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HomeMy WebLinkAbout13805 (14) �� �� CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � „� . 21660 E.Copley Drive Suite 190 ' (909)860-3195 Fex(909)861-3117 PR ESS �'�^'� BiJILDING PERMT!'APPLICATION FIRMLY � JOBSITE APPLICA�Tf ON PERMfT I ��Q P �-� o ADORESS 2-Sg1 D ��., GOPLEY �- DATE "1•�• '�1Q NUMBER� x � APN LOT� TRACT�f0�� DA EE CONST. � GROUP ,�, � OWNER . p ADDRESS?.03o M9�N �. SI� ZONING SETBACKS �w CITY_�_�lI�VC �IP�yj1� TEL9W�1�Z2•1`1Sa FRONT RW ❑ APPLICANT To��pL�n/' TEL7'�1A•7��I.ly� FiEAR ❑ � SIDEISIDE STAEET RW ❑ CONTRACTOR O QuS W�i L�-,itST�LTi a� Cc'��,�_ SIDE ❑ ADDRESS �3o MAi.I ST. S ti�-t� �2c� g C(TY—_I���C` CIL, ZIP Za1 TEL�Ih9-(v�2-[�15 PROPOSEDUSE G�l C�h�✓'- o�-Cree T/ +P� ARCH/ENG/ • DESIGNER �OaGG'�'7 ADDRESS�4���I'2G U�"' q 1 lr. , � NO.DWEL. NO. NO. � CITY _IY'u4{� ZIP1�LnlQ �TEL9+t9']Z�/•/ UNITS STORIES 2 BEDROOMS �n DESCRIPTION Sa.Fi. FACTOR PSF ADJ.AREANALUATION p� OWNER-BU�LDEp DECURATION SFRIAD�/REM O 8 I HEREBY AiFIM UHDER VEWILTY OF PEMIRY TNAi I MI E%EMPT FHp1 THE CONTMCTORS L4 GaragelCarport � CENSEUWFOR7MEFOLLOWIN�REASON�SEG70.71.68USWESSANDPROFESSIONSCOOE:ANYpTYOq (n WU/fTVNILIICNRF041fiE5ADEN.IRTONfJSTAUC..ALTER4VROVE,DElA0U51lORRLFA10.11NYSTRUG W patio/Deck 7URE,VRIOR TO RS 68UANCF.AL50 REOUIRES 7HE APPLICANf FOR SUCH PERAIIT TO i1LE A SIGNED W � STATEMENf 1HAT HE Ofi SME 6 t10EN5ED MIRSUANT i0 THE PROVISKKIS OF 7HE CONTMCTORS tF � � CENSE LAW(CHAPTEH Y(07MMENCN�WITH SECTqN 7D00�OF DM510N 10F TME BU51NE55 AMJ VR0 POOVSP� iE5510N5 COO�OR i11AT ME OR SHE IS EXEMVT 7MEREFR0IA AND TNE BASIS fOFi iHE ALLEGED E%EMC• T�ON.MINVKYATIONOFS[CTION70J1.6BY/NYAPVLICMlTFOFiAFERMITSUBJECT57HEMPLlCANTTO Z qe.poof F A CML VENAITY OF NOT MORE iHAN FNE HU/�DNED DOLURS(i600).): � OI./SONTIEROFTNEPROPERN,ORMYEwPLOYEESWIlNWAGESASiHEIRSOLECOAAPENSATION, COmmBfCldl � MALL DO THE WORK,N1D THE STRUCTURE IS HOT IHTfNDED OR OFFEHED FOR SALE(SEG.7W�,BUSF � N HE55 AND VROFESS:OMS OOOE:THE COffTiUCTOR9 LI�NSE UW OOES NOT APPLY TO AN OWNER OF ? /ROPERTY M1M0 BULDS OH M1FR0`/E57HEREON,AND WNO DOES SUp7 WOFK MMSELF OR MEilSELF qi � TMqIX1OMW50RMERONRIEMPL01'EES,GROVDEDT1Ui5UpIMPqOVEMENTSARENOTMENDEOCA Cfl LS1 pFFEqEDiORSALEIF,NOWEVERiMEBUIDPWORMIPFOVCMFNiLSSpIDNATNINONEYEAROFCOMPLE• � 'TqN.THE OYMER�BUILDEH WILL MAYF THE BUFiDCN OF VRONNO THAT HE Ofi 6NE DIO NOT BUILD OA 6/VROYE Fdi ME iVRPOSE OF SALE} W OL�OMMEROFTHEVRDVEHfY,JUAE%CLUSNELVCOMMCTIJnN17HLKENSEDCONTMC70R3 � 70 CONSTRUCT THE PR0.IECT(9EC.7oa�,BUSWE55 AND PFqFESSIONS CODE:THE CONTMCTORS U• V81118I1Of1 + ADJ.AREA CENSE UW DOE9 NOTMPLY TO AN OYR�ER OFA GflOPERTY WHD BUIlD3 OR MPpOVES THEREON,AND � YAfOCONiRAGTSiOHSUp/PRQlECf5MAT1ACOHfAACTOfl(5)l10ENSEDVURSUANiTOTNECONTRAG pUANTITY OES RIPTION � �E � Toas ucensE uw.�. O I/J.1 EXEYPf UNDCR SEC B.l V.G LORTNIS NGSdJ Q 3 � LL DATE ONNER V " � LICENSED CONTRACTORS DECLARATION � � w IMEREBVAFFWYUNDERVENILLTVOfPE0.tt1HVTHATIIWUCENSEDUNDEROf10VI51ON50FCHAP7ER V, S �fCOA1YFHClK1 WI7H SECTION 7000�OF OMSION�OF iME BUSINE451W�PROFESSqNS GOOE,A4D Z X W LICENSE IS W FULL FORCE MA EFFECL m � 110ENSE CUSS • � ��c.No..�0 9 5�t t y � �j DATE �'1-3O1 OO CONTMCTOR��J+W�i�-oJ��ZJC�I :� a � WORKERS'COMPENSATION DECUIRATION a � IHEREDYAFFIiUIUNDERPENALiYOFPERIURYONEOFiHEFOLLOWINGD[CURATIONS: � , Z , . � �IHAVEMON1LlWUNTAMACERfIFlCATEOFCONSEMTOSELFdNSUREi00.YloAxEiYS = � - � � . COMPENSAiION,�SiROVOEDBYSECT10N77o00FTMELABORC00E,FOHTTiEPERFORMANCE `U O OFiMEN'OFi1CfORWHICHTH15DERMITtSI55UED. �. , � � � � • �1 HAVE AND N1LL YAIHTAN WORNERS'COMPENSATION INSURANCE,AS REWIqEO BV SECiIC*! Q 7/0o OF hIE U90R O00E.FOR THE PERFORMNICE OF 7HE WORK FOR YAIICM TH15 PERAIIT 15 � . � ISSUED.MYWORKERS'COYPEHSATIONINSURANCEGRRIERANOPOIICYNUMBERARE: CONSTRUCTION ��� ��� �� ��• D � UAWEN �l(rM1��rISUiL],�[.��►�A PLANREVIEYJ f� lY� � POUCYM1l18ER 1 M�3o1381 Z(o�-O! ELECTRIC � ' .� •g � (Mssccnonr+c�noreeaM�moFn[rcw.�rswna+[��oouans�siw�cn�ss} PLUMBING . � • � -0�b 2 ICERTIFY7HATNIHEPERFORIMNCEOFTHEMK)i1KFORWV/ICHTHI50ERuiTISISSUE'J,I MIECHANICAL ` �� �lGV•� �7 SHAlLNO7EMPLOYANVVEP50NWMIYMANNERSOASTOBECOAIES'J0.1ECTTOTNE 1 . � WORKERS'COMaEN5AT1oNLAw50FCALIFORNI�IWOACPEETHATFI5��0ULDeECOME INSPECTIONFEE, � SU&IECTTOTMEWORKERSCOMPENSATqNG DFS ]7aoOFTHELA➢OP COOE.I SM1LL1 FOfiTMwfTH COMVLY Yn� ISSUANCE pDATE: '�' �I R APPLICANT: '����� SMIP � f O � ENERGY P/C � � WnHNiNO:FAILURE TO SECUHE WORKERS'COMVENSA7iON COVEHAGE IS UNUWFUL,MJO SMALL BE �y,,, SU&IECfM!EMPLOYER TO CRIMINAL VENFLTIES AND CNIL FNES UP TOONE NUNDRED T1i0U5AN0 ENERGY PERMIT �� DOl1ARS(f f 00,0001.IN AD�IltON TO THE COST OF COMPENSA7pN,DMIAGES AS PRONDED FOR IN � SECTnN77oeOFiNEIABOHCODE.wTEREST,�wDATTOaI:Ev'SFEES. RETENTIONFEE: � 'O OCONSTRUCTION IENDING AGENCY �. �T � IHEREBYAFFIPoAUNOERVENALTVOFGE1ilUMTHATiHEHEISACONSTRUCTbNLENDW4AGENCY � FOR iHE VERFOPYANCE OF iME WORK iOR WHICH TMIS PEfiMIT IS ISSUED�SEC.]OV7,CIY.C.� . W r lI � LEPIDEfYSHAME {�l�l IIArTf(k-�A�—�J�T-IIL . C LEtaOEH'SADDRE55 �S7.�CS�l�17t7. �icFTn�J h{A O�L�-I �p h W ICERTiFY71uTIHAVEREADiHISAPDLICATIONANDSTATETVUTTIEABOVEINFORMATqNISODRR[CT. � TOTAL FEES ;Y���, �' V• , � 1 AGREE TO COfAPIY YA7H ALL CRY ANO COU�T'ORDININCES AND STATE UN"�REUTwC1 TO BUILDiNO CONSTRUCTqN,AND HERCBY AUTqRQE REPRESENTATIVES OF TW 5 COUHiY TO EMER UPON h1E � ABOVE�MENTqNED iROPERiY FOR WSPEGTION GURPOSES. �Y� � � rJ/�n M�/� tr MENTS ��v•••-.� � � �Ar1AAl.C-S. 1 t�►�NAb,/� � b � mf� /�� � ¢ PERMRTEE NAM (PNIHn � v I�y[� iC1V ` � ��� ` � (�j B�ONATUR OFP 1 E �I OAiE � , � • -ZI-� RECPT.NO.� PND BY� VALIDATION ITE pertment Copy.YELLOW-finano�Copy,PINK-Aewt6or Copy,GOLD NROD-File Copy,GREEN-Applicent's Copy / /r+'1 1��D �� CITi Y OF DIAIVJOND BA(� . . � � '. 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