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HomeMy WebLinkAbout17069 (37) �� CITY OF DIAMOND BAR � � DEPARTMENT OF COI�IIvIUr1ITY&DEVELOPMENT SERVICES 21825 E.Copley Drive - (909)860.3195 Fax(909)861-3117 PRESS ''�� BUILDING PERM[T APPLICATION FIRMLY o DDRESS :� 1 l ,�L_(_ �''r DATECATION �1 _/'1� NUMBER�I�(1�_� �/c --��Q�� [_/1.2�ZL � issuE TYPE occ APN LOT TRACT DATE CONST. GROUP °C OWNER _COr�pAe(� C_��tJr, p ADDRESS-r�-21 ('.QoC.I GT. ZONING SEfBACKS gciTv D��n-r�rr0 �� ZIP TELS�- •l7 FRONT RW O APPLICANT TEL. REAR p zd. SIDE/SIDE STREEf RW D � CONTRACTOR �A�f SIDE ❑ ADDRESS1�_�. OAK n _• � o CIN 4S�C'D��jNA ZIPg 179/ TEL v`�•2(,S'C.�`3�$� PROPOSEDUSE � o ARCFUENG/ z DESIGNER a ADDRESS NO.DWEL. O. NO. � CITY ZIP TEL. UNITS STORIES BEDROOMS � N DESCRIPTION SO.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARA710N SFR/ADDIREM O p 1 HEREBV AFFIRM UNDER PENAL7Y OF DERIURY iHAT I AM EXEMPT fROM THE CONTMCTORS ll- G82pB/CarpOR W CENSEUN�FORTHEFOLLOWMGREASON(SEC.70.71.SBUSINESSANOVROiE5510N5COOE:ANYC1Tl'OR (J� U COUNTYWNip1REWiRESAVERMITTOCONSTRUCT,/�LiERIMPROVE.DEMOLISH,ONREGAIRANYSTRUC• W W NRE,PRqR TO ITS ISSUANCE,ALSO REW IRES TNE APPI�CANT FOR SUCH VER/AIT TO FILE A SIGNED W Patio/Deck � STATENENT TNAT HE Ofi SHE IS UCENSED PURSUANT TO iNE VROVISIONS OF TME CONTMCTORS L6 � � CENSE LAW(p1APTER Y(Cd.AMENCINO WI7N SECTION 7000)OF DIVISION 70F iME BUSINE55 Ml�Pq0- POOVSPB O iES5qN5CODE)OFiHATHEORSNEISE%E�APi7MEREFRdAANDTH[B�ISiSFORiNEA.LECEDEXEMP- (' V TION.ANVVKKATIONOFSECTION70�I.SBYANVAPPIMANTFORA�ERMITSUBJECTSTHEAPPLICANTTO Z Re•Roo1 A CML VEN�LTYOF NOT MORE THAN FIVE HUNDRED DOLURS(f50o).): � OI.ASOWNEROFTMEGROPERTY,OflMVEMP�OYEESWITHWAGES115THEiR50LECAMPEN5AT10N, � (,`OTTBfCl3� Z YnLL DO THE WOPIC/wD TM[STRUCTURE IS NO7 IN7ENDE�OH OFfEREO FOR SALE(SEC.)Oa1.BUSI� J N NE55 AND PROFESSIONS COOE:T11E CONTMCTORS LICENSE UW DOES NOT APPLV 70 AN DWY[R OF = VROPERTY VAIO BUILDS OR 11APROVES TMEREON.AN�WHOOOES SUCH WORK NII.ISCLF OR HERSEIF OR CL T/ROUCHHISORMEqOWNEM�LOYEES.PROVIDEDTHATSUCMIVPROVEAIENTSARENOTINTENDE�OR m O OFFENEDiORS/LE.IF,MOWEVE0.TME8UIl01NCORIMPppyEMENTI550lDVATH40t�CYEAROFCOMPLE� Z T10N.THE OWNER-BUIIDER WILL HAVE THE BURDEN OF PROVWG TMAT HE OR SME DIO NOT BUIID OR = MPROVE FORTNE VUR705E OF SKE). uJ 04�SOWNEROFTMEPROPERTV,AME%CLUSIVE�YCONTRACTWGWITMLICENSEDCONiMCTOfiS Q TO CONSTRUR THE iR0.1EGT(SEF 70M,BUSINF55 AYD PHOFESSIONS CODE.TNE CONTMCTORS LI� VdIU3Ii0f1 ADJ.AREA W LENSEUWDOESNOTACPLYTOANOWNEROFAVR07ERTVWHOBURDSORIIAP{qyESTHEREON.AND � YAqCDN7MCTSFOFSUCH7RQ1ECf5WITHACONTRALTOR(S)LICENSEDPURSUANTTO7XECONiRAC- OUANTITY DESCRIPTION FEE Y TORS LICENSE UW). � OIIWEXEMP7UNOERSEC. B.6P.G.FORTHISREASON Q � U u.. � DATE�� •O L OWNER H' Z �'— �U �Q LICENSE�CONTRACTORS DECLARATION W CC IHEREBYAFFIRMU�DERPEIULTYOFPE0.JURYTHATIAMLICENSEDVNOEAPROVISiON50FC11APTER U. p. O�COGMENCWOWITHSECTION70ao)OFDMSION]OFTHEBUSiNESSANDPROFE5510N5CODE,h.Y� Z �L MYLICENSEISINFULLFORCEANDEFF(LT. m � UCENSEqCLASS y .���1 UC.NO. ��^ � V DATE 1���'Q I CONTMCTOR d W � WORKERS'COMPENSATION DECLARATION Q NIHEHEBYAFFIRMUNDERPENALTYOfPEiWRVON[OFTHEFOLLOWINGDECLAMTIONS. Z _ .� �IIUVEIwDWILLMAIN7AINACEFRIFlCATEOFCONSENTTOSELF-MSUREFORWOfL(ERS' _ Q Cp�PEN5�710N,A5 PROVIOED BY SECTIOH]70o OF TME L�DOR CODE,FOP TME VERFONAANCE �U O OF TME WORK FOR WMICH iH�S PERMIT IS ISSUEO. � QW �IHAVEANDWILLIAAINfAINWORKERS'CA4PENSATIONINSURANCE,ASREOUIREDBV6ECTqN �7000F iHE W'OR COOE,FORTIIE PERFORMANCE OF TME WOPo(FOR YA1Ip1 THIS GERMIT IS � //�� D J 65UED.YYNOIU(EHS'COMPEN511TIONINSURANCECANRIERANDPOLICYNUMOERARE: CONSTRUCTION aLIJ(� j CARRIER PLAN REVIEW � POLICYNUMBER Z ELECTRIC ¢ � (fH55ECfi0NNCmNOTBE0d.6tiEfIDOFT�EPEMtTl5Fdi0h'EMRDf1EDDq1Aft5�f'm)q�tE554 PLUMBING Z I CCRTIFV THAi R1TH[PERFORIAANCE OF TNE WORN FOR WHICH THiS VERMIT IS ISSUED.1 MECHANICAL _ - (,�} SNALLNOT EAIPLOV ANY VERSON IN�M'AIANNCR 50�5 TO 9CCOME SU0.IECT TO TN[ ' � '� : �� � WORI(ER5COMPENSATqNUW50FGLIFORNI��NDACREETMATIF15NOVLDBECOME INSPEC710NFE �°`'-� I I SV6IEGTTOTHEWOFKERS'COMPENSATIONPROVISiON50F5ECT10N�70oOFTHEUBOR � +~' s WOE,ISNN.�FORTMM7NCOMPLYN'Ih/TrqSEPROV15iON5. ISSUANCE 0 � r p DATE: APPLICANT: SMIP Sf P �l � � WARNINC:FAIIURE TO SECURE W01iKER5'CAA�PENS�TqN COVERACE IS UNUwFUL.AND SNA�L BE ENEFGY P!C � SUQIECTANEMPLOYERTOLR:MINALPENALTIESANOCMLFP+CSUPTOONEHUNORCDiF10USAND ENEFGYPERMIT � DOLURS�f1W,0ao�,INADDITIONTOTMECOSTOFCq.1PEN5ATqN,D�IAAGE5A5PNOVIOEDFORIN �L]`� � SECTpN070lOFTMEUBORCOOE.INTERESi0.NDATiORNFY5FEE5. RETENTIONFEE:1-1'�-� ---"`'-----�---=. a CONSTRUCTION LENDING AGENCV PpE•ALT FEE: O � IMERCBVAFFIRMUNDEHPENJLLT'OFPENURYTIUTTHEREISACONSTNUCTIOnLENO:NGAGENCY FOH TME FERFOFMANGE OF THE WORK FOR WHICH TMIS PERMIT IS ISSUED(SEC.7ovl,CIY.G). Z W � IENDERSNAME S 1-� LENDER'SAUDRESS � � TOTAL FEES I y�„ � I CERTIFY THAT I HAVE RE+V1 THISAPPL�CATION ANO STATE THAT THE A90VE MFORIAATqN IS CARRECT. w IAGREETOCOMPLYYA7NALLCRYANDCOUN7YOROINANCESANDSTATEUWSR[UTWGTOBURDiNG � CONSTRlICT10N,ANDHEPEOVAUTHOi71ZEPEPNESENTATNESOFTMISCWNTYTOENTERUPONTXE Z !�W)VE�YENTqNEDVROPERTYFORINS�ECTIONPURVOSES. • CON1A[NTS 0 � C'�Q15ToP�-1�F� �/✓�i�s��m�i./ ¢ PERMIT(G[Ny.���M)L..`�/� � cn % �i� !•�•a1 (A SIGNATUHEOFPERMITIEE y DAfE � RECPT.NO. _ PAID BY VALIDATION WHITE—Department Copy.YELLOW—Fnance Copy,PINK—Assossor Capy.GOLDENROD—File Copy.GREEN—ApplicanCs Capy . _ : .. , .,- ,. -, . . _... .: • . .. . . .. .. .. . . . . . . . . . . . .. .. .. - .. . .,-.. . -.- . . . . . - . . r �-r-:� �:;= ��i�.rr;-�,��� �_r r-, ��,ec��"L'=� �+IClL.� �6_i,�.t.,'t i..�..� �___________,_..._--__.__T_..._____._ -- .-•— -.------- - --- -----.-.---.----_------- --- _._._____-�,__ __._--- ------------- _ �A�E-i:•�=:E.`flflkl �.�:.S..i ! 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