HomeMy WebLinkAbout16139 (9) _�,f�� Y CITY QF DIAMOND BAR
' DEPAItTMENT OF COMMUNITY Rc DEVEL4PMENT SERVICES
21660 E.Cc�ley Ihive Suite 19Q
(909)86Q-3195 F�(909)$61-311'7 PRESS
�'°�^���W BUILDING PERMIT APPLICATION - ;' ,� ���� FIRMLY
d DDRESS � - �� aA�CATION '�_'� ,�� PERMIT �� ( � P/C
p NUMBER �t #
� APN �OT TRACT "27� ISSUE TYPE OCC
DATE CONST. GROUP
p OWNER L"�T
� ADpRESS_,%��(%/ Uf3AU4�i811��-i�it/ �iTF 7l%i7 ZONING SETBACKS
� GITY�.�L11sc�— ZIP �IZ-TEL.Cfcf-�9'7�� 5j�U REAR� RW O
APPLICANT _ TEL. SiDElSiDE STREET RW [�
� CONTRACTQR_ LZ, �; S�pE t�
ADDRESS _���! •
� GlTY ZIP TEI. PFiQPQSEQ tiSE 1?,�l-- �-�, 'j' f
� ARCWENG/
DESIGNER,_��1�,�,_ — N0.DWEL NO. ND.
ADDRESS f�`�' __�--�1 S/"��--
� CITY ��:'7�--� ZIP� 70 S 7EL.7� U UN{TS STORiES BEDROOMS_ _
us DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATIQN
� 4WNER•BUILDER DECLARATION SFRtADDIREM
(, I HENEBY AFFIMI UNDER PENALTV OF PEFtttIRY THAT I MI EXEMPT FROM THE CdMRACTORS U- {`�yf8(J9/G8f}70R
IA.! CEMSELAIVFQRTNEWt1�JWWf3REtStNi{SEG.To3t.56USN7ESSANDPPOFESSiONStbDE:ANYCiTY6R (j�
COt1MYWHiCFIREfX/1RE9APERMITTpCONSTRUC7,ALTER,IMPROVE,DEMOLISH,ORREGAIPANVSTRUC. W ���
TURE,PRIOR TO ITS ISSUJWCE.AL50 REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED � Patio/Dedc
�� SIAFEMENT THAT HE oR SME!S llCENSEO PURSUtN7 TO TtiE AFiOViSiOMS OF THE t�NTRACTOFtS LI-
CENSE UW�QUPTER Y(CXIMMENCINO MATH SECTION)OOo�OF O�VISN7N 3 OF THE BVSINESS ANp PRO� � POOUSpa
FESSNNISWDE�OPTHATHEORSHEISEXEMPTTHEAEFpOA1qNDTHEBASVSFORThlEfu.LECaEDEXEMP• (�
'FIDN.ANYVIOLATKMOFSECTtQN7a3t.58YANYAPPIfCANTWRAPERMRSU&IECTSTNEAPPLiCRNTiO Z Ae-Rooi
r A CMl VENAI.TY OF NOT AIOqE THAN FIVE HUNDRED DOLUIRS(t5o0).):
� I.'11,ASQWNEROFTHGPR6PEHTY,OHMYEMPIOYEE544iTHWAGESASiMEiflSqIECUMPENSAT�F1, � �OlTirtiBfC�81
NfILL p4 TNE WORK,AND THE STRUCTt1RE IS NOT INTENDED PR oFFERED FOR SAI.E(SEC.7oM,BU51� J
� NESS MD PROFESSIONS<bDE:THE CONTMG70q5 LICENSE LAW DOES NOTAPP{,V TO AN OWNER OF �
PRDPERTY YAi68U�OR B#PROYES TFFEflEON,ANd WtiO OQES SUGH WOR1C HIMSEEF CIA HERSELF OR
CC 7HROU(iH HIS OR HEROWIJ EMPLOYEES,7ROVIOEb THAT SUCH IMPROVEMENTS ApE NO7INTENpED OR m
� UFFEREDWRSN.EIF,FIOY/EVERlNE6URONGORIMPRbVEMENTISS(NDWITHINONEYEAftOFCOMPLE• _
� 1KXi,TME pWNER$UlIDER WiLL NAYE TF�BURDEN oF GfiDviNG TNAT HE OR SN£OIQ Na7 9VttD OFS
� IMVRpVE FOR THE PURP4?&E OF SALEJ.
� OI.A30YMEROF7HI:PROPERTY,AMEXCLUSIVELYCdNTMCTiMflWITHUCENSEDWN3'RAGT6fiS
� TO CbFISTAUCF THE PRO,I�CT i�+EC.]04i,BUSitiE9S ANp Vi10FE55iON5 CODE:TME CONTRhCTORS 4I- VelU0tI0f1 ADJ.AREA�_�
CEN5E LAW DOES NOTApPLV TO AN ONMER Cff A pROPER'fY WMQ BUILDS OR IMPRQVES 7HEREON,AND
Yh7PC0lI7RACTSfORSUCHPftWECTSWiTHACOM7ftACTOR{S}UCENSEDPURSUANTTOTNECOMTRAC- QUANTITY DE$CRIPTION FEE
� 'fORSUCENSEUWJ.
O i AM FJ(EM4PT UNQER SEG 8.d 9C.FOR THiS SiEASpN �
� a
U
� �
n�� ormefl-- ——, U
w
�+�[ U�ENSED C6NTRACTORS DECLARATION W
CC t H£f�6Yf,FfiPM UNDER PF:N.VSY OF PER.iURY TFUT tAM I,ICENSED UMDER Pft6VISIONS{7F CHAPTER �
� •(COMMENGMIO WffH SEC170N 7aCo)Of DIV75!ON 3 OF TNE BUSINESS AND PROFESSIONS CODE,AND Z
MY LICENSE IS IN F11LL WHCE ANO EF4ECT.
[�/7 S`�, m
`��' UCEN3E CLASS �__ LIC.NO. �.�[ ��__ j
t^-� J
� DATE _, „_� CUNTRACTOR d
� � �_ _....
WLYRKERS COMPENSATIQN DECLARATiQN Q
� i H,y'F-gT,jjAfFiRRt UNDER PENAl.TY OF PER.IUftY ONE 6F THf,FO��ONANG DECLARATIONS: Z
Q p/�[_j/tlUV£ANbW1lLMAINTAINACEFiTIRCATEOFCONSEMTTOSE�f-tNSUflEFtNiW9RKEft5' _
y� COMPENSATION,AS PROVIOEp BY SEGTION 3�0o tlf T}1E LABOfi CODF,FOR 7HE PERFOqMANCE W
� TNE WOHK FOR 1YHICM THIS PERMIT IS 15$UE4. � �
@w f 1 HAVE AND WILL MNMAIN WORKER5'COIAPENSATION INSURANCE,AS RE�UIRED BV SEC"fION %�
�3Too 6FTH�IAeOR COOE,FORTHE PERFORMANCE Of fkE WORK fOArittlCH iHi$PERMiT IS �
� ISSVE6.MVWOR RS'WMPfN3ATN7NIN5URAN4"ECARNIE AN�POI.ICYNUMDERARE- CONSTRUCTION __�,,,
�1 �^- � '7'���� __ '�
y nxAntER " �"2:�f�G f��-}d' +�la'��_-rF—fii'S. PtANREViEW _ .._.. ._ ._
� roucv NUMeEr+,A�(. � ELEGTRIC ..... .. ....._..
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� (TFUSRECiYM1NE�NOTBEmMfxF7F.GhFniEPEw.111"ISwftaJE��tuwi'IEOWI,I,nasf8ieo)oqLEssJ. PLUMBING ,. � I .`)l.� _
LL!
� i CERTIFY TNAT M TiIE PERFOqMANCE OF TNE'l/ORK FOR WHICH THIS PERMIT IS ISSUED.I MECHANICAL _,,,__, � ___
(y SHA;.L NOT EMPLOV 4NY PERSON IN AN7 MANNER 50 AS 70 BEfAME&UBJECT TO THE
uj WOfUCERS'GOMPENSASpM i,pWS 0F CALlFpfN7Iq,pND AGRfE TftAT IF i SHOUi08FCAAAE �NSPECTION FEE , _
� SU&lEGi7C7THEWGRKEFS'Cf.1MPENSATIONPROYISIONSOFSECTION3]o OFTFIEUBOR —� � l
E,ISHALLFORTI�WITF+COMPLYWITHTHOS Pqo413�'�l^ON�S. � ISSUANCE ��S�G�J4! �
dDATE:.������[ APPLICANT: �. �/�:�-� ��' /�"` � SMIP _.. ...
Lk!
� WARNING:iMLURETO5ECV9EWORKERS'CbMPEN5ATKKJCAVERAGEISUNL4WFL14.,�Np5NAL48E ENERGYP/C +�' �.�J ^y—�a�� � _ __
� SU&IEGT AN EMPLOVEH TO(:FIA/INAL PENALTIES ANp CIVII.FINES 11P TfJ QVE NUNDPED TF+OUSAND ENERGY PERMIT �,j��+�;j��-,�,.+-.;-..,,�..�
pOLtAHS(i100,006},M7Ap6��lONTOTHEt'A8T6FCt7MAENSATK3N,DAMAGESASPF{OYfDEDFORiN --� —
� SECTqN 3700 OF 7HE 1.A80F,CODE,INTEREST,MIP ATTORNEY'S FEES. RETENTIC?N FEE
� CQNSTRUCTION LENDING AGENCY PRE•ALT FEE: ,��,�,� p������ _
� i HEREBY AFFIftM UNDEfl PEhtAt,TY OF PER.IURY 7HAT THEflE{g A('ANSTPtKTi6N lENptNG AGENCY
FOR THE PERFORMANCE OF'�i1E RK FOR WHICN TMIS PERMIT IS ISSllE�(SEC.ao97,dV C.). —"
3�L! `
� 4ENOER'S NAME �� —'.......— ..�...._. `.., ..
F'� 4ENOER'SADpRESS_
�� TOTAL FEES `��
i GEftTqY TNAT t HAVE READ�M�S APPlICA7KN7 AND STATE 7tiAT THEA9CVE M7fC�R6iATiON�5 CORRECT
� I AGREE TO G4MPLV WITM ALI.CITV AND CAUNT'O%DINANCES ANO STATE UWS RELATING TO BUILDINC
� cANSTRUC710N.AN�HEREH'f AUThpRRE REPRESEN7n71VF5 oP lHls CtlVNTv To EMFER UPON THE
ABt3YE�t�NTK7NE0 GROPERIY FOR RiSP TIQN PURPOSFS.
� CpMMENTS _,
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¢ pEHMITTEE NAME 4PRI ._ .. .__
U'? [K...Gr7,.i.
{� 51GNA PE � OA7E / '
{ RECPT.NO. � PAID BY VALIDATIQN,
S
� WMITE—De rtment
pa Copy,YEI14W—Financ�Capy,PINK—Asaessa Capy,GpiDENR60—Fiie Copy,GREEN—AppiicanCs Copy
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY 8t DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
PRESS
FIRMLY
JOBSITE
ADDRESS_-(/
APN LOT_�/YI TRACT�?C 7
OWNER L°��
�j
4
ADDRESS���G/)/i'19dC1
�1Cc.�ln/STF 7c%e7
CITY��laf�ZIP�/'L-TEL.cY�lg 7�7�y
APPLICANT!TEL.
CONTRACTOR_� �, , ,
ADDRESS�-�p�'T/
CITY ZIP TEL.
ARCWENG/�� !
r
DESIGNER,_� L
ADDRESS�/G-S
�� �
CITY��-ZIP 70 S TEL.7�U
OWNER-BUILDER DECLARATION
I HEREBY AFFRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSELAW FOR THE FOLLOWING REASON (SEC.7031.5 BUSINESSAND PROFESSKKJS CODE: ANY CITY OR
COUNTY WHICH REQUIRES A PERMITTO CONSTRUCT,ALTER IMPROVE,DEMOLISH,OR REPAIRANY STRUC-
TURE,PRKKi TO ITS ISSUANCE.ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SIiE IS LICENSED PURSUANT 70 THE PROVISIONS OF THE CONTRACTORS LI-
CENSELAW(CHAPTER Y(CXIMMENCING WITH SECTION 7000)OF DIVISK)N 3 OF THE BUSINESS AND PRO-
FESSK)NS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANY VKN.ATION OF SECTION 7031.5 BV ANY APPLICANT FOR A PERM I7 SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(5500).):
^ 1,AS OWNER OF THF: PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK,AND 1'HE STRUCTURE IS NOT INTENDED OR OFFERED fOR SALE(SEC. 7oH. BU51-
NESSAND PROFESSIONS(bDE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWIJ EMPLOYEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF,HOWEVER THE BURRING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE-
TION,THE OWNER-BUILDEii WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
^I,AS OWNER OF THE: PROPERTY,AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJIECT(SEC. 70M,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSELAW DOES NOT APPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAG
TORS UCENSE LAW.).
^ I AM EXEMPT UNDEIi SEC. B. d P.C. FOR THIS REASON
DATE OWNER
LP�ENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PE:NAL7Y OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(OOMMENCINO WITH SECI'KJN 7000)OF DIV75!ON 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY UCENSE IS IN FULL FORCE AND EFFECT.
/^'��
LICENSE CLASS�LIC. N0. �//�_
DATE CONTRACTOR
WORKERS'COMPENSATION DECLARATION
I HERE AFFIRM UNDER PENALTY OF PERIURV ONE OF THE FOLLOWING DECLARATK)NS:
HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TOSELF-INSURE FOR WORKERS'
COMPENSATKN,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
THE WORK FOR !YHICH THIS PERMIT IS ISSUED.
i
1 HAYE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WOR R
S
COMPENSAIK)N INSURANCE CABBIE AND POLICY NUMB
R ARE:
r
Q
CARRIER 7 �'j�_
POLICY NUMBER_,li 11 .11..->•1�
vl/(JT�T�
(TFYS SECiXXJ NEOO N078E OCAKE7ED OF THE PERMR IS FOR ONE HUhDREDDCUARS(5100)OR LESSJ.
I CERTIFY THAT IN ThIE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY 4NV PERSON IN ANY MANNER 50 AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATON LAWS OF CALIFORNIA.AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTlON 370 OF THE LABOR
E.I SHALL FORTIS
WITH COMPLY WITH TF10
�PROVISIONS.
Sf
/N,,
/
/
���f�y_��������
DATE:
[APPLICANT: ._.��
WARNING: FAILURE TO SECURE WORKERS'COMPENSATOOJ COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER 70 CRIMINAL PENALTIES AND CIVIL FINES UP 70 ONE HUNDRED THOUSAND
DOLLARS(5700,000),IN ADDn'ION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTK)N 3708 OF THE I.ABOF,CODE,INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY AFFIRM UNDER PEt•IALN OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF n1E RK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV C.).
LENDER'S NAME
�_ ��
r
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATKNJ AND STATE THAT THE ABOVE INFORMATKXJ IS CORRECT.
I AGREE TO COMPLY WITH ALI. CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OFfHIS COUNTY TO ENTER UPON THE
ABOVE-MENTK)NED PROPERI-Y FOR INSP TION PURPOSES.
�� �=yr
PERMITTEE NAME(PRI
K�L/
SIGNA PE MI DATE
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy