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Home My WebLink About19086 �.,� _ CITY OF DIAMOND BAR DEPARTMEM'OF COMMUNITY 8r,DEVELOPIv�ENT SERVICES � �.:w . 21825 E.Copiey Drive (909)860-3195 Fax(909)861-3117 PRESS """" BUILDING PERMIT APPLICATION FIRMLY � JOBSITE j � �J � ADDRESS�/ CRAriU �'/�� f-/y pAPE�CATION � -b NUMBEF��I �k/C I � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER �� Gtir o ADDRESS-� �CC L�' ZONING SETBACKS z CITY D� ZIP�/76S TEL - S-3LSS� FRONT RW ❑ p APPLICA T �� IZ��JJ(t��r' TE� �25'-�{'o� REAR ❑ � - SIDE/SIDE STREET RW ❑ � CONTRACTOR AuL L� SIDE � o CDDRESS� Z P � TEL — 53 PROPOSED USE /�ILt2GJ „�L'1(,�G/}{IA� ZYL��L• �� oARC NG/ z DESIGNER w NO.DWEL. NO. NO. a ADDRESS � CITY ZIP TEL. UNITS STORIES BEDROOMS � �n DESCRIPTION SQ.FT, FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADD/REM O 0 111EREBY AFFIRM UNDEA PBiALTY OF PERYJRV THAT 1 AM E%EMPT FRON 7HE CONTRACTORS U� G3f8g9/Ca1F10R W CENSELAWFOR7HEFOLIAWWGREASON(SEC.7031.5BUSMESSAN07POFESSpNSCODE:ANVCITYOH (f� C� COUNTYMMICNREOUIRESAPERMITTOCONSTRUCT,ALTE0.IMPROVE,�EMOLISH,OHREPAIRANYSTiiUC- w � w TURE,PRIOR TO ITS ISSUMICE.ALSO RE�UIFES THE APVLICANT FOR SUCH GERMIT TO FILE A SIGNED W Patio/Deck � ST�TEMENT THAT HE OR SHE IS LICENSED VURSUANT 70 THE PROVI$IONS OF TME CONTRACTORS LI- � � � ' s CENSE UW(CHAPTER B(COMMENCING WITH SECTION 7000)OF DIYISION 3 Of TME BUSMIESS ANO PAO- POpUSPB V FESSIONSCODE�OR7HATHEORSMEISEXEMPTTHEREFROMAN�THE6ASISFORTHEALLEOEDEXEMP- (!f V TION.ANYVIOU7qNOFSECTION703/.5BYANVAPPLICAN�FORAPERMITSU&IECT$THEAPPLICANTTO Z Re-Root � A qNl PEN/�LTY OF NOT MORE THPN FIVE HUNDRE��OLLARS�3500�.j: � ❑I,ASOYINEROF7HEPROPERTV,OHMYEMGLOVEESWITHWAGESAS7HEIRSOLECOMPENSATION, 0 COR1RIBfC13I Z WILI OO TNE WORK,AND TFIE STRUCTUqE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7a1,BU51• J � NE55 AND PROFESSIONS CODE:THE CONTRACTORS LICENSE UW DOES NOTAPPIY TO AN OWNER OF � PqOPEHTY WHO BUILDS OR IMPROVES THE{7EON.AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR CC 7HROUGHMISOqHEROMMEMPLOVEES,PqOVIDEDTNAiSUCHIMPROVEMENTSARENOTWTEN0E0�0. m Q OFFEREDFORSALEIF,I/�WEVER,lHEBUIIDINGORIMPROVEMENTIS50lDWITMINONEYEqROFCOMPLE• Z TION,THE OWNER-BUII-0ER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID ND7 BUILD OR � IIAPROVEFoqTHEPUHPO5EOF5ALE). ❑I,AS OMMER OF THE PROPERTY,AM E%CIUSIVELV GONTq�CTING WITH LICENSED CONTIUCTOR5 � TO CONSTRUCT THE PRQIECT(SEC.7os4,BUSINE55 AND PROFESSIONS COOE:THE CONTfUCTORS LI- VelU8t10f1 � � ADJ.ApEA W CENSEIAWDOE3NOTqPPLYTOANOWNEROFAPROPERTVWHOBU1LD50PIMVROVESTHEREON,PND � MM1IOCONTFUCTSFORSUQiPR0.1ECT5WITHACONTRACTOR(5)LICENSEDVURSUANTTOTHECONTMG QUANTITY DESCRIPTION FEE � x TORS UCENSE LAW.). � p ❑I AM E%EMPT UN�ER SEC. B.8 P.C.FOR THIS REASON � �L� l„',� C C f � � U LL � M7E OWNER V Q W � LICENSED CONTRACTORS DEGLARATION W � 1 HEREBYRFFIRM UNDER PENAIN OF VERJUflV h1AT I AA1 LICENSE�UNDER PROVISKKJS OF CHAPTER � e(COMMENCINOWIiHSECTqN7000�OFDIVI510N30FTNEBl151NE5SAND7ROFE5510NSCODE,AND Z t t AiY LICENSE IS M FULL FORCE AND EFFECT LlJ 2 m �. � �.Vl" � LICENSE CLA55 C� S 1 L{C.NO. ^ o� j � � �" DATE�1�"Q 1 CONTRACTOR d �� v- � U W � WORKEFS'COMPENSATION DECLARATION � J NIHEREBYAFFIRA1lIN0ERPENALTVOFCERJURVONEOFTNEFOLLOWINGDECURqT10N5:�� ' Z Q L' � _I HAYE AND WILL MAIN7AIN A GERTIFICATE OF CANSENT TO SELF-INSURE FOR WORKEflS' _' COMPENSATION,AS PqOVIDEU BV SECTION 37000F THE LABOR CODE,FOR THE PERFOqMANCE 'U Q OF 7HE woRK FOR WHICH THIS PERMIT IS ISSUED. � � I HAVE AND WILI MAINTAIN WOFKERS'CQMPEN9ATION INSURANCE,AS REWIRE9 BY SECTION Q 3�Do OF THE LABOR CODE,FOR TME PERFORMANCE OF THE WORK WR WHICH THIS PERMIT IS � ISSUED.MY WOHKERS'COMPENSATION INSUFANCE CARRIER AND POUCV NUMBER ARE: CONSTRUCTION J j CARRIER PLAN REVIEW ' � � POIICY NUMBER � t Z ELECTRIC � ¢ t � (fH455ECT10NNE�NOTBECOAAPIEfEDOFhEPEPMfLSFOFlONEFI.N�DRED00UMS(5100)OR�ESS} PLUMBING � � j Z I CERTIFV THAT IN iHE PERFORMANCE OF iHE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL "� L} SHALL NOT EMPLOY qNY PERSON IN ANY MANNER SO AS TO BECOME Sll&IECT TO THE � WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANOAGREETHATIFISHOUIDBECOME INSPECTIONFEE V� SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3'/0o OF 1HE LABOR � CADE.I S LL FOfiTHWITH COMPLY WITH THOSE PROYISIONS. ISSUANCE i � � L � / p OATE:�� APPlICANT: � � � SMIP �2� (� J WARNING:FAILUHE TO SECURE WORKEflS' PENSATION COVERAGE IS UNUWFUL,AND SHALL BE ENERGY P/C � LL SU&IEC7ANEMPLOVERTOCHIMINALPENALTIESANDCIVILFINESUPTOONEFRINDREDTFiIX13ANp ENERGYPERMIT OOLURS(St D0,000�.IN ADOITION TO THE COST OF CAMPENSnTION.�AMAGES AS PROVIDED FOR IN � SECT�ON 370B OF THE LABOR CODE,INTEREST,ANU ATTORNEY'S FEES. RETENTION FEE: / OCONSTRUCTION LENDING AGENCV PRE-ALT FEE: � I MEREBV AFFIRM UNDER PENALTV OF PERIURV THAT THERE IS ACONSTRVCTION LENDINO A6ENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERAl1T IS ISSUEO(SEC.aoe1,CIK C.), Z W � IENDEH'S NAME _ F-' LENDER'SADORESS W IGERTIFYTMATIHAVEREADTHISAPPLICATIONANDSTATETHATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES 33� � l�-0 J � , � I AGREE TO CAMPLY WITH ALL CITV ANO COUNTV OROINANCES ANO STATE UWS qELATINO TO BUIL�MG � CANSTHUCTION,AND HEREBY AUTMOR2E REPRESENTATIVFS OFTHIS COUNTV TO ENTER UPON THE Z ABOVE-MENTIONEDPROPERTVFORINSPECTIONPURPOSES. 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Fs <� ' ' /� �'�P ��'�� •� _ _ _ _ a � ; — -- . , _ __ � � � � _ _ _ _ _ � � ___._� . __ — -___ --� � � E �� . r , �3�a . . � � _- _ __ — — — ___ ___�_.__�_ ___._ _ _. , _ _ . _ _. � __a , � _ � _ j � �� _�-�� c..� ��:v (. ��.s� ��-��__ 5�-�-%� _ . _ � _�'� ��w�.--�� i��: �-� �t� '` ►v� 2 k_ /�—�H-- : � _ i . _ _ i +.; V.: .�"��,-�" _ t +�: �— (�-��-�� • _ . — -_ _.— �1 ° _ �z�, '�.-�"2� � 1 s �r c�� 22�� _ �—� � ___ . �� —� � _ _ ______ , � . _ ��.�� t� �� _ �-�l�r b_3 _ lUt�� ,�� _ � _ _ _ _____-_ _ _� _ _ _ � � � . . _ __._ � , __ _ _ _ _ Sr� _ _ _ _ _ - _._ ____ . _� w�� _ � . _ _ -- -. ; �. � . _ 1 � . _ _ _ __ � ' ��Pi ; �� _ _ _. _ __ _�__ _._� „ _ _ _ , �, , , } �� _ _ _ _ — —_ _ �. � �� __ ._ .. _ _. _ _ _ : _ . _ — � � __ _ _� � — —�. _ _ _ _ _ _ __ � � ; _ ___ . __ _ __ __ . �.,_. _ .� _ � � �� : � q _ _ _._ ..._.....,�._. .._,,,.,__ ...__._.,._ ._.. _.�.,_.. .__...} ... ..�-. .,. . _.._. ..�.__ '^_�. , m...�. . ... _., e�.. e .�,.,....._.,-....._ _.._ . >»...........n.......... ......«....«mo ..... p,.....� ..�..� �--.,,..�-«_.,.._...�. .«.�.m ,�.i..J � . � WORKERS'COMPENSATION DcCLARATION 5� I heieby,�f��m,�o� � �,o�e a�e,,;f,�o,e of�o�=e�,,o self APPLICATION FOR BUIlDING PERMIT i ac e,or o cerrificore or Wo�kers'Compenstion Insuronce,or o ceintied copy rhereof(Sec 3800,La6.C.) , � Cf3UNTY OF LOS ANGELE$ BUILDING AND SAFETY �PolicyNo. Company � Ceriified copy is he.eby��.�ished � FOR APPLICANT TO FILL IN eU��oiNG � ❑ ADDRE55 Cerlified copy is filed wi�h the county 6uild�ng inspeo- eui��iNG / lion deparimenf. � qDDRESS ��G `G ' �OCA11'Y, \` / NEAREST �.�" Da1e Appliconi CITV 6 �! ZIP CROSS 5T. -��L�..1�� CERTIFICATE OF EXEMPTION FROM WORKERS' N�.OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF�OT / NOW ON l01 � MAP BOOK GAGE PARCEL (This seaion naed not be completvd iF�he permit is Sor o�e USE ZONt mnP �1 hund�ed dollars($i0o)or'�ass.) `zna etOC[ �oi No. � �, No. Y } '��" TEL 57ECIAL a I certify tha��m the parformance of the wark for which ihls � OWNER NO.f CONDITIONs O permif is i ued,I shall na�em lo ' manner o�5 It'i GROJv 7vpE FlRf PkOG55ED Bv p y ony persan in any ' U so as f b�`' 6je<t ta the Worket5"C Tp¢n50n1�an�L . ADD2ESS � CONST ZO � �//�� a��'�////'f ary � zia Z (J � A .Dota Appl�co r J_ F S�AiISTICALCL°.SSIFlCATIpN ACT. CONDO. NOTICE TO APPLIC�INT: If, oiier makin �his Ce�tificaf f ARC:�ii[cro TEL. � `q V Examprio�, yov should Lecome su6ject �o •he Workers' ENGiNeex < � NO I.L� fi,n55 No.�DWEu.uNirS_ i M Gompensorion provlsions of ihe Labw Code,you must forth- qoo�Ess SEw[e Mav Z wi�h romply wi�h such provisions or �his permir sholl be . deemed revoked. CONiRaC70R NO. eK. a�, VALIDATION IICENSED CONTRACTORS DECLARATION �� hereby affirm thol I om licensed under provisions o{Chnpler 9 ADDRE55 ? R N�. VALUATION ymmmencing with 5ection 700D)oi Divisian 3 0+ihe Bosiness and �i� � �� Professions Code,ond mv lice�se Is in F�II force and effecr. cliv ��u55 8 S(�.FT rv0.OF NO.OF �HECK License Number Lic_Class S�ZE S70RiE5 FaMILiES ONE . Co�ha<br po1e DESCRIv1lON�F N'ORK NEW S � I am exemp�f.om�he licens'irg requ'irements as 1�m a � ADD � licensed orcti�iec�or o regis�ared professional enginear Ai7ER � FINAL ) octing y prafessionoi copocily (Secfion 7051, ❑ DA7E /� �0 / REP�IR Boslneas ond ProSess�ons Code). use oF � fINAL E%ISTMG 3LDG. DEMOI Lic.or Reg.No. Oate APPLKANt iEl. � OWNER-BUILDER DECLARATION �oR'NT� �U No. �y 4 I hereby atfirm thot I am exempt from�he Con�.octar's llcenze c-y �-`�""" Law fOr ihe f011owing reason �Seclion 7031.5,Business und /.DDRE55 W st� Professions��ode�: oRESFNi �� '76`a4A awioiNc Y�. I, as own r of the property, or my mployees wifh ApDRE55 woqes os rhel,sole:ompensonon,wfll do rhe work ond �ocniiTr �7-�G'"�y fr+• •••2,1 � �he str�c��re 1s rw�,I�readed or of�fered Sor sole(Secrien 7044,Busrrie5s and 7ro`essipns CodE). MOVING iEl, I,os ownar of fhe propeny,am xdus�vely cantracti��y coNruAc,oR no_ 1.. .3 9,7 0 witF lirens=d canrracro.s�o consrr�cr the projecr(Seo- qDoaE55 s J 9�'](�? +�on 7044,Buslness ond Frofassions Code} . • ° , RE011IREO iOTAL SETBACK FROM E%IST. CONSTRUCTI'JN LENDING AGENCY SE7 BACK �AR'J HWY PROP.LINE WIDiH O S��'�8� I he.e6y alfi,m i6o��he.e�s a:o�si.o�i�on lending agency for FRnr.� rhe par4or oi ehe work for wh�cn�his permi�is+ssued � a� � �77�� Y� (Sac.3097mC v�PC1- �SIOE " a.L. � �,.a . . ..� Lender's Name `�[� q /� � e.;7Q,FQ � lender's Add�ess P.C.Fee 5 J-1, ` Pe.mif Fee �//-� I erfify thor I hove read ihis ooplicatlon ond srare ihot the � ` '?��5 L� Iss ance Fee �J� a6ave Info.ma+lon is cor�x�..1 aqree io<omply wi�h all Counry ,es�;yor��Fe= U �� Q r�j Jr,.�� o�d�nances ond Sro�e lows relo��ng to bo�lding consrrunron. imol Fee und hereby thorize�epresenlanves.of this Co��nry io e . � � Qupon ihe a o��e- en�loned propeny fo�fnspecnon p�.poses. � a � • �I�f� SEE REVFRSE FOR E%PlANA10RV IANGUAGE � � � . Syno��re ol Appl�.coni g ni C�o�e �s , PLANS TO APPLICANT �RSPECTON'S NOTl� � OWiVER-BUILDER DEC[.ARATION 1 he�eby affirm tFw�1 am axempt from�ha Cflntractols � . . licen>e Law far the follawing reason. (Sec. 703L5) . T"x R�� AP'�o�� Busine:s and Prnfe::ioxc Cade:Any city�r c�uniy u.�6ich No. Dofe No. Dafe . . requires a parmit to�onseruct,alter,improve,demo/ish, or reQaisany strssctrsre,prior 10 ib iuuance,oLso requiras � � - ibe o�plicoet Jor saeb per�nit to j+'le u sigalad sutement --- tbot be is licensedpumwnt to tba provi.rions of tbe Con- � � tractor'n License Low(CbaQter 9J(tonmancif+g w+tb Sao- rion 7000/oj Dioisiow 3 0/ehe Bu.riness anJ Profesriona CoJe)or[hat be ic exempi iherefrom a�d tbe batisfor tbe o!leqed eremytion.Any a;olado+s of Sectian 7031.5 by R�guirod pa}�Reeoivad any applicant f r a fesmft sssbjecb ebe applicanL to a civfl f1VProYpy � or Approvad , penalty of not more ibaa Jioe bundsed Jolkrr(SSOOJ.f' Yas Ne Q ,, r o4 the prope�ty,o�my emp�oyaes w{th Waier Cerrlfiwre .�oges as thev sala compensatlon,will do the work,and � iha siructure is not intanded or offered ior sole(Sec 7044) � Heahh De artment -� . . ,'�Jsss(fie+'+'o*d Pr'ofassions Coda:Tbc Cortra-tor's Licerue P :.,„�qvi:does�aot;4QPly to an oanw oJpropeity who builds ,�,or irnprones tbereon,and u�ho dau sucb work bir.ueljw Fire Cepartmenr � - ebrougb bis own employses,pmvided ebat sucb im- provement.� are not intended or offered jor sale. /j, Grading � � however,ibe building orimp�oo¢mant is sold within ona . yenr of aomplation, ibe owxer-buiLi�r wili bane tbe Geologicol - burden nf proving tbat be did r�ot build or improue for � ehe purposa of sala/. Pedesrrian Protedion � (Fenmj(Canooy� � ❑ I,os ownerof the properry,am ezdusively mnfror tl�with licen:ad contractors�o comtruct the projact(Sec. � 7044)Bwiaeu o�d Professioou Code:The Con[rxtori Special Inspecfio� Licerue Law does no2 apply tn aa�oa�ner o/prop rty mbo (Conc.)(Masoory)(Welding) � � buiGG nr imprave.r ebereon,aed wb�cnetracts jor sucb projects witb a conEract�J licenred pursunnr to tbe Lor orainoge . � Controctor's Lirense LowJ. Parking ❑ !am exampt ondc.5ec. ,8.8P.C.fo.thls reason , � Data Owner � Approvmis Dees IntpMor's 3ignamr� � . � � �. INSPEC70R'S NO7E5 ' Location— . (Serback 8 Yards) FoundaFons - � Siob Fram Energy Insulafio� lo�hl�rywnl I= Interior Lcth--Exterior � - � � House Number-- Correct 8 Posted Final— Emer on Front t s ao l --- - •'=�':T. — .: , CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION JOBSITE Z°/ ADDRESS (OO ru -Acv APN LOT TRACT OWNER GH/ ADDRESS Z(L CITY D ZIP�i?6s TEL 5-269 APPLICA T TEI 6 LS'-AS'o- CONTRACTOR,/L•CR ADDRESS CITY•ZPTELL ARC ENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER-BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE :ANY CITY OR COUNTY WHICH REOUIRESA PERMIT TO CONSTRUCT,ALTER,IMPROVE, DEMOLISH. OR REPAIR ANY STRUC- TURE,PRIOR TO ITS ISSUANCE.ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION.ANY VIOLATION OF SECTION 7031.6 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).): ^I.AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044,BUSI- NESS AND PROFESSIONS CODE: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 OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE. IF, HOWEVER,THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE- TION,THE OWNER-BUILDER 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 CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI- CENSE LAW DOES NOTAPPLY TOAN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANTTO THE CONTRAC- TORS LICENSE LAW.). ^I AM EXEMPT UNDER SEC. B. &P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE.AND MY LICENSE IS IN FULL FORCE AND EFFECT. 3 LICENSE CLASS(�S LIC. N0. DATE 41 -kV 1 CONTRACTOR WORKERS'COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: -I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS' COMPENSATION,AS PROVIDED BY SECTION 37000F THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER POLICY NUMBER (PHIS SECTION NEED NOT BE COMPLETED OF THE PERMIT IS FOR ONE FUFDREDDOU.ARS($100)OR LESS} I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR OVISIONS CODE,IS ALL FORTHWITH COMPLY WITH THOSE PPR / S. �( DATE:/�"'!DL APPLICANT�(-r/�� WARNING FAILURE TO SECURE WORKERS' PENSATION COVERAGE IS UNLAWFUL,AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS($100,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. INTEREST.AND ATTORNEY'S FEES. CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3087,CIV.C.). LENDER'S NAME LENDER'S ADDRESS 1 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. 7/kit NAM(PRI) E E E. DATE WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy PRESS FIRMLY P/C APPLICATION i PERMIT I9oi fn - T 1 21'0 1 DATE NUMBE ' # LZ J.- ISSUE TYPE OCC DATE CONST GROUP ZONING SETBACKS FRONT RW p REAR 0- SIDE/SIDE STREET RW ^ SIDE 0 PROPOSED USE AJ 1L)Su f/'4106- �YY1C N0. DWEL. N0. N0. UNITS STORIES BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREAIVALUATION SFR/ADD/REM Garage/Carport LU Patio/Deck LL Pool/Spa Z) 0 Re-Roof Z 0 Commercial 5 co Valuation ADJ.AREA QUANTITY DESCRIPTION FEE F U W Lu W z Z 0 0 Q L 0 w CONSTRUCTION PLAN REVIEW- L ELECTRIC PLUMBING MECHANICAL INSPECTION FEE V ISSUANCE SMIP ENERGY P/C, 19 ENERGY PERMIT RETENTION FEE: PRE-ALT FEE: TOTAL FEES 33? .2) 9 �/(0 L)q CO ENTS RECPT. N0. PAID BY VALIDATION 3(� '.3 f7 _I J J^'^'• WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self in,",certificate of Workers'Compenstion Insurance,or a certified copy thereof(Sec. 3800, Lab. C.) 'Policy No. -Comport Certified copy is hereby furnished. Certified copy is filed with the county building inspec- tion department. Dole Applicant CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100)or less.) I certify shot in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to beCOmgsublect to the Workers'Cympensat ion L Data Applicant NOTICE TO APPLICANT: If,after making this Certificat Exemption,you should become subject to the Workers' Compensation provisions of the Labor Code,you must forth- with comply with such provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license Is in full force and effect. License Number tic. Class Contractor Date tam exempt from the licensing requirements as I am o licensed architect or a registered professional engineer acting in my professional capaciry(Section 7051, Business and Professions Code) Lic.or Reg No . Date OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Code): 0 I,as.-nor of the property,or my employees with th wages as their sole compensation,will do the work and the structure is not intended or offered for sole(Section 7044,Business and Professions Code). I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec tiou 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY hereby affirm that there is a construction lending agency for the performance of the work for whim this permit is issued (Sec. 3097,Civ. C-) Lender's Name. Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with oil County ordinances and State lows relating to building constructon, and hereby thorive representatives of this County to enter .,on the a we prenIiioned property for inspection purposes. E�rff .APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN FILPIDING A DDRESS BUILDING r S�G ADDRESS ova �L LOCALITY Ss NEAREST CITY b C ZIP CROSS ST. N0,OF BLDGS. ASSESSOR SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL U ZONE P , + TRAGT T015 LOT N0. NO 7�7 BLOCK TEL SPECIAL OWNER N0.5- CONDITIONS DIS ICT GROUP TYPE FIRE PROCESSED BY ADDRESS CONST ZO CITY ZIP Z Q � ARCHITECT 0/ TL/II STATISTICAL CLASSIFICATION APT. CONDO. ENGINEER L�T NO I.�N- CLASS N0. DWELL. UNITS ADDRESS SEWER MAP CONTRACTOR TEL NO BK PG, VALIDATION -fl C ADDRESSJ N0. VALUATION CITY LIC. Q�1^'/_^' CLASS $OW SO Ff. INC. OF N0.OF CHECK SIZE STORIES FAMILIES ONE DESCRIPTION OF WORK NEW $ ADD ALTER J FINAL)) REPAIR 0 DATE////,0/,P/ USE OF FINAL EXISTING BLDG DEMOI APPLICANT TEL. . Fs �PRINT) N0. ADDRESS SO BUDN G ILD @7654A BU ING ADDRESS L a. �G� LOCALITY " rr•• • < 21 MOViNG TEL. I'< -39.76 CONTRACTOR N0. ADDRESS < e. 3 9 7 6 3 REQUIRED YARD HWY TOTAL SETBACK FROM EXIST. 5 SET BACK PROP. LINE WIDTH 0 5 1 2-81 FRON, -97761 A SIDE PL .....1 39 I <• � 7/ I79,50 PC Fee$ Permit Fee . 79,5C Iss a Fee Uenr e tiger nn Fee 6 05.1 5-81 Total Fee SEE REVERSE FOR EXPLANATORY LANGUAGE Q iRs I PLANS TO APPLICANT INSPECTOR'S NOTES Tot Returned roved A No. Data No. Date pp I Requi red Date Reeelvad s Yes No or Approved Approva Water Certificate Health Department Fire Department Grading Geological Pedestrian Protection (Fence)(Canopy) Special Inspection (Conc.)(Masonry)(Welding) Lot Drainage - Parking Approvals Da te Insp eet or'e Signature Location- (Setback&Yards) Foundations Slob Frame Energy Insulation lath/Dry- all-Interior Loth--E�erior House Number- Correct&Posted Final- Enter on Front �s ao OWNER-BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Low for the following reason. (Sec. 7031.5) Business and Professions Code:Any ciry or county which requires a permit to construct,alter, improve,demolisb, or repair any structure, prior to its issuance,also requires the applicant for such permit to file a signed statement that be is licensed pursuant to the provisions of the Con- tractor's License Low(Chapter 9)(commencing with Sec- tion 7000)of Division 3 of the Business and Professions Code)or that he is exempt therefrom and the basisfor the alleged esemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a tiesl penalry of not more than five hundred dollars(5500).): ^I,as owner of the property,or my employees with woges as their sole compensation,will do the work,and the structure is not intended or offered for sale(Sec. 7044) Business and Professions Code:The Contractor's License „aw does snot apply to an owner of property who builds or improves thereon,and who does such work himself or through his own employees, provided that such im- provements are not intended or ofd red for sale. If, however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that be did not build or improve for the purpose 4-1.). ^I,as owner of the property,am exclusively contrac- ting with licensed contractors to construct the project(Sec. 7044)Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law). ^ !am exempt under Sec., B.SP. C.for this reason Date Owner INSPECTORS NOTES