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HomeMy WebLinkAbout12869 • �__, CITY OF DIAMOND BAR �j � i DEPARTMENT OF COMMUNITY&DEV OPMENT S RVICES 21660 E.Copley Drive Suite 190 , (909)860-3195 Fau(909)861-3117 PRESS � , �'��" BUILDING PERMIT APPLICATION FIRMLY �� JOBSITE ,� d � APPLICATION PERMIT ����()'J_dj P/C , ADORESS_°`�•F•.l.' a- , ..� ��. .I DATE �'� NUMBER L�r��I__ # �- APN LOT TRACT ISSUE TYPE r OCC DATE CONST. GROUP p OWNE�". ' , i o ADDRES o1 I E �At,-�'�• .�� '/i"1, ZONING SETBACKS � CITY ' . / 'F•'I g IP B, • •r.� TEL. '7e FRONT RW LJ_.,__ APPLICAN'f TEL. REAR fl,__ z SIDE/SIQE STREET RW LJ __ � CONTRACTOR�p' '' fC.l` .•:I ^ '�; SIDE n__ �. ADDRE,SS �^�tl� - '�� ti �' , z pROPOSED USE � CITY ''t.�!� ZIP F� i TEL.., •�,�'� o ARCH/ENG/ � - w. DESIGNER — NO.DWEL. NO. NO. �, ADDRESS UNI7S_ i STORlES BEDROOMS � C1TY ZIP TEL. — � - cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION �, OWNER•Bl11LDER DECLARATION SFR/A�D/REM O 8 I HEHEBY AFFIRM UNDER PENALTV OF PERIUqY THAT I AM EXEMPT FROM 7HE CONTRACTORS LI- G8�£1(]B/COfpOfl CENSELAWFOR7XEFOlLOWINGREASON(SEC.7031.60USINESSAN[7PROFESSIO45CODE:ANVCITYOR (� _ U �IX1NTyW1{;��{REIXIIRESAPERMRTOCONSTRUCT.PLTEH,IMPROVE,OEMOUSH,ORRF.PAIRANYSTRUC- w NRE,PRpR TO IT8 IBSUANCE,AL50 REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W P8fi0/DBCk STATEMENT TYAT HE OR SHE IS LICENSEO PURSUANT TO THE VROVISIONS OF THE CONTRACTORS LI- �� CENSE UW(CHAPTER 9(COMMENCINO Wihl SECTIqY 7oaa)OF DIYISION 9 OF THE BUSINE55 AND PRO- '� POOUSPB FESSpNSCODE)ORiHATHEOR5HEISE%EMPTTHEREFflOMANDTHEBA515FORTHEALLEGf:DE%EMP- � V TfOti.ANYVIOLATqNOFSECT�O:J7o31.56YANYAPPLICAMfORAP[FlMITSU&IECTSTMFFPPLICANTTO Z qe-Rool � ACIVILPENALTVOFNOTMORETHqNFNEHUNDREDDOLlAR6(f50o).): p ❑I,ASOWNEROFTMEPROPEFiTY,ORMYFMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, � CORImB�Gidl � Will DO THE YYORK,AN�THE STRUCTUflE IS NOT 14TENDE�OH OFFERED FOfi SALf:(SEC.70a4,BUSI- J � NESS AfJD PROFESSIONS CODE:iHE CONTRACTORS UCENSE LAW DUES NOT AAPLV TD AN OWNEH OF � PflOPEfliV Wl10 BUILDS OR IMPROVES TMEFlEIXJ,AND WHOOOES SllCll WOIiK HIMSELF OR HEflSF.LF OR wTMROUGHHISORHEROWNEMPLOYEES,PFlOVIDEOTHATSUCHIMPROVE6IENTSARFNOTINTENDE�OR m � OFFEflE�WRSALE.IF,HOWEVEFiiHEBI11LqNGORIMPROVEMEMISSOL�WITHINONEYEAflOFCOMPLF.� Z TION,THE OWNER�BUILOER WILL HAYE ZHE 9UFDEN OF PF40VING THAT HE OR SHE D!�NOT BUILD OR = IMPROVEFORTHEPLIPPOSEOFSALE). W f71,0.40WNEROFTMEPFOPEfl7V,AME%ClU51VELYCONTRACTMfrWiTHLIGENSEDCONitiACTOfiS Q TO CANSTRUCT THE Pfl0.1ECT(SEC.70N,BUSINESS AND PHOFESSIONS CODE:THE CONTRACTORS U- V8IU8t1011 __ _. _____ADJ.AREA_ � CENSEUWDOESNOTAPPLYTOANOWNEflOfAPFlOPF.RTYWH06UIL�SORIMPqDVLSTNEftEON,ANO - -- -'- YhIOCONTRACYSFOflSU�HPROJECTSWITHACONTRACTOR�S)UCFNSFDPURSUANTTOTFiECONTRAC- Q�jQNTITY DESCRIP710N FEE � iORSLICENSEUW.). � J � OIAMEXEMPTUNDERSEC._.. _____.,_B.&P.C.FOPTHISAEASON Q E }' _ U � -- -- -----— CC , �ATE_ UWNEfl__._. __... U z w p LICENSED CUNTRACTORS DECLAFATION LL� � 1 HEREBYAFFIPM UIVOEfl PENAITY OF PERJURY THAT I AM LICEiVSEO UN�EF PflOVI5iON5 OF CXAPT[f? �• B(COMMENCINOWITHSECiqN70DOJaF01VIS10N30FTHE�USMESSANOPROFESS'O�YSCA�F,AN� Z � �-��������.?� c� X IdY LICENSE IS IN Ft1Ll FOHCEAND EFFECi. ,�,�j.� '°� W � (� ��/ 1 Z.C%!w � � LICENSE CLASS �'�% __LIC_NO. _��. `��,�. }'� J V OATE__�lL.`�.�""3�.� _ CONTRAGTOR '�1.. �.'�,�^�' a W d� WORKERS'COMPENSATION DECLARATION �; JJ j� Q � 1 HEREBY qFFIRM UN�EF PENALN OF PERIURV ONE OF TI�IE FOLLOY/ING DECLAR0.?IOYS: Z � _I HAVEAND WILL MP.INTAINACERTIFICATE OF CONSENT TO SELF-INSUPE FOq WORKFNS' _ CAMPENSATION,ASPROVIOE�BYSEGTION37o00FTHEWBORW�[.FOHTHEP[HFORMANCE U Q OF7MEWORKFORWHICHYHISPF.RMIYISISSUED. � � W _INAV6ANDWILLMAINTAINWOHNERS'COMPENSaTIONIN5URANCE,ASliE�UIREDBYSECTIOv Q 37000FTHELPBORCO�E,FORTHEPEPFOHMANCEOFTHEWOPKFOflWFIIGHI'Y115PERMITIS ISSUEO.MY WORKER9'WMPENSA710N INSUflA CE CARRIER ANO POLICY kUMBL ARE: CONSTRUCTION _ _ _ _ ____ __ / q-�.,, _ -" "_'_' Q CAFRIEP_"����'��r•�F ��c`��<<� PLANREVIEW � _�-t_" " � ' '-' ' "-"__'- '_' -___ � POIICY NUM.BER ` �.�.�_ ^"-�C�� u. ELECTRIC Z � - _' -_' __-'_ '_-Z� Q � � (�t�ISSEc7lcavNGmra70ECL'Y+mI.ErFDOFn�PEF4wrl5waorvEVN��a)aEocalnqs(tm}oR1.Eas� PLl1MBING __. _ ____, : W '_-_" ' "_'-'_ . Z I CERTIFY THAT IN THE PE1iFORMANCE OF THE WORK FOR WHICH TH�S PERMIT I5�SSUED,l MECHANICAL (,r} SHALL NOT EMPLOV ANY PEfi50N IN ANV MANNEft So AS To�F:COME SUBJECTTo iHE (`n WOFKERS'COM7ENSATIONLAWSOFCALiFORNI�,ANDAGREETHATIFISNOJLDF3CCOME INSPECTIONFEE S '_' - _'__'- "._._.... � SV0.IECT TOTHE WORKEFS'C01h9FNSATIDN Pq041SfONS OF SECTION 370o qF iHE LABUR �' "'" � CO�E,ISHALLFORTHWITHCOMPI'/WiTH O ISSUANCE `- ' � � �j"�^� ------- -.-. .... -�--- p UATE: ��1-'�C�"i`-'_ APPLICANY: ._. �-`o"'.�a�' SMIP —__-_ __— - -.__ _--_'_ � � ENERGY P!C J WAHNING:FAIW fl[TO SECURE WOflKERS'COMPENSATION GOVER�GE IS UIJLAWFUL,AND SHAI.LtlE ---- � ��--�--- -�---�- � Sll&IECTANEMPLOYEflTOCRIMINAIPENAL'fIESANDCIVILFINF.SUPTOONEHUNDREDTHOUSAND ENERGYPERMIT } ODLUHS(Y100,000),INADDITIONTOTHECOSTOFCOMPENSPTIO4,OAMAGESASPROYIDEDFORIN -�------ - ---- - -� ----�-- -�--- J SECTION37060FTHEIA90RCO�E.�TEAEST,ANDAiTORhEY'SF£E5. RETENTIONFEE: ,. � -'_ a CONSTRUCTION LENDING AGENCY PRE-ALT FEE: p - ---., ....----- ---- � IMEAEB7AFFIFlMU�DEAPENALTYOFPERJURYTHATTHEflE7SACON5IRUCTIOYLENOINGAGENCY � FOR THE PERWfiMANCE OF iHE WORK FOR WHICH 7HI5 PEPAAIi IS ISSUED(SEC.3oW,CIv.C.). --"--" ----"- z w --�-- ...--- " -- � LEN�ER'SNAME___'_____-�'_-'.... "__-__"_ ' ""'__-_'_ _--""'_ '-"' _" "__" � F= LENDEH'SAD�FESS ___.___-.___ .- I w� TUTAL FEES ! ICERTIFYTHATIMAVEftEADTMISAPPUCATIONANOSTATET14ATlHEABOVEINFORMATIONISCARRECT. IAGREE'OCAMPLYWITHPLLCITYAhDCO:1NTYORDINANCESA4U5TATELAWSREL4TINGTOBU 01 ' � CONSTRUCTION,ANOMFHEBYAUTHOHIZEREPRESENTPTIYESOFTHISCOUNTYfOE i UPDdiY Z ABOVE�MENTIONE�PPOPERTY FOR INSPECTION PUFPOSES. �� -y COMMENTS s _,�'���`�,Fys1t_, a ,C.,-�-� -- ---- -- ---- I m CERMITTE�NAMEIPRIMT) � � _ _ �, � -� _--�„'�_��_"^"'.."—��....` , -- __"'_-_' _ —_ _ _ - _ _ y SIGN�TUREOFPERMITTEE DATE = RECPT.NO.��._PAID 8Y __ ,� VALIDATION _ ~ WHITE-Department Copy,VELLOW-Finance Copy,PINK-Assessor Copy.GOLDENHOD-File Copy,GREEN-Appli t's Copy � . _ __._ ._ . __�.._ . . _..., _ . _. . ._. ___. .._ — -- -- -.._ _ .. .... a. . . _ .. � � : � ' � � � , � � � � ' � ( ; i ' � � ` � � � , i � ��, � I � I � ; � _ c �� . { � � : . . ' . . . ' . - � ' � . �� � . � � , i � . . �.� � ! ( + i _ ' I , I � � ' � ` !. ( � � � r��� � . � ' ; +t , ; ` . � . ,. . , , , , i . j � "� -. _,., a - __ . . .., _ _ _ ... _- - �_ r . � . . . � . ' ; . _ �� , � . '�� � � -1 j ; , ,. � 'r.. . _ , � - , � " . . i � ; . 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