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HomeMy WebLinkAbout16467 (9) � � � CITY OF DIAMOND BAR ---�— DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �`�� 21660 B.Copley Drive Suitc 190 �`',� `�pRESS � � (909)860-3195Fax(909)861-3117 �/� ��������� BUII.DING PERMIT APPLICATTON FIRMLY JOBSITE APPLICATION 1.�� ` ' PERMIT i( (.,�(� P/C a ADDRESS�_�Z?I C�����L��'��-� _ �'_ DATE_ �J� 1 �'��� �, NUMBER lG t `t�� # � �SSUE NPE dCC APN LOT_ TRACT_ DATE CONST. GROUP p OWNER r Al�l��/�?�t�a� . p ADDRESS SQ Y - . ZONING SEfBACKS �"' CITY� Q c^� _I.�-��. ZIP I TEL. 'i��6���� REART RW �i -- APPLICANT TEL. SIDEJSIDE STREET_ RW f7 CONTRACTOR � l�' N 5 '/�' /`i�/t;= SIDE L] � ADDRESS � ° 'a C'r're.�:+'.^. ds�: ' :; CITY[� ZIPJ�l?� TELg,��4/,S(�f PROPOSED USE p ARCWENG/ � W DESIGNER — NO.DWEL. NO. N0. a ADDRESS — UNITS_�� STORIES BEDROOMS � CITY __ ZIP TEL. � — DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � oOWNER•f3UILDER DECLARATION SFR/ADD/flEM Q I HEREBY AFFIRM UNDEfl PENALTY OF PE0.NflY THqT I AM E%[MVT FqOM THE CAMRACTOPs ll- � Gdfd9fi(C8�70fI [iJ CENSEL4WWRTHEFOLIOV/INGRE450N�5EC.7031.5BU51NE5SANDPROFESSIONSCODE:ANYCITYOR (n U COUNfYWHICHREWIRESAPERA/ITTOCONSTRUCT,ALiER,IMVROVE,OEMOLISH,OflREPAIPANvSTftUC� ' W P8Si0IDBCk Z' NRE,7RpR TO ITS ISSUANCE,/�L50 REOUIRES Th1E APPLICANT�-0fl SUCH PERAIIT 70 FILE A SIGNEO U� - �, SiATEMENT THAT HE OR SHE�5 LICENSEO 7URSUANT 70 THE PROVISION5 OF THE CONTfiACTOAS ll� c CENSE LAW(CHAPTEfl B(CLNdMENCINO WITH SECTiON�000)O�DNISION 3 OF THE BUSiNE55 ANO PflO. � PaOUSpd V FES510NS�E)OqTHATHEOFSHEISEXEMPTTHEREFROMAN0T11E6R51SFORTHEAIIEGE�EXEMP- (� V TION.PNVVIOLATIONOFSECTION7031.5BYANYAPPLICANiFORAPERMIT5U0.1ECT5THEAPPLIGANTTO Z Re-F7oof � RCNILPENALTYOFNOiMORETHANFIVEHUN�qEDDOLLAR5�S500J.): ❑I,ASONRJEROFTHEVROPERTY,ORAIYEMPLOVEESWITNWAGESASTHF.IRSOLECONPCNSATION, � CoRIRIBfC18I WtLI DO THE WORN,ANU iHE STRUCTURE I5 NC7f INTENDED OR OFFEPEO GOR SALE(SFC.�O4<,BUSL J NESSAND PHOFESSIONS CODE:7XE CONTflACTOAS UCENSE fAW DUES NOT APPLv T0 Ml OWNER OF . �' PflOPERT'4AWBUII.DSOPIMPROVES7HFREON,AND�41iOWE55UCHWORNHIMSELFORNERSEIFOR � � �' THAOUGHHISOH HFf70WN EMPLOYEES,PROVIDEO TNAT S��CH IMPROVEMElrTS ARE NOT INTEN�ED OR m W. OFFEREDFOHSALE IF,HOWEVERIHEBUILDIIdCOftIMPROVEMENTI5501�'NITNIN�NEVEAROFCOMPLE� �•. �TION,THE OWNER-BUIlOER N7LL HAVE 7HE 6URDEN OF PROYING'fH4T HE OR SNE DID NOT BUitA OR W„ IMPROVEFORTHCPURPOSEOP3ALE} _ ❑I,AS ONMER OF THE PROPEHIY.AAI EXCLUSIVELV CONTRACYING WITFi LICENSE�COY7RAC1 OFS � TO CONSTRUCT YHE PHQIF.CT(SEC.%oM,HUSINESS pND PROF[SSIONS CADE�l'HE CCNTRACioRS LI� � Va!uation__..,_,___.____._^.FDJ.AREA.._.____ __ _ '�� CENSEUWDOESNOT�IPPLYTOANONMEROFAPROPERTYWHOBUIL�SORu�PROVESTHEfaE0N.A4D F� �N41000NTqACTSFURS11CMPflOJECTSWITNACOYTRACTOR(S�LICF:NSEDPURSUAN(TOTliECONtRAC- � QUANTITY D[SCRIPTIOY FEE TORS L.ICEN5E LAW.). - Y. a /� /� �(3'��' I!IlU.7EXEMPTt/NDERSEC.__._._ ._._..__8�$P�C.FoaTH�sREhSoti ' U ��Gf�/C'��C-E° �� ��y�/Y� 5�,. _` _ ____ '" '-__ � /C��./���� r __ _ �' �DATE__'_ __._owNfa._. -.... _'.._"._ U Z�� - -- — ' W � � LICENS[D CDUTRhCTORS D[CLARA710N � � w -- IHEREBYAFKIHMUN�ERPENALTYOfPER1URY711ATIAMLICENSF.DUNJERPROVIsIONSUFCHAPTFR � d; 9(COMMENCING WITN 6ECTION 7C00)OF DIVISION 30FTHE 3USINFSS AND PPUFI=.SSIONS C0�[,ANO Z _ MY LICENSE IS IH FULL FORCE ANO EFfECT. �: 7rd-''K) r) ;. � �! IICENSE CLASS�A / _���___LIC.NO.��!��1-L�7�,�.-@-� .: J ~� DATE��C���f�- CONTI7ACTOHLY..!`.s'��!�3LN� d - -- — __ WORKEGiS'COMPENSA7IUN DECLA�'fKN����Nc � ¢ ^� � � �',' IHEflF.BYAFFIPMUND[RPENALTYOFPEKIURYONEOr.TiEFOLLOWINGDEGiARATiONS: z '� ,`- �; Q � �- _IHAVEAN�WIL'.MAINTAINACERTIFICATEUFCANSENTTOScLFINSUNEFORNKJRKERS' x — --__ �., COMPEkSATiON,ASPflO'lI�EDOYSECTIONJ7NOFTHElA80RCO�F.,FORTHEPERVOR4IANCE �U oF THE WORX FOR WF11CH 7HIu P£RMIT IS ISSUF.D. � O - � __IHpVEPNDWiLLM0.1NTAMWOHI(ERS'COMPENSATIOYMSURANC[.H5flEQUIRED.OYSECTiON ;E. � �'� Q 37000FTHELABOFCODF,FORTNEPERFORMnNCEOFTHEWORKloFWFIICHTHISPEFMITIS �r. � ' ._ ISSUED.MYWORKERS' M.NSATIO/N�IN�SURANCECARRIERRNUVOUCYNUMBE1iAlIE: �.� CONSTRUCTION ....___._—._..._.__,. , ._'_"_ "__'____ .. �� �� _ L"/!l.I�^ -----�—�^�-.-�'-r�/. .._ ... PLAN REVIEW -----.—'-_—'..__.. } CMRIER_._ � A� C���_f,8.�Z7 b—� -." _____. .__ Z . 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SMIP '_' P'�". ..�..�.. � �-�:.r:s { �x� O _'_..'__—....-_--_ . , ��- W � ENERGY P/C ' : � WAqNING:FAIWHLTOSFGIIREWORKER3'COMPC-NSATONCOVEflAGCISUNUWFUL,ANDSHALL6E , "' ' t*.�'�� ' " ' � "---" ',��,�. � SU6.IECTANEMPLOYERTOCRIMINr1LPENALTIE5MIDCIVI:I�INE5UPi00NEHUN�REDTHOUSAN� ENEFlGYPERM{T � i �� � " WLLARS�iloo.000),INAD�ITIONTOTNEC0.5TOFCOMPENSATpN.DAMAGESASPHOVIDEDFORIN - -���--f'--C'-�—'��--}(--'--"- -'- � SECTION310BOFTF{ELABofiCoOE,iMEFEST.ANDATTORN[Y'SFEE9. RETENTIONFEE: 1 ___ .- a CONS7RUCTION LEN�ING AGENCY PRE-ALT FEE: �� _ y ___ - --- -- ,_ -....-<--.-'-.: ,,:. O CL IHF.FENVAFFIpMUNOEHPFNNLTYOFPERJURYTHAT7H[NE�SACONSTRUCTIONLENDINGAGFNCY ---�^�^•'^"'"""--""""����'���� �� i � FOfi:THF.VERFORMANCE OF ThIE WORK PoR WHICH THIS PLRMIT IS IS5UED(SEC.3D3).CIV.CJ. - -� � � � �� , �W -_- '-_ -._ _- " '_' __ � LEN�ER'SNAME_ _'...___....._' _-."_. ...-_..___ i . 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