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HomeMy WebLinkAbout12274 (13) CITY OF DIAMOND BAR � ^--�'� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES ��� � � � 2166D E.Copley Drive Suite 190 j � �� ����°��� BUII,DING PE `RMTT APPLICATION � FIRMLY � � JOBSITE APPLICATIO PERMITj L- P/C � o ADDRESS������� ��-.-���� DATE NUMBEW��� # � � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER ��_���-� _ ADDRESS G 2,� c't- � �- ZONING SETBACKS Z �y FRONT RW ❑ CITY ZIP TEL. '� g APPLICAN"f v.-> TEL.r�? +' REAR ❑ � SIDE/SIQE STREET RW ❑ � CONTRACTOR . �� J ,��� t' SIDE ❑ ADDRESS � �.`�n� a_ .: � °C � � PROPOSEDUSE��-��I�Zr- {,�'��� ���'��'- �f�� �i�C- �� � � CITY ZIP� TEL.��i-, �1��� {?i � Iw ARCH/ NG/ " '�-�g_ �o f � . q s °`" ,r � DESIGNER �� ADDRESS N0.DWEL. NO. NO. � � UNITS STORIES � BEDROOMS e � � CITY ZIP TEL. j � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREA/VALUATION . � OWNER-BUILOER DECLARATION - . SFR/ADD/REM � O p: 1 HEPEBY AFFlflM UNDER PENALTY OF PERJURY THAT i AM EXEMPT FflOM THE COMHACTORS Lf- GHf39P/C8(POR .W- CENSELAWWRTHEFOLLOWMGPEASON(SEC.7031.58USiNESSANOPPAFESSIONSCD�E:ANYGTYOR .:(n C,�- COUNTVYMICHHEQUIHESAPERMITTOC6NSTRUCT,ALTEfl,IMPROVE.DEMOLISH,ORREPAfpANVSTqUC- �_ W pg(i0/DBCK I W, 7URE,PflIOR TO ITS ISSUMlCE.PL50 REQUIRES THE APPIILANT FOR SUCH PERMIT TO FILEASIGNED � W i � S7ATEMENT THAT HE Ofl SHE IS LICENSED PURSUANT TO THE PROVISIDNS OF 7HE CON7RqC70F5 U- _ - CENSE UW(CHAPTER e(COMMENCWG N7TH SECTION]oao)OF DIVISION 3 OF THE BI�INESS AND PRO- ' V" POOI/Spa 1 � iE83pNSCODqORTH:4THEOR5HE15E%EMPTTMEREFROfdAN�YHE8A51SFOflTHEALLEOEDEXEMP- V- iION.A(JYYKK.ATIONOfSECT10N703t.56YANYAPPLICANTFORRPERMITSUBJECTSTHEAPPLICANTTo .`Z RB-ROOf � � 'O_ ACIV�LPENALTYOFNOTMORETNANFIVEHUNDREDDOLLARS(55a0)_)� -� ❑I,ASOWNEflOFTHEPROPERTY,ORMYEMPIOYEESWITHWAGESASTFiEIRSOLECOMP[NSATION, '-.�- COfi1f11BfCl2I � -.Z._ WILL DO THE WORK AND TME STRUCNRe IS NOT MTENDED OR OFFERED FOR SALE(SEC.7094,BU51� -J NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW OOES NOTAPPLY TO AN OWNER OF �� PROPENTYYhiOBU�LD30RIMPROVESTiEflEON,ANDWNO00E55UCkIWORKHIMSELF011HER5ELFOR -+m -.I .Q-- THRW6HHISOfiNEROWNEMPLOYEES,PROYIDEDT1iATSUCMIMPfiOVEMB�tiSARENOTIMENDEDOR W- pFFEqm{pRSALEIF,HOWEVER711EBUIL0IYGORIMVPOVEIAENTISSOLDWRHINONEYEAROFCAMPLE- '� ' �'- -Z=. -TION;THE OWNER�UIIDER WILL HAVE THE BURDEN OF�PROYING Th'AY HE OR SHE DID N07 BUILO OR -'�- --.... . . . .. .... . .. . . _.. _... . . . . ._. -j -�_ IMPqOVEFORTHEPURPO5EOF5ALE). .� � _W ❑I,AS�NMEROFTHEPROPER7Y.AMEXCLUSNELYCONTRACTINGWITNIICENSEDCONTRACTOflS _ - --�' TO CONSTRUCT THE PROJECT(SEC.1044,BUSINE55 M1D PROFESSIWS CODE:THE CONTRACTOPS LI. VBIUHI10I7 '�� ADJ.AREA -.W-. CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTYWHOBU�L0.40HIMPHOVESTHEREDN,ANO -_�: WHOCONTRACTSWRSUCHPROJECTSWITHACONTRACTOR(5)LICENSEDPUHSUkNTT07MECONTflAG QUANTITY DESCRIPTION FEE - � : TORS UCENSE IAW.�. s0' ❑IAM EXEMPT UNDER SEC. e.a r.a FOa TniS REqsor� " � -� �LL� .. . � � . DATE OWNER ` r z w � -:'n—�•�_-_ LICENSED CONTRACTORS DECLARATiON _ �j � �_- 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM IICENSED UNDER PROVISIONS OF CHAPTER _' � - _� 9�COMMENCINGWITHSECTKKJ7oWJOFC1Yi510N30FTHE8USINE53ANDPROFESSIOI:SCODE,AND - Z � W LICENSE IS IN FULI FOSiCE AND EFFECT. _� ��� y� �� � �O' � - `2 ;0 UCENSE C S LIC.NO. � r J ..�r_ DATE / CONTflACTOR e"^ . �a °..a � # �� na�; ' WQRKERS'COMPENSATION DECLARATION -. a � �6 � _�, IHEREBYAFFIRMUNDEfiPENALTYOFDEti11RVONEOFTHEFOLLAWIYGDECLARATIOYS: . Z _ � :�-- IHAVEANDYUILLMAMTAINACERTIFICATEOFCONSEMTOSELF-INSUftEFORYlOflKEflS' -�. _ '_��- �COMPENSATION.RSPRDVI�EOBYSECTION37000FTHEL�60RCODE,FORTHE?ERWRMdNCE • W �. Of THE WORK FOR WHICH THIS PERMIT IS ISSUED. -� - - � -W- IHAVEAND\VILLMAINTqiNWORKEflS'COMPENSATIONINSURANCE,ASRE�UIREDDYSECTION � t �J 1b _Q: a7o00FTHELABORCWE,FORTHEPERFORMANCEOF?HEWOP.KfOFWHICHTHISPERMIT�S �. .fi /i � - ISSUED.MY WORKER5'WM.PryE�NSATION INSURANCE CARRIER ANO POIICY NUMBER ARE: CONSTRUCTION / I �y '�- �l.�"�3 ��� CARRIER��—"`�r��! t � PLAN REVIEW -�- POLICVNUM6�a �f ELECTRIC Z' �.<; ��55ecrpr�hemr�oieEoot.fxErEooFn�aEtuar�swaariEtnA+nr�ooa_tnas(s+ao�oat.�ss} - PLUMBING � Ot _ �W� I CERTIFV THAT IN THE PERFORMANCE OF THE WORK FOF WHICH THIS PERMIT IS ISSUED.I MECHANICAL Z. _.(J;- SHALLNOTEMPLOYANYPERSONINANYMANNERSOA5T06ECAMGSU&IECTTOTHE --_N; WORKERS'COMPENSATION LAWS OF CALIFORNIA,ANO AGREE THAT IF I SHOULO BEGOME - INSPECTION FEE ;-�" SUBJECTT07NEWORKERS'COMPENSATIONPROV�SIONSOFSECTIDN97000FTMELA60R - GO�E.I SHALL FOFiTNWIi}7 COMPLY WITH THOSE P VISIONS. F �SSUANCE i ._� � ____.���i.rns9 6' O� l�� '' ! s - pp7E; '� APPIfCANT: ,TS;�•}i SMIP �; / W= ENERGY P/C _�' WARNING: AILUflETOSECUfiEWORKERS'C�1.iPENSAT�ONCAVERAGEISUNLAWFUL,ANDSHALLBE •'�; Sl)&IECTANEMPLOYERTOCRIMINALPENALTIESPNDCIVIIFINESUPTOONEHUNDREDTHOUSAND — �--ENERGVPERMIT - - � -- -' - - - ' DOLLAflS(f1oD,00O),INAODITIONTOTHECOSTOFCOMPENSATION,DAMAGESASPROVIDEDFORIN �-J-- S£CTION37080FT1ELABORCO�E,MTEREST,PNDATTORNEI"SFEES. RETENTIONFEE: t �: �- ��'�� �=. � _'d' CONSTRUCTION LENDING AGENCY .PRE-ALT FEE: i O*: _:.� IHEi7E0VAFFIflMUNDERPENALNOFPERIURYTHATTHEREISACONSTPUCTIONLENDINGAGENC7 _ ___ _ FOR THE PLR WftMANCE OF'fHE WORK FOR WHlqi THIS PERMIT IS ISSUED(SEC.309�,CIV.C). Z; WI: � �.'. LEN�ER'S NAME_.__. F=- LENOER'SAODRESS - � + ��: ICERTIFYTHATIHAVEREADTHISAPPLICATIONANOSTATETHpTTHEA80YEINFORMA710NI5CORRECL .' TOTAL FEES - '�` 1 pGFEE TO COMPLV N7TH ALLCITV AND WUNTV OR�INANCESANO STATE IAWS RELATING TO BUILDWG - - CONSTflUCTiON.ANDHEREBYAUhIOflIZEREPRES[NTATNESOFTHISCWNTVTOENTEFUPONTHE �g �'` 6 f -.? ABOVEMENTIONED PROPERTY FOft INSPECTION PURPOSES. 1 / g� _ �- COMMENTS - ,L � � � .� 1L C J"�'T� -.p- n. —�— --_��_� d �: _Q= PER EE NIUd-(PRINn ^r - � � _ � �'' 7 n 2 _ n 2'7 / ��N S�ONA E ATE � -"'^�-� � -- RECPT.NO. PAID BY VALIDATION : _: `-�~` WNITE-0epahment Copy,YELLOW--Finance Co PINK—Assessor Co GOLDENROD—File Co GREEN— IicanPs C py. PY� PY� aPP �PY ; �-�----�F �� �x � � z�&�` € J x �� 3�� �. ��� G 7 -�� i � . IT`�i .� :.S' � �:F # ; I 2 . m �� �.`�,�� �.� � 5 ;�. � i �a , � _ � �� '� �� �..s. e �"� �i , Y; - � I " � -� 1 '�'.a�,'�'���1 � �'��e . 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