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HomeMy WebLinkAbout12495 � _. . r.... �lU r�. �.. �,� _ CITY OF DIAMOND BAR -� DEPARTMENT OF COMMUNI.TY&DEVELOPMENT SERVICES .�-. �� . 27660 F..Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PR ESS ''"''.HN'�� BUILDING PERMIT APPLICATION FIRMLY � JOBSITE ¢ ADDRESS,Z�����'��`� a �'�1 A�f�`l APPLICATIOy � ���� PERMIT r� �!C p —�— DATE f � s� NUMBER�. � ISSUE ` TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER ADDRESS� Ci,' �°I,�' �•S �`1�'���./�� ZONING 5[TBACKS � FRONT qyy ❑_ _ _ Z CITY ZIP TEL. REAR ❑____ g APPLICANT `� _� TEL. SIDE/SIDE STREET___ RW ❑ �� CONTRACTOR ��N,? �w�'��I�F' SIDE [-� ADDRESS e a���� ��'�'�'�/s I,Y 1 C A ,�' - .� — � �' �� �' ,� ,� PROPOSED USE a�� ,���.�4„°�''I��t'" >/S ; �d,� , " ��'_���� a CITY ZIP�_ TEL. � '�`A . '7 t • "' �o d., - _ , .r b w ARCW G! w z DESIGNER w NO.DWEL. NO. . NO. �i� o. ADURESS � CITY ZIP TEL. UNITS STORIES _BEDROOMS__ � � DESCflIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER-BUILDER DECLANATION SFR/ADD/REM O Q 1 HEREBY AFFIRM UNDER PETlALTY OF PERIURY THAT I AAA E%EMPT FROM THE CONiRACTOHS L�� G2fe]0/CefPOfl ' W CENSEL0.WFORTHEFOILOWtNGPEASIXd(SCC.�o31.56U51NF.S5HNOPROFESSIONSCAOE:ANYCITYOR (n U COUNTYNh11CHNC-0L1IRESAPEFMRTOCAYS7RUC7,AL7ER,IMPROVE,DEM.OLISH,ORpEPA1RANVSTFUC- W Pg�iO/DBCk Z��' TURE,PRIOR TO ITS IS6UANCE.ALSO REQUIflES 7HE APPUCANT FOR SUCH PERMIT TO FILE A 516NED �W STATEMENT TMA7 HE OR SfiE IS UCENSE�PURSUqNT TO TME PqOVISIONS OF 7HE COtJTRACiORS LI� �"U CENSE LAW(CHRPTER B(CCYdMENQN�WITH SECTION 7000)OF DIVISION 3 OF THE B1151NE5S pN0 PHO• LL' P001/SP2 FESSIONSCODE)ORTHATHEORSHEISEXEMPT'fHEREFROMANDI'HEOASISFOFTHEALIEGEDEXEMP• � TION.MIYVqLATKKJOFSECTION�o31.58YlNYAPPLIC�NTFOqAPERMITSUBJECTSTNEAPPI.ICANTTO z qe_p�� A CIVIL PENAL7Y OF NOT MORE THAN FIVE HUNDRED DOILARS(S5ao).): Q ❑I,ASONRJEqOFTHEPROPEHTV,ORMVEMPLOVEESWITHWAGESASTHEIRSOLECOIAPENSATION, � Commercial � Z WILLDO THE WORK,AND THE STRUCTUHE IS NOi INTEND=�OR OFFERED FOR SALE(uEC.�049,BU51� J � NE55 AND Pf10FESSIONS CO�[:iHE fANYRACTORS LICENSG LAW�OES NOl'APPLY 70 AN OWNER OF . � PROPERTY NRdO8UI1DS OR I/APROVES THEREON,AND V1i{O DOES SUCH WORK NIMSELF OR HERSELF OR � THRDUGHHISORNEROWNEMPLOYEES,PflOVIDEDTHAT9UCHIMPROVEMENTSARENOTINTENDE00R ' m � Q- OfFEFEDFORSPLEIF,HOWEVER,THEBUILOMGORIMPqOVEMENTI550LDWITHiNONEYEAROFCOMPLE� � TION,THE OWNER$UILDEFi WILL HAVE THE FIUFDFN qF PROVINO THAT HF OR SHE DID NOT BIIII.D Op IMPROVE FOR THE PURPOSE OF SALE�. � ❑I,AS OWNER OF THE PROPEIiTY,AM EXCLUSIV[LY CANTRAGTING W ITH LICENSm CONTRACTORS ¢ TO C�NSTRUCT THE GRQIECT(SEC,704d,9115ME55 AND PROFESSIONS CODE:THE CONTRACTORS U- V8If1Bf10l1 W CENSELAWDOESNOTAPPLYTOPNONRJEROFAPflOPEH7VWHOBUILDSORIMPRWESTHEREON,AND ---���--�-�---ADJ.AREA__._,.,_._,_..._____. __ � WHOCOMRACTSFORSUCMPROJECTSNATHACONTRACTOR(5]LICENSF�PURSIIANTTpTMECONTflAG qUANTI7Y DESCRIPTION FEE � TORSIICENSFIAW.). CIIAMEXFMf'TUNDERS�C._______,_,__,__,______8.6P.C.FORTHISREASON Q � U LL � DATE OWNER I- . � Z —___"'_.'.__.__...__'_.-- U . .F LICFNSED CONTRACTONS DECLARATION W J � IHEREBYAFFIRIAl1NDERDENALiYOfPER111RVTHATIAMLICENS[OUNOLRPROVISI�NSOFCVIAVTER � d 9(COMMFNCWOWi7HSECT10N700D)OFDIVISION30FTHEUUS:NESSANDPROFESSIONSCO'JE,AND Z X� MY UCFNSE IS IN FULL FORCENdD EFFECi. m — ta� 4'� � LICENSE CLASS LIC.NO._���1�,___ "�Y j �. DATE �' �T CON7RACTOR_[�.ea�_[�✓�q a W , �'' j - t; � WOflKERS'COMPENSA710N DECLARATION -+ - � a �� � IHEHEBYAFFIRMUN�EflPENALTYOFPERNRYONEOFTMEFOLLOWINOOECLARATIDN5: z � IHpVEMlDWILLMAIN7'AINACERTIFICNTEOFCONSENTTOSELF�INSUfiEFORVlORKERS' � --- 2 Q �"�COMPENSATION,ASPiiOVIOEDBYSECTION3"/nDOFTHE�APORCO�E.FORTHEPERFOFMANCE � O OF THE WOPK FOR WMICH THIS PF.RMIT IS ISSUEO. � �� Q ___IHFVEANDWILLMAi1drRINWORKERS'COMPENSATiONINSURANCE,ASRE�UIREDBVSECTION ✓^'� `� � � �. Q 37000FiHElABORCODE,FORTHEPERWRMANCEOFTHEWOflKFOflWHICHTHISP[RMIT:S � U�' / '� '.' _ ISSUED.MV WORKERS'COMPENSATIO IN5URFNCE CARFIEF AND POLICY NUMBER ARE: CONSTRUCTION _.,____„, _ __ . �_�G�_ ` � CARRIER��"���.���r���..__..._._......_-�---......._---------- PtAn Aeview __---...........-- --.......---------- . � aaicvnu�Ea___C.� _ EI_ECTRIC : --------- � - --._... ------- - ' � (MISSECt10NNE�NOTBECOh�LEfEO hiEPER�MISfOiiONLkiUnDAEDD]I.W7S(StOD)OpLESS� PLUMBING . ._.........._._._-...._ _'_"' �..y �Z I CERTIFY THAT IN TNE PEHFORMANCE OF TH[WORK FOR WH:CH 7HIS PFRMIT IS ISSUEq I MECHANICAL � , _.....---"_"_'_- ___ ;� SHALLNOTEMPLOVANYPERSONIN�NYMANN[R50ASTOBECOhIGSUFlJF.CTTOTHF. ,;. � �' � WORKERS'COMPENSATIONLAWSOFCALIFURNIA,ANDAGREETHATIFISHOULDBECOME INSPECTIONFEE � �� ..___.._. ._ Yt� = SUQIECT TO THE WORKERS'COMPENSATION PPOVISIONS OF SECTION 370o OF THE LADOR • CADE,ISHAILFORTHWITHCONPLVWITHTHOSEPROVI iads. ISSUANCE ,_.....__ ' � __._, ,__ = t � , ��,(J L� fJ�h/ • r SMIP r, .�: DATE:-� I�"'/". APPLICANT: "��F-�.—___"'.....'_.— - _-_._"_ ;. .�4' 'J WARNMCFAIWRE"fOSECl1iiEWOHKERS'COMPENSATIOYCOVERAGEISUNLAWFUL,ANDSHALLBE ENERGYP/C .. a..._��-�r-;,- �. `� ��-'----......._...----------.._.. . ;LL�'; SUBJECTANEMPLOVERTOCFlIMINALPENALTIESANOCIVILFINFSUPTOONEHUNORf:�TNOUSAND ENERGYPERMIT V1d{ _i__tl INN�/ DOLIARS(5700.000),INPDDITIONTOTHECOSTOFCOMPENSATION.DAMAGESASPHOYI�EDFORiN - `�'���--�-��--- -... _.. �J: SECTION97080FTHELABORCODE.INTEREST,AN�AiTORNEY'SFEES. RETENTIONFEE: .CC; ,�v� iA��/�'�T y.� "_'_'_ _ `� CONSTRUCTION LENDING AGENCY PRE-ALT FEE: 4yy�1TY T�7��a�!w�.77i►ir.J�1w'N�37� O� IB�WSi\`,��:�il���� .�� I HEREBYAFFIflM IINOLR PENALN OF PEFJURV THATTHERE IS ACONSTHUCTION LENDING AGENCV '�� FORTHEPERWRMANCEOFTHEWORKFOHWHICHTHISPEFMITISISSUED(SEC.3097.GV.C.). '- <: Z' yi W' —_"_' LENDER'S NAME � �,= _,.'__"--_"_-"__ ____...__.. F-: LEN�EH'SADDFFSS "_...""-----'_"--'—..... _ � TOTAL FEES ' � 1 CEflTIFY TMAT I MAVE REAO THIS APPLIGATION AND STATE THAT TME ABOVE MFORMATION IS COHRECT. �' W I ACREE TO CAMPLV WITHAL�CITI AND WUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING � i n... ,�` :Z, CONSTRUCTION,PNDNEHEOVAUTHORIZF.RLPRESf:NTATIVF.SOFTHISCOUNTYTOENTERUDONTHE A80VE�MEIVTIONED PROPERTY FORINSPECTION PUHPOSES. �^ ,{ Q COMMENTS. ,�_-` .• �� �� __ � _+ �' r I, � --- ------ m PERMI E N (PRINT � �'- �,¢� ._. r T� Q - �+- ----- , ;v�� . ' _—������f _ _... � �(n SIQNANREOFP TfE (� r AT �--�'�J]�� ��;: _, -� RECPT.NO. _.._.___._�.._PAID BY ., VALIDATION_ � j; ~� WHITE-Department Copy,YELLOW-Finance Copy,PINK-Assossor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy i: j•. t ,_. .,... ,_ , �� � �� �� ��� � ��� �� � � � t � � � ; , �� � , � �_ � , : i ���� t�#���t 5 3 5 n � , f I ; � & t �I � o i fi i 3 . � , a ' � ����� .. 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