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HomeMy WebLinkAbout13319 (14) �� CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&.DEVELOPMENT SERVICES 21660 E.Copley Drive Suite 190 (909)860.3195 Faa(909)861-3117 PRESS ����'�� BUILDING PERMIT APPLICATION FIRMLY y JOBSffE APPLICATION PERMR ` P/C o ADDRESS � I � � DATE -��� NUMBEFi 1 A c� ISSUE TYPE OCC APN LOT� T ACT DATE CONST. GROUP p OWNER �` ADDRE55 ZONING SETBACKS Z CITY �Y`V�L✓l � ZIP� TEL. ' FRONT RW O g APPLICANT TEL. REAR ❑ � SIDE/SIDE STREET RW ❑ CONTAAC OR � SIDE O � ADDRESS * PROPOSED USE CITY 21 TE � ARCH/ENG/ • UESIGNER NO.DWEL. NO. NO. ADDRESS UNRS STORIES BEDROOMS � CRY ZIP TEL y DESCRIPTION SO.Fi. FACTOR PSF ADJ.AREANALUATION Q OWNER•BUILDER DECLAFiAT10N SFR/ADDIREM O p I HEilEBY AFFlNM UNDER VENALTY OL OERAIRV THAT 1 AlA E%EI-�VT iROII TM[CONTRACTORS L4 Garage/Carport lL CENSEUWFORTMEfOLLOV:INOREA50N(SEG7o3i.6BU5�NES5ANDPROFE5510NSCODE:AN'ICRVOR (n � � � � COIIMYN}X7/REOIMESAPEHMRTOCOhSTPUCT,KTEfi,IMf'fiOVE,DEMOUSM.ORRCPAIRANYSMUG W patia'Deck � �" iURE,PRqR TO ITS 158UANCE,A150 REOUIHES TNE APPLICANT FOR Sup1 PERMIT TO FlLE A S�GNED W � ETATEMEHT THAT HE OR SHE IS LICENSEO NJFi5U11NT TO TNE PROV610NS OF THE Cn0l1MCTORS L4 � CEN9EUW(CHAVTFR9(COMYCNCWOWITHSECTION7JOD10FD�Y�S�ON]OFTNEBUSINESSANDPRb � POOUSF� iESS10NS COOE)OR 711AT HE OR SHE IS EXEIAPT TM[REFROM AND iME 6ASIS FOR iHE ALLEGED E%EMP• TqN.MIVVIOLATqNOF5ECT10N7W1.6BYANVA7PLICANTFORAPEiWITSUBJCCT5T11E�PVlICANTTO Z RrRool � ApVILVENALTYOFNOTIAORE7HNIFNEINNOREDDOIURS(f500).): � OL�40WHEHOFTIEPROPERTY,ORYYEMPLOYEESN�TNWAGESASTHE�RSOLEC04PENSATqN, O COrtIrtIBfCl31 � ' 1MLL DO 717E riOFK AYD TNE STRUCTURE IS NOT IMENDED Oit OFFERED fOR SJLLE(SEC.7ou.BU51• J ' NE55 N/D VROiE55lONS WOE:T11E CONTMCTORS UCENSE lAW DO[5 NOT ACPLY i0/u70WNER OF N PIiOPERTYIM�OBUlD50RIMPiqVESiHEREON,AhDYAlOWE55UpIWORKHIMS!'LFORHERSELFOR � Q TNROUGHH190RNENONMEYPIOYEES,VROVIOE�TFIATSUGIMPROVEMENTSARENOTNTENDEDOR m ' � OFFERED�ORSALEIF./ION�EV[RTME6ULDw60RIMPROVE41EMI550LDWRXMONEYEMOFC047LE• Z 'TION,TNE OWNERAUILDER W1LL W1VE THE BURDCN OF OROVINO TMAT HE OR SHG 0�0 NOT BUIID OH � MPfWVE FOH THE VUA705E OF SALEF � ❑�ASOMMEROFTMEPfqPEffi`/,AMEXCLUSIYELYCONTMCTW�Y/ITNLKENSEDCONTMCTORS i0 CONSTi1UCf TF1E PH0.IECT�SEG 7oN,BUSIAE59 N1D Vf10FE55IONS COL'E:T1[CONTM�TORS LI- V01t10ib11 ADJ.AREA CFHSE UW DOES NOT MPLY TO AN OWNER OF A PROPERTY WHO BUQDS OH IMPFlAVES TM[RLON.AND � WI/OCOMMCTSFORSUCHGRQIEGTSWIhiACONTRACTOR�S�LIC£KSCOPMSUMITTOTHECONiM0. QUA TV DESCRIPTION FEE � TDRSLICENSEUw4 OIAMIXEMPTUNDEHSEC. B.�P.C.iORTHISRE/SCN Q U 3 Q 1 � LL' DATE OwNER V � UCENSED CONTRACTORS DECLARATIOy W ' w A t`. � 1 NEHEBYAFFIRM UNDER PENALTY OF FERIURV THAi IAA1 LMENSED U�DER VROVISiONS OF CHAPTER U, � ��GOMMENCNOMliTMSECTqN70o07OFDMSqNJOFTIIEBUSINC5511N�PRCFESS�ONSLOCC,N:D Z X MN IICENSE IS W ML FORCE M1D EFFECi. lL .ryr�' /` � �` � IICE SS_ �`� LIC.h0.�� � � J �'j DATE _CONTMCTOR� p�.� _ . a w J v5 � WORKERS'COMPENSATION DECLARATION � �t i U � 1 HEREBYAFFlRM UNDER PENALTV OF PERri1RY ONE OFiNE FOLLOw'+iC OECUMTqNS. �� N , Q � �IhUVEANDW:LLUANTNNIICEFTIFIGTEOFCqi5ENT70SELF•INSUREFORNJRKERS' _ COMPFNSATpN.ASVROVIDE00YSECT10N77o00FTMEUBORCOOE,FOIiTMEPERFORMAVCE W OFTHE WON(FOR WHIG1 TNIS iEpAIIT IS ISSUED. � `2 ��I lu'JE 11M7 w'LL MAINUw WORKERS COMCEnS�TqN iNSUMNC[.AS RE W�RED BY SECTION Q �� 77000F iME L/➢OR CODE.FOR TIE PERFORAUWCE OF iH[WORK FOR YhIICHTM!S PERMI715 , � ISSIIED.WNOpKERS'C011FENSATIONINSURANCEGRRIERA40PDLICYMJIADER�RE: CONSTRUCTION � uRwER� � O� PLAN REVIEYJ _'^r�� � �l"_/, L.// � poucrNuuBER _ � _ ELECTRIC � j_��= � (f1�S5ECiriJ![IDNOTe[LOI.iIETEDOFTEPfMST6FdiWEHll�i%1[��fil[SS1. PLUMBING W MECHANICAL �1`� b�I� Z 1 LERIIFY THAT pl7}1E PERFORMANCE OF THE WOHK FOR WNICN THIS PER�AIT IS ISSUEO.I (J SMILLLNOTEMPLAYu1YGEN50NNMIYMrNN[1t50A4708ECOM[SUOJECTTO7nE � WOPo(EFi'COMPENSATIDNUWSOFCN.IFOR.��Ml�AORCEiMATIF15MdiL�BECOAIE INSPECTIONFE[ S SUBJECTTOTNEYlOitKERS'WUPEI:SAT � VISIONSOFS :7� THEU^OR I� ��n�vnn� n� PAov ibn5 ISSUANCE ����U % 4} ' p DATE: APPLI ANi: . SMIP il � ��+ f`�� � ENERGY P/C �+�, p ��'" '�' ��Z AR WARNI .FAILUR�iOSECUREN'ORKERS'COM 'NSATIONCOVEMGfISUNUWfUL.IWDSNALLBE �I1�=-�72+-�;��e�i}��L �+ � SUBJECfINEAIDLOYER70CR1uINALOENALTIESMOCMLfINESUPTOdJEHUNDREDTHOUSAND ENERGYPEFlMI /'� �*Tj`CA'('(.TY DOLIARS(t10o,000).NADDIiiO1lTOT51ECOSTOFCOUPENSATqN,DAAI�GE5A5VROV7DEDFORIN �U���� ,_.4.!�. • � J SECTqN770sOfTHEUBORCOOE,INTEREST,ANDATTONICY'SFEES. �EjENTIONFEE: Q a CONSTRl1CTION LENDING AGENCY pRE•ALT FEE: Q IHEREBVAFflFlMUNDERPENALTYOFPE0.NRVT1UTiMEREISACONSTAUCTIONLENDINOAGENCY d FOqT1EVCRWRM/NCEOF7NEWOPXFORWHIdITMiSPFRAIITISI55UED(SCC.�OY7,C�V.G�. � � � LEHDERS NA/dE � � LENDER'SI�DORESS W I CER7IFY TMAT I HAVE READ 7HIS IIPPLILATION AND STATE THATTiE AOOHE C�FOFiMATION IS CORR[CL TOTAL FE ES 1 � IAGREETOCOMR`/WITHALLCfTYMlOCOVNTYORDIN/wCE5AND5TATEUN'SREUTINOTOBU0.DIN0 CONSTRUCTION,AND HEREBY AUfHORIZE PEPRESENTATIVES OF iH15 COVNTY TO ENTER UPON TME Z AOOVE�YEN7qNCJPIiOPENttFORINSPECTqNGUR{'OSES� COMMENTS � �����\ .�— 17 L m CF NA/�E WRTJ� w �� / (A TUH[OFPERMIiTEE OA7E � FiECP� FAlD BY VALIDAT10N WHITE-0eDartment Gepy,YELLOW--Finance Wpy,PINK—Assessor Capy,GOLDENROD--File Copy,GFEEN—ApplicanCa Copy . 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