELOPMENT DEPARTMENT �� � � �,.¢ 21660 E.Copley Driv�Suite 190 ` � �,,,i`"'� PRESS � (909)860-3195 Fax(909)861-3117 �,_.,,,,_:- �'""' BUILDING PERMIT APPLICATION FIRMLY o ADDRESS. �I ��•� ���K..' �ir -� DATE CATION�a���� NUMB R "� ��L N+C c� ISSUE � TYPE OCC � APN LOT TRACT DATE CONST. GROUP p OWNER �����d: z�a/y E''1` o ADDRESS .`��`��� Cfi���-�s�r•6 i�cy!' ZONING SETBACKS Z CITY�' ZIP�� TEL.��/•_���.5� FRONT RW ❑_ ! p APPLICANT TEL._ REAR ❑ SIDE/SIDE STREET RW ❑ ¢ CONTRACTOR -= i'�• �' '� � SIDE U � ADDRESS . � �—�� ` , PROPOSED USE l'�'1?��'� «�� r" ri�I � CITY� �y ZIP �'��d/TEL. ���� fLS�'� � � u `^�-� ->-. h w ARCHlENG/ � z DESIGNER NO.DWEL. NO. a ADDRESS UNITS STORIES ' BEDROOMS f � CITY ZIP TEL. � N DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER-BI:ILDER�ECLARATION SFR/ADD/REM � Q I HEREBY AFGIflM UNDER PENALTV OF PERJUFlV THAT I AM EXEMPT FRdA THE fANTRACTORS LI� G2(dJB/C2fPOA W CENSEIAWFORTHEFOLLOWINGRFASON(SEC.7031.58USINESSANDPROFESSIONSCODE:ANYCITVOR (n U CAUNTYWHICMflEOUIqESAPEflMITTOfANSTPUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIHpNYSTpUC� I W PatiolOeck ,� W TURE.PRIOR TO ITS ISSUANCE,ALSO REQUINES THE APPLICANT FOR Sl1CH PERAl1T TO FILE A SIGNED ;; � STATEMENT THAT HE OR SHE IS UCEN6E0 PUfiSUANT TO THE PHOVISIONS OF THE CONTRACTORS ll� � CENSE LRW(CN�PTER B(COMMENCING WITH SECTON 7000)OF DIVISION 3 0F THE BUSINESSAND PRD� u' POOUSP9 ,t � FESSIONSCAOE�OR7HA7HEORSHEISEXEMPTTHEREFFOMANDTHEBASISFORTIiEALLEGEDEXEMP� �(� j � TION.ANYVIOLATIONOFSECTION7031.SBVANVAPPLICANTFORAPERMITSU&IECTSTHEAPPLICPNTTO Z qe-Roof A CIVILPENAL7Y OF NOT MORE THAN FIVE MUNDRED DOWRS(SSCO).)� �y 0 I.11,ASOWNEROFTHEPROPE(iTY,OFMVEMPLOYEESWITHWAGE5A5THE1flSOLECAMPENSATION; 0 COmmOfCie) { Z WILLDO TNE WORK,ANO�HE STRUCTURE IS NOT INiENDEO OR OFFERED FOR SALE(SEC.7�I4,6USI- J � N NESS AND PFOFESSIONS CODE',THE GONTHAGTORS LICENSE lAW DOES NOTAPPLV TO AN OWNEA OF j PRODEFTY Yh10 BUIL�SOR IMPROVES THEREON.AND WHO OOES SUCM WORK HIMSELF OR HERSELf OR �� THflWONH150RHEROWNEMDLOVEES,GROVIDEDTHATSUCNIlAPROVEMENTSARENOTINTENDEDOR m i OOFFEREDFORbALE.IF,HDWEVERTHE9UIL�MGORIMPROVEMENTISSOIOWRHINONEYEAROFCOMPIE� TKKJ,iME OWNER-BUILDER WILL HAVE THE BLIROEN OF PROVIN6 THAT HE Ofl SXE DID NO7 BUILD OR i = IMPROVE FOR THE PURVOSE OF SAIE). � � L'I,ASOWNEROFTHEPHOPERTY,AMEXCLUSIVELVCONTRACTING,WITHLICENSEDCONTRACTORS TO CONSTRUCT THE PROJEG7(SEC.70<4,BUSINE5S AND PROFESSIONS COOE:THE CONTRACTOR&LI• V21u8tiOf1 __._.,_______ADJ.AREA W CENSEL4WDOESNOTAPPIYTOANOWNEROFAGROPEHTVWHO8l11LO30RIMPHOVE9THERE-0N,ANO � NMOCONTMCTSFORSUCHPRQIECTSWITHACONYMCTOR(5)LICENSE�PURSUANTTOTHECONTNAC- QUANTITY DESCRIPTION FEE Y TOFS LICENSE LAW.7. Qu I AM E%EMP7 UNDERSEC. �.L P.C.FORTHIS flEASON U '?i __"_ '_ � � DATE OWNEH � Z W � LICENSED CONTRACTORS DECLARATION W IHEREBYAFFIRMUN�ERPENALTYOFPERJURYTHATIAMLICENSEDUNDERPROVISIONSOFCHAPTER � ! d 9(COMMENCING WI7H SECTION 7000)OF OIYISION]oF THE 6USINESS PND PFOFESSION3 CODE,AND Z �? X MY UCENSE IS IN FULL FORCE AND EFFECT. ' m LLf �s p� �� � LICENSE GLASS C- `'��✓ LIG.NO. � �7�-7 - j � � � V DATE����;�� CONTRACTOR :s . ' '�.� a .. n �� 'Y W e,�. �. i�,`���: .F:�. Z /� . ... � WORKERS'COMPENSATION DECLARATION `-''/ � �� 9 t=i� '�{ "„/ . U � N 1 HEflEBY AFFIRM UNOEfl PENALN OF PERJURV ONE OF THE PDL�OWING DECUNATION� \/ Z � � � _IHpYEANDWILIMAINTAINACERTIFICA7EOFCONSEMT09ELF-INSUftEFOHWORKERS' _ `s•1� � .. zt . � Z COIAPENSA710N,AS aROViOED BV SEC710N a7oo OF 7HE LABOH CODE,FOR THE PERFOflMANCE � a OFTHEWORKFORWHICHTNISPfRMITISISSUED. � t W .�IHAVEANDWILLMAINTAINWORKERS'COMPENSATI�NINSURANCE,ASREQUIRED9YSECTION � O 37000F THE LABOR COOE,FOR THE PERFORMANCE OF THE WORK FOfl WNICH THIS PEFMIT IS -- ISSUED.MY WONCKEN$'COMyP—ENSATION INSURANCE CARRIC-F AND VOLICV NUMBER ARE: CONSTRUCTION j CARHIER =^'� Y"'lv:�_ PLAN REVIEW _ ZDOLICV NUMBER �i"�� C 7 ELECTRIC _____ ¢ � (IHISSECiIONNE�NO7BE00MPLGTEDOFTNEPEWNiISFOHONEMNDfiEDOq1Ni4(ft00�OR PLUM8IN ,__. Z I C[HTIFY iHAT IN THE PERFORMANCE OF THE WORK FOF WHICH THIS PERMIT IS ISSUED,I CHANIc;e�� _ ti V' SHALL NOi EMPLOYANY PERSON IN ANY MANNER SOAS TO BECOME SUBJECT TOTHE ��� Uj WORKERS'fAMPEN5ATIONLAWSOFGALIFOFNIA,ANOAGREETHATIFISHOULDBECOME INSPECTIONFEE _ Sll&IECT TO THE WORKERS'COMPENSATION PROVISIONS OF SEC710N 37ao OF THL U1BOH S CODE,I SHALL FORhIWITH COMPL�WITH THOSE PROVISIONS. ISSUANCE � � SMIP p DATE: APPLICANT. __,__ � ENERGY P/C J WARNINO:FAILVRE TO SECURE WOPKERS'CAMPENSATION COVERAGE IS UNLAWFIII,AND SHALL 9E LL SU&IEG7ANEMPLOVER70CflIMINALPENAtTIESIWDCIVILFlNESUPTOONEHUNDREDTHOUSANU ENERGYPERMIT OOLLARS(5100.0OO�.IN AODITION TOTHE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN I '� -SEC710N 3708 OF THE LABOR CODE.INTEREST,ANDATTORNEY'S FEES. RETENTION FEE: I O CONSTRUCTION LENDING AGENCY PRE-ALT FEE: ___ IQ IHEREBVAFFINAIUNDERPENALTVOFPERJl1RVTHATTHEREISACAN57pUCTIONIENDINGAGENCY I n- FOR THE PEflFORMANCE OF THE WORK FOR WHICH THIS PEFMIT I5 ISSUED(SEG 309�,CIV.C.). Z W i � LENDEfi'SNAME__ � i— LENOER'SA�DRE55__ .--. ! � TOTAL FEES � ICERTIFVTHATIHAVEREADTHISAPPLICATqNANDSTATETMATTHEA80VEINFORMATIONI5fARFECL � � IAGREETOfAMPLVWITMIILLCIT'ANDCOUNTYORDINANCESANOSTATEUWSRFLATINGTOBl11L�ING � CONSTRUCTION,ANDHEHEBYAUTHORIZEREPRESENTATIVESOFTHISCOUNTYTOENTERUPONTHE Z PBOVE�MENTIONED PROPERTY FOR INSPECiION PURPOSES. COMMENTS Q ..��vsa�� �• �.,.�'�a/�,i' I � PERMITTEE NAME�PRpI T) a . 11�� � .��, . � � J 9 � �' �:��� � � -�",�-�',�-°-�- - � N SIdNANRE'OFP M� EE DA � RECPT.N0. PAID BY `- � VALIDATI- � . WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD--FIIe Copy,GREEN—ApplicanCs Copy _._�,__ ..... .....,r._�.,...�. ..--_ ::-.__. ....._�.. ....I .. ,C19{!) c .� � •. (� "�t1 'SS��ij'as (�y G.IUs J` C.� '7 �� ff' �7 � 1�:iSFi� TJ -� UA'7 t'! �� ��l� I �Rc�i,l .I . .� ..� Z���212!a�I•ri-RR�_"t5 � rrt p. _�7G�Oi0i��Q� C1IA �;-.3�7 �Em -� . �-I - � ' � ;q�{Ss�y,�y:. 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