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HomeMy WebLinkAbout16951 � � DEPARTMENT{}F CC}MMti7vTI'Y&DEVELOPMENT SERVIC��C.�C �� � � ,! `� CTI'Y OF DIAMOND BAR � _ _ _�-'`�` ___ ES _..i�,. 21825 E.Copley Ihive (404)860-3195 Faat(909)861-3117 � PRE$$ su�LnuvG r��T��cICATION FIRMLY o� JOBSiTE �f� � ^��� APPUCATION - ��,�-��� pERMIT � �(— P/C ADDRESS__� OATE NUMEEft__�� # —��'��,�" acc °-° APN ,�. � L 7 TRACT DA E� Cd ST. GROUP p OWNER -�4_'L2..� o ADDRESS L�,,,� �_ T}'� ZONtNG SETBACKS Z CITY__N � ZIP� _ TEL� "�� FRONT _ RW ❑ � APPLICA T ,_ TEL. REAR � � SIQEtSIDE STREET �yy �� Q CONTRACTOR_ SIDE ^., p _ ADC}RESS � CITY ZIP TEL. PROPOSED USE � ARCH1ENGl i iz DESIGNER� — NO.DWEL. NO. NO. q� ADDRESS = GITY ZIP TEL. UNITS STORIES BEDROOMS cn — � dESCRIPTION SQ.�T. FACTOR PSF AdJ,AREANALUATION � OWNER-BWLDER DECLARATIQN SFPIADDlREM O (7 f HEAEBY AFF�RM UMOER PENALTV OF PERJURY TNAT I AM E%EMPT FROM THE CANTRACTORS LI� G2f2JB/CBfpOfl W CENSELAWFOqTNEFOLLOWINGREASON(5EC.7031.SBUSMESSANDPROFE5510NSCODE:ANYCITYOp Cf7 K.J C�tJNTYWNiCHflE4U3RE$APEAMlTTOCANSTRUCT,Al7ER,IMPROVEDEAlt#_ISH,bRREPAiRANYSTRUC� � W 7URE,PRIOR 70 ITS ISSU4NCE,ALSO REQUIRES THE APPLICANT FDq SUCN PERMI7 7o FILE A 31GNED W Patio/DgCk .� STATEMEN?7HAT HE OR iHE!$LICENSED PUFSUANT Tq THE PROYISI�NS OF THE CpNTRACTQRS i.t- � " � CEN5E lAW{CHAPTER 9 t���NCING WtTN SECTIDN 7060)OF DIVIS�ON 3 Of THE BUSINE55 AND PRp- POOVSPB FESSIONSCDDEjpRTHA'fHEOR5HEISE%EMPTTHEFEFROMANOTHEBAS13FORTHEALLEGEOE%EMP� (� � TION.ANYV'qlAT14NOFSECTION7o3i.5BYANYAPPLiCAN7FOftAPcftMiT5U8.tFCTSTF#EAPP�tCANTTp z R8•f2W1 r A CIVIL PENAt.NOF NOT NORE THAN FNE tNNORED DOLLARS(S`�0�.): � OI,ASOWNEROGTHEPR4PERTY,ORMVEMPLOYEE5WITHWAGESASTHEIRSOLECOMPENSATION, 0 �OtT1t7187C�8I Wlll DO FHE WOFK,Nib'(HE STRUCTUftE i5 NOT INTENUED ChR 4FFERED FOft SAIE{SFC.7ae4,gUSi- J � NESS AND PROFESSiONS COOE:THE CANTqACTORS LICENSE LAW DOES NOT APPLY Tp AN OWNEF OF � PROpERN WHO BUILDS ON IMPROVES THEFEON,AND WHQ DOES SUCH WONK HIMSELF OR HERSELF tlR ('[ THflWGHW50RHEROIM4EMFL0Y£ES,PFOVIDEOTHATSUCHIMPROVEM6Ni5AREN6TiMENDEDOR � ��� „�W OFFERE�FORSAI.E.IF,HI7YYEVER.THEBUILDINGORIMPROVEMENTISSOLDWITHINtlNEYEAROFCOMPLE� Z TION,THE OWNER�BUILDEi WlLL HAVE TNE BURDEN pF PRDVING 7HAT HE OR SHE QID NCJT BUI�D 4R �- @dAFtOVE FOR THE PURPQSE OF SALEj. �u ['.�]I,ASOWNEFlOFTHLPRl7PERTV,AMEXCLUGNELYCONiRACTINGWITHLiCENSEDCONTrlAC70RS [[ TQ CANSTftUC7 TNE PROJECT{SEC.?oa<,BVSINESS Atds PR9PE55ICM15 G44E:TNE CONTRAC70RS I.I- VBlt/dti011 ADJ.AFEA I.17 CENSEL4W60ESNOTAPitYTOANOWNEROFAPPOPERfYWHOBUII.DSORIMPR4VESTHEREON,ANp — � WHOCONTRACTSFORSUCHPROJEGTSWITIiACONiRACTOR(5)410ENSE�PURSUANTTOTNEC4NTRAG QURNTITY OESCRIPTlON FEE � TORSUCEYSEUW.}. � ❑i AM EXEMFT UNDE3 SEC.�__ i B.H P.G FOR THIS PEASON Q C) � -- . ..._.`_ [C RATE OWN`Fi F � � -.. ........ . w � UCENSED CONTRACTOftS DECIAFATIQN W CC I HEFlEBV AFFIRM UNDER PI:NALTY DF PERJUHY THAT I AM LICENSED UNDER PROVISIONS OF CNAPTER � d 8(CAMMENCING WITH SEC'�KKi TOW)OF QIVISIfltd 3 QF TNE BUSINESS AN6 PftoFE5S'ONS CODE,rtND Z IX MY LICENSE IS IN FULL FORCE AND EFFECT m Q L�CENSE CLASS_._�, ,_ LIG.NO. .. � � � U DA'E GONTftACTOR,,, __ d W � Wt?RKERS'COUPEN5ATION DEGtAHATiQN � ���� � 1 HEREBYAFFIRM UNOEF PE NALTY OF PERJUFY ONE OF iHE F�LLOWING DECiAR4?IONS; Z � _INAVEANDWILLMAWTAINACERTIFlCATEOFCONSENTTUSELF�INSUFEFOFWORKERS' a ,� COMPENSATiON,AS PftOYi�EQ 8Y SECIlON 3'flu pF THE I.AgpR CODE,FOR THE PERFOflRtANGE G) OFTNE WORK FOF1 WMICH THI$PERMIT IS ISSUED. w (:] � Ow _I HAVE ANp WRL MA�MAIN WOI�CERS'COMPENSATION INSURANCE,AS REOLIIRED 8Y SECTION 3l0o OF TNE LABOR CODE,FOR THE PERFO%MANCE OF T'HE WQRK FOR WHICH THI5 PERMIT IS i55UED.MY WORNERS'CAMPENSATIQN iNSUftANCE CARRIER AN��I.7CYNUMBER ARE CC}NSTRUGT(ON J —.... � CARRIER ._ PLAN REVIEW ,. ZPoucrwuMeea� ...__ ELEGTRIC .. 4 � (i}NSSECTC7NNEEpNOTBEmMCtEfEDOFiH[PERMti�SFORONEHUFAREDOq.,{,qRs(610olORLESS). PLUMBING _,,,_ _ 1 W � i GE£STIfY THAT IN TtiE PEftFQAMAMCE OF iHE W{}RK FGR WHICH THIS PERMR t5 I5SUE0,i �ECHAF`IICA� C,�} SHA�LNOTEMPL0Y4NYPERSQNINANYMANNERSOASTOBECOMESUBJEMTOTHE � � Uj WORKEflS'COMPENSA710N IAWS Of CALIFQRNIA,AN�AGAEE THAT IF I SHOULD BECOME �NSPECTION FEE __ _ St18JECT TO THE WORKERS'COMPENSATION PROVISIONS 6F SECTiON 3]o60F IHG tABOP � COOE,ISHALLFOPTiWITHCOMPLVWITHTHOSEPROVISIONS. ISSUANCE ,_ _ y p DATE: ,�_ APPLIGANT. „_„ _ SMIP � WARNIX�'G.FAItUftE TO SECU3E WOAK[RS'COMPEN$ATIOti CAVEflAGE IS Uh'IAWFUt,AN6 SHAIi 9E EFfERGY PIC _ � SUBJECT AN EMPLOYEF T4 CRIMINAL PENALTIES PNp CIVIL FINE5 uP TD ONE HUNDpED THpUSANq ENERGY PERMIT DOLLARS{{100,000),IN ADDI170N TD THE COS f OF.^.OMPEN5ATION.DAMAGES AS PROVIDED F�R IN ........... � SECTION 370U OF THE 1A60F CODE,INTEi1EST,AND hTTOftNEV'S i`EES. pC �, RETENTION FEE: ,_ „ QGONSTRUCTIOF!I_EFIDING AfiENCY PRE-ALT FEE: _ � IFIEREBYAFFIHMUfJDERPEPIALTYOFPEFUURYTHATTHfREISACANSTAUCT10NlENQiNGAGENCY _ FOR THE PEfl(-0ftMANCE OF��HE WORK FOR WHICH THIS PERMtT IS ISSU€O jSt;C,309�,CIV.C.j. �� ' — W _ ,S� �EtiDEfl'S NAME ..._ ...... ._..._..... . > 1— LENDEft'SADDRESS wI CEflTIFY THAT I HAVE READ�"H4S APPLICATIONAN�5TATE INAT S'NE C80VE INFORMATION�5 COftRECT TOTAL F EES � F �� � I AGREG i0 COAAP�Y WIiH ALt.CITY ANO COUNTY ORDINANf.ES AND STATE IAWS RELATWG TO BUILD�NG � CONSTRUCTION,ANp HEREB"AUTHORILE REPR EMTATNES OF7HIS COUN7YT0 ENTEF UPON?NE Z A60VE�MENTIONE�PROPFRIY FORtNSPECT PURPOS£5. a COMMENTS_...._., . � � ��+ � . --— . . . —... .. _ m PERMITTEE NpME(PRINT ¢ �,,� �,.,,_ /tl�j j — �_ ,�_ �_ N 61GN E OF PEqMI ���DATE ��^ Z RECPT.NO._ � PAID BY VALIDATION �` ~ WHITE—Departmenl Go YEILQW—Finance Go PINK—Assessor Ca GOIDENROP--Fife Co GREEN--A licani's Ca PY, RY� PY. PY. PP PY r i : �4 �r `1 i�i m ��,,,yq'�` �^n � 1 i ��y��5 �d ���� ,. .���,.,-'�`�� i i..n; e,;" ���. 1 �a�a�p d'"`�'�g .t�r�^��,a���ea.°'�s"�� . �< ., .�, . �, �. . _ : � v . s • �, : � ... ba .�,�. ' . . . ., . � , , � .- �,m , t ' o: � a, ... .. . .. . , a�.. , . '. . _ ; . . . k=t ,�: . � . .. . . . . . _ .. .� .. . .. . .. .. .. . ,- _ ��. . . `I,^�t�-C + .., _._ . � ..�' .. . _... .._ . . ... ... _._ . ._. .. ... � ,. .. .. .. . . . ... ._ ._ - .. .. _. . .. .. . . ,:, ' m ' � s�.�.�a_r _... .... ... ...... __ _ �.,. �,. : < , �,u . . .. . .... ... ... . ..... . . . . ....... ... . ... '��. � ,- _ � '_ - ��i ,: �.. `r,� �, '� �` b�14=i..�i . ... ... . . ... . ._. .. ..._ _._ ; ' � � _ 9 = fi d� ': . . ... .. . ... . ... �: (� ..- - � . � .m 4 �'i�,[-€i ry�R �. .. e'f i i �_a��g ��, F� �sEri."'� .. .... ..._ . .... ..... - ey,.. " _ s. . . . . . .. _ _.. .�. Md �� a . 3 . - c..:. .._ . _ . ... .. .... 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FACTOR PSF ADJ.AREANALUATION SFR/ADD/REM � Garage/Carport W Patio/Deck u- PooVSpa Z Re-Roof 0 Commercial m Valuation ADJ.AREA QUANTITY DESCRIPTION FEE J Q U f- U W J W C7 Z CD J d J Q U Z Q 2 U w CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING M ECHANICAL INSPECTION FEE ISSUANCE y SMIP ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE-ALT FEE: TOTAL FEES �Q COMMENTS RECPT. N0. PAID BY VALIDATION WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy �,S�-c;����