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HomeMy WebLinkAbout11126 (5) " CITY OF DIAMOND BAR COMMUNITY DEVELOPMENT DEPARTMENT .,,� . 21660 E.Copley Drive Suite 190 PRESS � (909)860-3195 Fax(909)861-3117 e ""' BUTLDING PERMITAPPLICATION FIRMLY JOBSITE ° ! APPLICATION PEFIMIT ��� P/C � o' ADDRESS ����/ � DATE � NUMBER--�%1 ' "� # � � ISSUE TYPE OCC r APN LOT TRACT DATE CONST. GROUP � pOWNER .:...-.-ti � �.�=a.---ti� . ADDRESS `��.�'� L�--¢-� oJ _..--,-�+ry ZONING SETBACKS � FRONT RW__ ❑ S CITY ��"-'=�p-' �,.j ZIP T . APPLICANT a .- , �-=�--E-K•� � TEL. b �-�! ' REAR ❑ , SIDFJSIDE STREET RW Cl QCONTRACTOR .� C.`-'.r-cw.h...c.c-� Q��'� j - ' SIDE U__ � ADDRE S d -�.,�' Gic�-..E_CJ.r . 'Y`b-,-,.-�.-��c.� r � � � � u�.-�-�-�«n � � .. PRO D USE 'Y'ur�'y ��• C'-.�3"'�%;G�t�-���0'������ CITY ' ZIP ra'�7.� TEL. �0 j S��/ � � � 2-'71� ;�L`_�E3 O h�6 6['> w ARCH/ENG/ z DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS � STORIES � BEDROOMS ; = CITY ZIP___ TEL. � � DESCRIPTION SQ.Fl: FACTOR PSF ADJ.AREANALUATION F � OWNEFi•BI:ILDER DECLARATION SFR/ADD/REM l O j p 1 HEREBY AFFIRAI UNDER PENALN OF PEFJURY THAT I AM EXEMFT FROM THE CQNTf7ACTOPS LI- G0fB98/CBfPOR ' W CENSELAWFORTMEFOLLOWMGREASON(SEC.709t.5811SINESSANDPROFE5510NSCO�E:ANYCITVOR (n S ZCAUNTYVJFIICHREOl11RESAPERMITTOCDNSTRUCT,AL7ER,IMPFlOVE,DEMOLISH,ORREPAIRANV5TRl1G W pall0/Dedc +. W TURE.PRIOR TO RS ISSUANCE.A�SO REQUIRES THE APPLICAM FOR SUCH VERMIT TO FILE A SIGNEO W � STATEMENT THAY HE OH SHE�5 UCENSEO PURSUANT TO T11E PROVISIONS OF THE CONTMCTOHS LI- � � CENSE LAW(CHA7TEH 9�CAMMENCING WITH SECTION 7000)OF OIVISION 3 OF THE BUSINESS AND PHO- � PooVSpa � O FESSIONSCODE)ORTHATHEOqSHEISE%EIAPTTHEREFROMAN�THEBASI5FOR7HEALLEGEDEXEMP- F V TION.ANYVIOUtTIONOFSECTiON7091.5BYANYAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Raof F A CIVIL PENALTV OF NOT MORE THAN FIVE HUNOfiED DOLLAHS(f5o0).): e � f.11,ASOWNEROF7HEPROPERTV,ORMVEMPI.OVEESWITNWAGESASTHEIRSOLECOMPENSATION, 0 CommBfCiel " Z WILL DO THE WORN,AND TNE STRUCTUPE IS NOT INTENDED OR OFFEREO FOR SALE(SEC.7aid,9USI- J � NESS AND PROFESSIONS CWE:THE CONIRACTORS UCENS[LAW DOES NOT APPLYTO AN OWNER OF A � DROPEPTYWH08UILDSORIMPROVESTNEREON.ANOWHODOESSIICHWORKHIMSELfOflHERSELFOR � F � THROUGHHISORHEROWNEMPLOVEES,PAOVIDEDTHATbUCHIMPROVEA/ENTSARENOTIN7ENDFDOR m t W pFFERE�FORSFLE.IF,HOWEVER,7HEBUIL0INGORIMPflOYEMENTISSOIDWITHINONEYEAROFCOMPLE- � Z TION,THE OWNEP�BWL�ER WILL HAVE THE BUROEN OF PROVING THAT HE OR SHE DID NOT 9UILD Ofl � IMPROVEFOR7HEPURPOSEOFSALE). � []1,AS OWNER OFTHE PROPERTY.�M E%CW SIVEIY CONTRACTIYrG WITH LICENSED CONTMCTORS � Q TO CONS7Rl1CT THE PRQIECT(SEC.7a44,BUSINE55 AN�PFOFESSIONS CA�E:TME CONTRACTOHS LI� VdW8ti0f1 __ ADJ.AREA W CEN5ELAWDDESNOTAPPLVTOANOWNEROFAPROPERTVWHOBUILDSOHIMPPOVESTHEREON,M10 = WHOCONTRAGTSFORSUCHPRQ1ECTSWITHACONTRACTOR(S)LICENSEDPURSUANTTOTHECONTMC- QUANTITY DESCRIPTION FEE YTORSLICENSEUW). i � J i � ❑IqMEXEMP7uNDEHSEC. __ ,__B.BP.C.FORTFN&fiEASON U � �i '_' ' _'_ ___ - ::'se�wy S � ";a . �, � � DATE OWNEF__' '-- U ''�"� �'� '''°1'� d Z W t � LICENSED CONTRACTORS OECLARATION W � � 1 HEREBV AFFIRA/UNDER PENALT'OF PEFJl1RY THA71 AM IICENSED UNDER PROVISIONS OF CHAPTER Z ``��� Y p. 9(COMMENCINO WIiH SECTION 7000)OF DIVISION 3OF THE BUSINESS PND PROFESSIONS CODE,AND �X MV LICENSE IS IN FULL FORCE AND EFFECT. m • ,. " O ' � i F LICENSE CLASS/_���IIC.NO.__��%�7������ � � t V pq7E j/��'��CONTRACTOR,_ .(fc-- ^� «1-R�-�.< d � w r � � WOiiKERS'COMPENSATION DECLARATION � ! � � IHEREBYAFFIRMUNOEHPENALT/OFPERJURYONEOFTMEFOLIOWINGDECLARATION��/� U [ (� Q : O I HAVE AND WILL MAINTqIN ACERTIFICATE OF GONSENT TO SELFdNSURE FOR WORKERS' 2 � COMPENSATION.ASVROVIDEDBYSECTION37�OOFTHELABORCOOE.fORTHEPERf-0RMANCE U i a OF TME WORK FOR WHICH THIS PERMIT IS ISSUfD� � �t � �/ f I HAVE ANU WILL MAINTAIH WORKERS'COMPEtiSATiON INSURNICE,AS RE��tFEC 6Y SECTIO`: ( �' / Q 37a00FTHELABORCOOE.FONTHEPERWRMANCEOFTHEWOFKFOPWMICMTHISPERMITIS -- Yl./. `�� ! ISSUED.MY WORKERS'/C�OMPEN_�SATW�SURANCE CARRIER AND OOLICY NUMBER ARE: CONSTRUCTION �� � � jcaawEa_.____. •�.—_..__ _ PLANREVIEW � Z POUCV Nl1M6EF�1���""���_—�_._ ELECTRIC i a (iHISSECIKYJNE�NOTB[0�.4°LEfEDOFTHEPEMHfISWF10NEHlNDHED00L1AR5(E10D)ORLESS) PLUMBING . � 0 Z ICERTIFYTHATINTHE7ERFOFMANCEOFTHEWORKfORWHICHTHISPERMITISISSUEO.I MECHANICAL _ t C,r} SHPLLNOTEMPLOYANYPERSONINANVMANNERSOASTOBECOMESU&IECTTOTHE � (n WORKERS'CAMPENSATION lAWS OF GALIFORNIA,AND AGftEE THAT IF I SHOULD OECOME INSPECTION FEE j SU&IECT T0 THE WORKERS'CAMPENSATION PROVISIONS OF SECTbN 3700 OF THE IABOR � ! � CODE ISHALLFOrH�TMWITHCOMPLYWITHTHOS;PROVISIONS. • ISSUANCE p DATE: ��(L— APMICANT: �' � C -�..t=.%+..�.i._r" SMIP � i � ENERGY P/C ___._..__ WAHNING�FAILURETO 6EWRE WORKERS'COMPEN5ATION COVERAGE IS 11NLAWFIIL,AND SHPLL BE � � SUBJECTpNEMPLOYERTOCRIMINALPENALTIESANDCIVILFlNE3UPTOONEHUNOREOTHOUSAND ENERGYPERMIT ______—. DOLLARS(f��D.00O).W ADDITION TO THE COST OF CAMPENSATION,DAMpGES AS PROVIDED FOR IN [! � SECT�ON 9�06OFTHE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. RETENTION FEE: � pW„ CONSTRUCTION LENDING AGENCY PRE-ALT FEE: _ � IHEREBVAFFIRAIUNDERPENPLTVOFPE0.ILIPYTHATTHEREISACONSTRUCTIONLENDINGAGENCY F n- FOR THE PERf-0RMANCE OF THE WORK WR WHIqITHIS PERMIT IS ISSl/E�(SEC.3o9'7,CIV.C.). & � --- ------ --- __ --- � _ � LENDER'S NM1E ; H LENDER'SADDRE55__- - �-� � ICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETHRTTHEABOVEINFORMATIONISCORRECT. TOTAL FEES � w I AGREE TO CAMPLY WITH ALL CITY AND CAUN7Y ORDINANCES AND STATE tAWS PELATING TO BUILDING �,,�� f � CONSTflUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OFTHIS COUNTY TD ENTER UPON THE � / . �//�/� ��� � pBOVE�MENTIONED PROPERTY FOR INSPECTION PURPOSES. -� ��f !��.���-� l�f" � Z - - Q COMMENTS_, J �E)/Yl �C� ! i �( / 4!/�.i �'•� C�, m , � PERMITTEE NAME(PRINT) _ }' Q � /!� � � C� G�f �tJ� 2.c_.e,f /�.�/J � _ 9 � SIGNAT�TREOFPEHMITfEE —��ATE RECPT.NO. a � PAIDBV � VAIJDATION ( S � WHITE-Depanment Copy,YEL�OW-Finance Copy,PINK-Assessor CoDY.GOLOENROD-Fila Copy,GREEN-Applicant's Copy � 8 _�._.._,_..� ,. I � � � � � , - �---, �-- i ; -r � __7—�__... �. _—4----�--- ,_�. y,._� :. e ' ; i. � �� � �..1 .� ' t :- � v�-3�+� -}���I i I �� I.:T-{-� , _. I, `i i. �,. ' • —�1. .}I� -� , i.. �} 1ru ; t � f s � - " � €. ,} ,., I ,', , ' , q. 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