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HomeMy WebLinkAbout15015 i I � CITY OF DIAMOND BAR � ' --"��--� DLPARTMENT OF COMMUNITY&DEVEL�PMEIVT SERVICES � 21660 E.Copley Drive Suite 190 (909)860-3195 Fa�c(909)861-3 L 17 PRESS 'v^°+ BUILDING PERMIT APPLICATION FIRMLY o� JOBSITE APPLICATION ��°# �/�� PERMIT (�''jl�' � P/C ADDRESS G D/A/T�fZ. _ DATE V �" NUMBER °+.�'"�� # $ -- ISSUE �" � „'f'�'pE OGC APN L07 TRAC7 DATE__ �'' _ �l�ONST. GROUP � OWNER ^ O o ADDRESS ��__ ZONING SETBACKS � CITY�/QM1C1p,��R—. ZIP 1 TEL. FRONT RW ,r� APPUCANT TEL._ REAR __ IJ__ � SIDE/SIDE STREET_ RW__ I7_ CONTRACTOR�j��,�f/Al�� SIDE __ ❑ ADDRESS � � CITY�t�h ��9�-- ZIp TEL �__ ( 0 3 PR�QPOSED USE �IOtGS�-,�. o ARCWENG/ � DESIGNER__ ���f�- �,�,i, ADDRESS NO.DWEL. NO. NO. , � C�TY ZIP TEL. UNITS _______ STORIES _ BEDROOMS N ---- - v� -- DESCRIPTION Q FT. FACTOR PSF ADJ.AREANALUATION ¢ OWNER-6UILDER DECLARATION SFR/ADD/REM O I HEREBY AFFIRM UNDER PENALTY OF PERtt1RY THAT I AM EXEMPT FHOM'THE CONTflACTORS ll� G9f99B/CflfpOfl W CENSELAWfORTHEFOLLOWINGREA50N(SEC.7031.5911SMESSANDPfiOFE55iO4�CAGE�ANYC11'YOH (f� U COUNTVYVli1CHqEWIRESAPEflMITTOCONSTRIJCT,A.TER,!MPFOVL,DEMOUSH,ORREPAIRANVSiRUG W TURE,PRIOR TO IiS ISSUANCE,AL50 qE�UIRES THE APPLICMIT FOR SUCH PERMIi TO FILE A SIGYEO W PaIlO/DBCIC _ STIITEMENT 7HAT HE OH SHE IS LICENSED PURSUANT TU THE PROVISIONS OF TNE CONI aACTORS LI� � '�� CENSE LAW(CHAPTEfl 9(COlAMENCING WITH SECTION'lo00)OF UIYISION 3 OF THE BU6MESi AND PAO� � POOUSp2 FESSqNSCODE)ORTHATHEORSHEISEXEMPTTH[REFROMANDTNEBASISFORTHFALIFGF.UEXE1dP� (� V TION.ANYVqLqTI0NOF5ECTION70S1.58YANYAPPUCANTFOHAVERMIT5UQIECTSTHEAPPLiCANTTO z Re-Roof � ACML PENALN OF NO7 MORE THqN FIVE NU��RED DOLLARS(f5W).): .o CII,ASOWNEROFTHEPROPEHTY,ORMYEMPLOVEESWITHWAGESASY4EIRSCLECOMPCNSATION, COfI1rt78ICi81 � Z WIi100 THE WORK,AfJD TME STRUGTUHF,IS NOT INTENDED OH OFfERFO FOR SALE(SEC.7044,BUSI� p _ � NESS NJ�PqOFES510NS COOE:THE COY'f0.0.CTORS LICENSE LAW DOES N�TA�PLY TO AN OWNER OF j PROPER7Y WF106URD5OR IMPROVESTHEREON,AND WHOOOES Sl1CH N/ORK41!MS[l'r UR HEFSEIF OR � TMROUGHHISORMEflOWNEMPLOYEES,PqOV1�E�THATSUCMIMPAOVEMeNTSPAENOTINTENDEDOR m W OFFEREUFORSALE.IF,HOWEYER7HE9UILUINQORIMPNOVEMFNTIS&OLfIWRHINONEYEAFOFCOlAPL[� _ -��- 'TION,THE OWNER-BUILDEft Y/ILL HAYE THE BUflOF.N OF PROVING THAT HE OR SHE OIU NOT BUIID Ofi � IMPROVE FORTHE PURPOSL OF SALf). �,y,� OI.ASOWNEROFTHEPROPEFiTY,AMEXCLUGIVELYCONTRAC7INGWITHI!CENSEDCbN71�7AC70RS � TO CONSTRUCT THE PROJEC7�SEC.7044,BUSINESS PND PROFfSS10N^u COf.)[:THE CONTRAC'fORS LI� V01UBIi0n _ __ _ ADJ.AREA CENSE LAW DOE3 NOT ApPL'!TO AN ONMER O'A PROP[FlTY NlFN)EUILU'u Ofl IMPqqVF.S THEREON,Ml0 —'—'---- � WFIOCONTMCTSFOFSUCHPR0.IECTSWIlHhCQNTRACTOR!3)LICENSEDPl1PSl1Ah!TfoTHE�7NTRAG C}UANTITY DL-SCRIPTION FEE Y TOR5l10ENSELAWJ. _ _ QO IAbi EXEMPT UMDEFl SEC. _____B.8 G.C.FOH THIS RFnSON Q. � � �� � U -----'---��---.._......__ — . LL � —_ DATE__,_'__'_OWNEN __ _ ' U � ' � _ . � _ — _ L61� _ �Q LICENSED CONYRACTORS U[CLRRATION W OC IHEREBYAFFIRMUNOERPENRLTVOFPERJURV?HATIAMUCEN&EDUN9ERFROVIEIONSOFCHAPTfR � p� B{COMMENCINQ WITH SECTh�N 7000)OF DI415:ON 3 OFTHE B1151NE5S ANO PROFESSIONS GODE,A�D Z _ _ �L MY LICENSE IS IN FULL fORCE PND EFFECT. m .0 LICENSE C S LIC.NO.� j �___"""_' �V DATE.� �___ CONTfiACTOR�f�� f1 — W � ! ..� WORKERS'COMPENSA710N DECLAqAiION �� � - � 141EHEBY AFFI{iM UNDER PENALTY OF Pc'fUURV ON[OF THE FOL�OVOING DECL.IHATIONS: z � � ___._IHAYEANOWILLMAINTAINACERTIFICATEOFWYSfNT70S[LF-INSURF.!-ORWORKF.:HS' 2 � — (N)MPENSATpN,AS PROVI�E�0Y SECTION 37000F THE LA[3DH COD[,FOR THF.PFRFORNANCE W�_..___ Q OF TME WOflK FOp WMICH TM!S PEfi�SIT I5 155VE�. � 'Qu� _I NAVFAFlD WILL MAINTAIN WORKERS'CAMPENSAT!ON INSUFANCE.AS HEQII!RED OY SECiIOV e7000G THE LABOH COOE.FOR 7NE PE(iFGP.!AANCE O�T41[WORK FOR WFIIC4 THIS PERMIT:S �� /'� � ISSUED.MY WOFlI(E%S'COMPEIiSATION INSIIHANCE CAHRIER ANU POLICY NUMBEfl ARE: CONSTRUCTION __ _____ �. �., CAFRIER_ . �� � �� � —_......_...... PLAN AEVIEW --......--------- ----------�---.........----- .. 0 Po��cYNUMeER"_/� �� _"__—__"""_—__' ELECTRIC _____ _... �;"i'r4."� �.:.-t� Z � • Q � .r;''1.'::.;; ...�. -._...—...- ----'-- - (iIUSSECTICNNE�NOTBECOMFLEiEGCFTI-IEPERNtIU"FORONEFfJFC7REOGOILAPS(510D�ORLf.;S} PLUMBING '�' �-"� � � -...._.............. ...---'— �. ..------- � Z ICERTIfYTHATINTHEPERFOAMANCEOFTHEW�HKFOqWHICHTFiISPERMITISI55UED,l MECNANICAL ___._,.,.__ .:��•,r��f_ � � SNAILfiOTFMPLOYANYPEHSONINFNYlAANNERSOASTOOE.^f]Mf_SJBJ[CTTOTIIC: � . *. .. ' �j) WOHKERS'COMFE4SATIONLAW50FCALIf'OHNIA.ANUAGNEF.1'MA7IFISIiOULDBECO!dE INSPEC710NFEE ___ _____ � ' _ � SUBIECTTO THE WORKEP.S'COi.iPENSATION PRUVISIONS OF SECTION 3700 OF THE LA90R . : � � COOEISHALL ORTHWIT}1COMPLVWITMTHOSEPROVI�ON. ISSUANCE ___...__, � �� �.n SNIP .. . ., p �ATEO��_ !7-K._. APPLICANI': '__'_"_" "' � . :;..�� " .` �' �. _— • , --�r---' _ J WAqNING:�IUHE SECUREWORNERS'COMPENSATIONCOVERAGEISUA�AWNL,ANDSHALLBE ENERGYP/C -_ � �' � SUBJECTANEMPLOYERTOCRIMINAIPLNALTIESMDCIVILFINESUPTOONEHUNDNEUTHOUSANU ENEFGYPERMI7 � � DOLLARS(S10D.0o0),IN ADDITION TO THE COST OF COMPFNSA7ION,DAMAGES AS PROV:Df�f=OR IN �������������-�-�������--�.- _.............___....—__—.._ �� '� SECTION37080FTHELABOHCODE,INT[REST,ANOATTORNEV'SFEES. RETENTIONFEE: _,_ ___ _ OCONSTRUCTION LENDING AGENCY pRF-ALT FEE: ___ w LENOEFi'S NqM RMANCE OF HE WORK FOR W4 CH TNIS PERMIT IS ISSUF:D SCC.3o8]OING AGF_NCY " � I HEREBV AFFIRM UNOER PENA�F PEHJl1RY THAT THL���S A�THUCTI�N LEN CIV.C.). —'.................._._—"'—"'._....._—'...._.._ .. � � ( —...._—_"'_'"""'"" ' /�[��',/y� _. ._.........."_—'—'_ _'_'_____ � 1—, L[NDLR'SAD�RESS _. /�;�"(/..�L,�.�._,����� 2r � — G [r // // � ICER7IFYTHATIHAVEHEMI7HISAPPLICATIONANOSTATF.THATTHFABOVEINFORMATIONISCORfiECT. TOTAL FEEJ /�}J��� � w I AGREETO CAAIPLV WITH F1.L CIN�NO CUUNTY ORDINANCESAND STATE LAWS iiELATINC l'O DUILDING [ r �r � � � CONSTflUCTION,ANDHEREBYAVTHORIZEflEPRESENTATIVESOFTHISCOUNTYTOENTEflUPONTHE z ABOVE�MENTIONEO P PEFTY FOH INSPECTION PURPOSES. ' � COMMENTS_-_ _—.-----._...___— — � � ���� J � '__—_'—_'—____...__'___'_—""_ __--_ "_'_ ¢ PERMITTEEN El MT) "__—"'___ "—"_'___'"' __"_"' _' - (n " ... • : , . uJ SIGNAT E F PEI - --�' ���� DATE — —''— -----���- --���— - -----` — 2 RECPT.NO. PAID BY __.,_.___�___ ��ALI�ATION_ ~ WHITE--C)epartm nt Copy,YEI.OW—Finance Copy,PINK—Assessor Copy,GOLDENROD--File Copy,GREEN—ApplicanTs Copy