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HomeMy WebLinkAbout14216 (19) � - ! CITY OF DIAMOND BAR i ��— DEPARTMENT OF COMMUNITY&DBVELOPMENT SERVI S 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-31 l7 PRESS '���»�°�,� BUILDING PERMIT APPLICATION FIRMLY � � JOBSITE •7 i�'(�f„ L UL�� .��IZ.111.�G� DATE CATION�� '�� INUMBEf�, � �. #/C 0 ADDRESS :.Zr� �V ISSUE TYPE OCC � � APN LOT� TRACT DATE CONST. GROUP i: p OWNER .f�h+G �[1ve��r`n _ � o ADDR SS��,Owc\ �a nMCr. ZONING SETSACKS — Z �J z�� � u' c�Tr h � ZIP�$_QS� TEL7''�Ie�c� g'�,� REART RW U---- � � APPLICANT 1—TEL. (.�.T��� SIDE/SIDE STREET RW ❑ � � CONTRAC70R� �-+. SIDE _ LJ_.__.__ ��+ � ADDR�SS� �eri� �/Q,� �p PROPOSED USE___ � w A CW rG/� +,~ � ZIP. �.�c'� TEL. l•?�A [oCl�-I --- --- ( z DESIGNER NO.DWEL. NO. NO. Y y ADDHESS UNITS_ STORIES BEDROOMS i � CITY_. ZIP TEL. z � - DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUA710N OOWNER•BUILDER DECLARATION SFR/ADDlREM "� p I HEREBY AFFlPM UNDER PENALTV OF PERJURY TMAT I RM EXEMPT FPOM THE CONTRACTOHS LI- G8f8QB/CBfPOf[ �' W� CENSEUWFORTHEFOLLOWINGREASON(SEC.7031.5BUSIN[33AtVDPFOFE551OY5CO0E:ANYCITYOR .: (n U COUHTYWHICHRC-0UtAESAPERMffTOCONSTRUCT,ALTER,IMPROVE,OEMOLISH,OHflEPAIRANYSTRUG �;�1� �� � Patlo/Deck }i W NRE,PRIOR YO ITS ISSUMICE,AL30 REOl11RE3 THE APPLICANT WR SUCH PERMIT TO FlLE A SIGNED W STATEMENT 1HAT HE OR SHE IS LICENSED FUflSUANT TO THE PROVISIONS OF THE CONTRACTOfiS LI• i'�� � CENSE LAW(CHAPTER Y(COMMEt�INO WITH SECTION 7000)OF DIVISION 30F THE BUSMESS AND PRO• LL POOUSpO ! FESSIONS LODE)OR THAT HE OH SHE IS EXEMPT THEREFROM AND TFIE 8A515 FOR THE ALIEGEU EXEMP- .�t TION.ANYVIOLATIONOFSECTION7031b6YANYAPPLICANT�ORAPEflMITSU&IECTSTHEAPPLIC�NT70 � Z Re-Roof j� F ACMI PENALTY OF NOTMORE TNPN FiVE HUNORED DOLLARS(f500).�: ❑I,M90WNEROFTHEPROPERTV,ORMY[MPLOVEESWITHWAGESASTHEIRSOLECAMPENSATION, 0 COfIlrtlefClBl si .�' .N7LL DO THE WOiLC AND THE STRUCNRE IS NOT INTENDED OR OFFEHEO FOR SALF(SEC.7044,B1151- J f NESSANU PROFESSKKJS CADE:THE CONTRACTORS LICENSE lAW ODES NOT APPLV TO Ml OWNER OF �'S N' PROPER'fYWFiOBUILD50RIMPROVEShiEREON,ANONM1IODOE&SUCHWORKHIMSELFORHEHSELFOR � ,� �� TMflOUGNXI50RHEHDWNEMPLOVEES,PROVIDFDTHA75uCF71MPRDVEMENTSARENOTINTENDEDOfl� � m �'� OFFERm FORSALE IF,HOWEVER,hIE BIIILOING OR IMPF04EMENT IS SqD WITHINONE YERR OFCOMPLE- �TION,THE OWNEfi$UILOER WILL HAVE THE BURDEN OF PNOVIYG THAT HE OH SHE DID NOT BUILD OR `j IMPHOYEFOHTHEPUflP�SEOFSALE�. '.W� ❑L0.SOWNEROf7HEPROPER'TY.AMEXCIUSNELVCONTRACTINpWITHLICEN5E000NTflAC70R5 ' :Q TD CANSTRU.M THE PRQIEC7(SEC.701a,Bu51NES5 PND PROFESSIONS CODE:THE CON7RACTORS LI- � V81U6�IOtl ___._.,,.._.._.__— _ADJ.AREA„____ � �W� CENSELl�WDOESNOTAPPLYTOANOVYNEROFAPFOPFRTYWHOBUILDSORIMPROVES7HEREON,AND s� MRiOCONTRACTSWRSUCHPRQIECT5W17HACONTRACTOR(51LICENSEDPURSU/WT70THECONTRAG QUANTITY DESCRIPTION FEE � TOpSIJCEN3ELAW.). -- ��'��.' ❑IAMEXE7APTUNDERSEC. B.BP.C,FOR7HISREnSON � �,. Q � � ,O U � �� �-- --- aC �LL'.: OATE_ OW4ER '' 'r Q. W !� .�� LICENSED CONTFlACTORu DECIARATION '' W ;� �������, I HEflEBY AFFIRM UN�ER PENALTV OF PERIURV THAT I AM UCENSED UNOLR PROVISI�NS OF CHAPTER � :'��-'• G(QOMMENCMXiW1TFI5ECT10N7000)OFDIVISION30FTHEBUSINESSANDPROf-E-.SS:ONSCOOE,AIJO ��' � ' Z � MY LICENSE IS IN FL1LL/FD�flCEAND EFFEC7. /a� � m �� ��0��� UCENSE CLASS y��___LIG NO. ���_![.L_— � � H, y � ''V"� DATE�Q• �-__,J -�4_ CONTRACTOR____ , . '' ` � W .I ;��! WORKERS'COMPENSATION DECLARATION ¢ I �. V } ��'� 1 HERf9V AFFIRM 11NDER VENAITV OF PER7URY 04E OF THE FOLLOWING�ECLAflATIONS: + �: Z i a � ��O�' _IHAVEANOWILIMAINTftINACERTIFICATEOFCANSENTTOSELF-INSUFEFORWORKEHS' 2 , ''..�', COMPENSATION,ASPRONOEDBYSECTION37000F?HELA�OIiCODE,FOHTHEPEPFOHMANCF W • _ 9F THE WOflK F9H WHICH THIS PF.RMIT�5 155UEU. � '� v :'�� �1 I HAVEAND WILL MAINTAIN WORKERS'COMPENSATION INSIIflANCE,AS REQUIRED BY SECTON ��.Q:� 37DOOF7HELABORODDE,FOFiTHEPERWRMANCE0FIH WORKFOflWXICHTHISPERM1T15 ; ISSUED.MY WO RS' PENSATION I NCE CARRI R AND�OLICY NUMBER ARE: CONSTRUCTION _._.__—. �.�,. CARRIER �-�e—' --- . � PLAN REVIEW ` --...�]�---.._ �:0��� pq.�CVNUMBER Ir�7E-►f.G7�s��.�1� ELECTFI,�C t ; .�. � -----..._..------- — -------- ���,� �ss[cnovn��noreEo�r.s�ErsooFn�aeawr�sroaon�r:w.x�E000iuns�sioo�oa�[ss). <:.PLUMBING ----._..._.— ,0: ,.,,w, ��,�,n : ;Z. I CERTIFYTHAT IN 7HE FERFOPMANCE OF THE WOFK FOR WHICN THIS PEHMIT IS ISSUED.I MECHANICAL _.______ �; :.;�(J� SHAt.LNOTEMP40YANYPEF50NINANVMANNFRSOASTOBECOlAESUOJECTTOTHC: .`y,',-;;";j;�.,. . � � :.�� WOFKERS'COMPENSATKKJIAWSOFCALIFOHNIA,PNUAGREETHATIFISHOULDOECOn1E INSPECTIONFEE __.,......._...._ '� = SU&IECTTOTHEWOiiNFRS'CAMPENSATIONPROVISIONSOFSECTION37WOFTHELA80R ISSUANCE � �.�.. �� -�j� GODEISHALLFORThIWITHCOMPLYWIhiTHOSEPROVI510NS. ----------�----- --�---------- — .,0�� SMIP �, p..�... �Va �,:, r+.,•:.�aa.. ,:p; DATE:.__C APPLICANT: _.__ ������-i�-.-�".'—____'___—__' . W� ENERGY P!C __...____— :J'. WI1qNINGFAILURETOSECUREWORKER5'CAMPENSATIONCOVERAGFISUNLAWFUL,ANOSHFLL�E ".':y'%e(�{-l.-;..'-i�,-;,.,:•..y;r,_�.;.��..g -"�^ SU&IECTANEMPLOVEftTOCRIMINALPENAI.TIESANDCIVILFlNE6UP700NEHUN�PEUTHOUSAND -ENERGYPERMIT'�� " ^ - ._—__._ DOLURS(fi W.000).IN AUDITION TO THE COST OF COMPENSATION,DAM�OES AS PROVIDEU FOR IN � �� SECTION37oeOFTHELABORCODE,INTEREST,ANUATTORNEI"SFEES. RETENTIONFE�����F P^��i 4� ..._..._._.. ._--- �,.�., ONSTRUCTION LENDING AGENCV PRE-ALT FEE: ._._—__.__..— — :;'��� I HEpEBVAFFIRM UN�ER P NALTV OF PERJURY THAT THERE IS ACANSTfiUCTION LEN�ING AGENCY __ _ ____..___.___ FOfl THE PERFOFMANCE THE WORK WR WNICH THIS PERMIT IS ISSUED(SEC.3097.CIV.C.�. 1 Z O � _w —"__"_ _'_'"_'_—__ _—____"" �� LENDEB'5NAME___ � .. �' .. _ _._—_"— . __..___—'—.... ' F- LF.NDC-R'SADDRE55___' --.—...._.. --'""'-'-- uq.-'.`J � � ICERTIFYTHATIHAVEREADTHISAPPUCATIONAN�STATEh1ATTHEA60VEINFORMATIONISCOflFECT. TOTAL FEES �� � " � IAGqEETOCOMPLYWITHALLCITVANDCOl1NTVORDINANCESAN�STATEIAWSRELATINGT09UILI7ING � CONSTRUCTION,AND HEREBY AUTHORRF.REPRESENTATIVES OF THIS CW N7V TO ENTER UPON THE � ABOVE�MENTIONEU PHOPERN FOR INSPECTION PURPOSES. COMMENTS_ —_._ _ : � Or,l �S ��� -- -- � m PERMITTEE NAAIE(PRJI�T) �.f < ."''C�se �A� � i n�� tn •���t�tJ! Jai✓ --- -- y SIGNANHE OF PEHIAITTEE DATE � Z RECPT.NO. __PAID BY � � VALIDATION�I���� ���� WHITE—Depedment Capy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy.GREEN—AppliranCs Copy _ . _, „ �; , -� .. i � 6 � �3i�'"a . �. 1 ... ( � � k � i i '. �� r �� � � _ .� � � � ��''�"�'� � ,, ; . � •. 4 t f r f i ,--� � s,�: � ����7��, � � � i� I �� � 1 , i T i - I ;} I. �� � � t � �i I� ��, �� � i � C a � ���t .� �f�, � � V � S � Y, i .t � , ,� � }� i � � , .t; t :,i -!� .`i �, .. � a � t I 1 �� •_ ht�i�P � r k '. � ' I ; y ! �y� ' � , � %� �.�� ��'� ` ,� '� .�, i , i i . 't i i ��.h a ; ' - �, � i �: � � � kb�� M s A ' I . � . � � I �� E I �� � i ��a � ���� ..�� ... ,3�:.,r�. � # ' i �'; � .'' I ' � i j , I � � � � ' � , � � _ �'�3.r � � i - t--� � � > - - �. ,;... '��_ : --- - - -- �_._ " � � �y�� .. l ' ; , I ` ; � ( ! I I Ii � , ` ��� � � 1 � �� � ,� � � ' , I � ��� � � �!, � (I ,�� � � % I ' ',� i ' �. _ d � �, �7i'G 3 Y ! 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