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HomeMy WebLinkAbout17093 J� CITY OF DIAMOND BAR � DEPARTMENT OF COMMUNITY 8c DEVELOPMENT SERVICES 21825 E.Copley Drive '" (909)860-3195 Fax(909)861-3117 PRESS `'�'� BUILDING PERMIT APPLICATI�N FIRMLY } JOBSITE � C'L fl ' ' ,�� APPIICATION� �` o I PERMIT ��1� P!C o ADDRESS L� DATE NUMBEfl� t � ISSUE TYPE OCC � APN LOT� TRACT Y 7�y_�>C� I� 0 DATE CONST. GROUP p OWNER p.f1.W1CV\ 1�Mr t�l�FS�'� �t-G ADD�S ��`F'KD 1 �P���1 LE P�'LU l7 ZONING SETBACKS �w r- � FRONT FiW ❑ g ciTv 1 oj3'�Af�� ZIP�4�_Q_3 TEL31C�!���� i0 APPLICANT TEL. REAR ❑ SIDEJSIDESTREET RW ❑ � CONTRACTOR '�1--.13 i:•C..C�T�t G SIDE ❑ Q ADDRESS fL�2�S 1tSt�- '� L'(-. � CITY '��r'tL� �1r�� ZIP�Ill73 TEL.�1L'�YCS�1 PROPOSEDUSE w ARCH/ENGJ W DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNEA-BUILDER DECLARATION SFR/ADD/REM O �W CENSIEUWFORTNE�FOLNOVnNGREASON�EC.mR38U5INE55ANDVROFE5iON5WD:EANYCIT'OR Garage/Carport ZCOUNTYNMICHREOUIRESAVERIAIiiOCONSTRUCT,l�1TEiLMPROVE.OEMOUS1tORREDAIqANvSTqUG � TUAE.PRIOR TO RS ISSUANCE.ILLSO REOUIRES THE APPIIC.WT FOR SIICH PfR�./1T TO FILE A SIGNED w Patio/Deck w STATEMENT TH�T HE OR SHE IS UCENSED PUFSUAN'TO iHE 7ROVISIONS OI'THE CONTMCTORS LI� w � CENSE UW(d1APTER i(COMMENCING WITN$ECTION 7000)OF OIVISION 7 OF iHE BUSINE55 AN'J PflD• u' PooVSpa FESSIONSCADE)OflTW�TMEOR5HE15E%EMPTTHEREFROM/WDTHEBASISFORTHEALLEGEDEXEMP• (� V TION.ANVVIOlAT10NOFSECTION7071.6BYANV�FP�ICANTFORA7ERMITSUBJECT9THEAPPLICANTTO Z Re-Roof ACMLVENALTY OF NOT MORE TNAN FNE HUN�RED OOlURS(SSUO)); Z ❑I,ASOWNEROFTHEPRODER7Y.OHAIVEMPLOYEESWITHWAGESASiHEIRSOIELOMPENSATiON. D COmrnBfCial WiLL DO TME WORK,AND THE STRUCTURE t5 NOT INTENDED OR OFFERED GOR SA�E(SEC.70u,BU51• J NE55AND PROFESSIONS COOE:THE CONTRACTORS UCENSE UW DOES NOTAPGLY TO AN OWNER OF N PROFERTYWYq8URD50RIMPPOVESTHEREON,ANDWHODOE55Up/WORNHiMSEIFORHERSELFOR � [[ TMROU('tIHI50RHEROWNEMPLOYEES.PROVIOEDTHATSUCHIMGROVEMENTSAR"cNOTNTENDEDOfl m QOFFEHEDFORSALE.F,/10WEYER7HEBU0.01NGORtlA4ROYEMENTI550lDWiTNiNONLYEAROFCOM7lE• Z TqN.THE OWNER�BUIIDER WILL MAVE TME BURDEN OF PROVINO TMl1T ME OR SHE DiD NOT BUiLO OR = IMPROVEFORTHEPURPOSEOFSALEI w ❑4�OWNEROfTHEPROCERTV.A/AEXCLU5IVELYCONTRAGiINGWITML�CENSEOCONTRACTORS �, TO fANSTRUCT iHE VRQIECT(SEG 70U.BUS WESS AND DROFESSIdJS COOE�.TME COMMCTOR5l6 VaIU8t10f1 ADJ.AREA W CENSEUWDOESNOTAP7LYTOMlOwNEROFADROPER7VWHOBUiLO50RIlICROVESTHEREON.AN� � MRqCONTRACTSFORSUCHPR0.IECTSWITHACANTRACTOR�S)LICENSEOPURSUMfTTOTHECONTMG OUANTITY DESCRIPTION FEE � TORSUCENSEUW). , OIAMEXEMPTUNDERSEC. B.6V.C.FOFTMISREASON Q u" OATE OwNER f" . � Z W �t� LICENSED CONTRACTORS DECLARATION W ¢ IMEREBYAFFIRMUNDEFPENAITYOf7ERJUiiYTMATIAMIILENSEDUNDERPRON�lON50FCMAPTER Vr p., 9�COA�MENCWOWRHSECTION1000)OFpIVI5lON7OFTME9USINE55ANDPROFESSiONSCO�E,�NO Z X MYLICENSEISINFULIFORCEANOEFFECT. � UCENSE CLASS 'G��� liC.N0. ����"�'�� j F— V DATE�� 17_� coNrancroa-"�'t��'r.—.L�-TR�L a w i � WORKERS'COMPENSATION DECLARATION I Q = U � INEREBVAFFI{iMUNOEFFENQTYOFPE0.NFYONEOFTMEfOLLOW�NGDECLARAnONS. f� ¢ � _IIUVEMlOWiLIMAiNTAINACERTIFICATEOF�pNSEMTOSEIF�INSUREfOiiKURNERS' _ � COMPENSATION,ASPROVIDEDBVSECTION]7000FTHEUBORCODE,FORTHEPERFORMANCE W OFTHEWORKFORWHICMTHISPERMITISISS:IED. , � � �t IUVE AND WIL�MAMT/UN WORKERS'COFIPENSATqN INSURANCE,AS REWiRED BV SEGTqN O 97000FTHELA90RCODE,FORTHEPERFORMMICEOFTMEWORKFORN'H�CHTNISPERMITIS ISSUED.MYWOR� CO ENSATbNINSUR�ECARRIERAND�OLICYNUMOERARP CONSTRUCTION � C/�ARIER a�i �� T"l�•L PLAN REVIEW � VOLICYNUMBER �7•�1�C1 E.'I�SiE�� � ELECTRIC � (fH55ECiDNNEmNOTBEOp.1PLE7EDOF1IEVEAXT6�p70rEFl.�JD0.1AA51t�001a11E55} PLUMBING Z ICER7IFYTNATPITHEPERFOWdaYCEOFTMEY/ORKFORWHIp1THISPERA11TI51SSUED.1 MECHANICAL (•} SHALLNOTEMPLOVANVDER50NINANYIAANNCRSOASTOBECG1IE5uBJECTiOTNE � WORKER5COMPENSATIONUWSOFCALIFORMA,ANDACREETMATIFISHOI.DBECOME INSPECTIONFEE SUBIECT TO ME WORKERS'COMFENSATION FROVISIONS OF SECTION 7]00_O��c UBOR COOE,ISHN.LiORTHWITHCOMP�YWIT/TMOSEPROV15lON � ISSUANCE p DATE: APPLICANT. ..:ll���'�j!�� �� SMIP � ENERGY P!C � WARNING:FNIURETOSEWNEWOflKERS' _NSAtqNCOVEi�ACEISUNLAWFUL.ANDSHALLBE � SU[iJELTANEMPLOVERTOLRIMINALPEN TI MlOCIVILFWESUPTOONEMUNOREDTHOUSAN� ENEH�YPERMIT DOLUIRSIf100.0001.��DI710N707MEG oFCOMPENSATKKJ.D�/AAGE5lI5PNOV10EDfORIN ¢ SECTION770BOFTHEUBORCOOE,IN7EREST,/UNDAiiORNEY'SFEES. RETENTIONFEE: a CONSTRUCTION LENDING AGENCY , PRE-ALT FEE: O Q IHEREBVAFFIRYUNOERiENALTVOFPEFiIUHYTMATT//EREISALONSTNUGTION�EN0INGAGENCY �Z- FOHTNEPERFORMANCEOFiHEWORdFORWNICHiH157EFMITI5155U[�(5[C.7oo�,Crv.C.). W � IENDER'SNM7E F_ LENDER5h7DRE55 � ICERTIFYTHATIHAVEREADTHISAPVLICATIONANDSTATETNATTMEABOVEV.'FOFMATIONISCARRECL TOTAL FEES • �O w IAGREETOCOMPLYWITHAIICfTYANDCOUNTYORD:NANCESANOSTATEUWSREUTINGTOBUILDING � fANSTRUCTION,AI:D HERE9v�UTMORRE NECRESENTATNES OF THIS COUNiY TO ENTER UPON TNE ZABOVE�1AEMqNEO VROPERTV FOR INSPECTION 7URPO5E5. � COMMENTS � � vvuz� C�. r L s ¢ iERMITTF(/NAME(PRItfT7 /� '�`�G I� /' Cn � �/ � � Si EOFPERAAI7TEE D�fE , � � RECPT.N0. PAID BY VALIDATION WHITE—Department CopY•YELLOW—Fu�ance Copy,PINK—Assessor Copy.GOLDENROD—File Copy.GREEN—ApFlicant's Copy �;...,.. �-.��-: . ,��--:•,�� ;�3ft�: . � . _ F.:�+`-..��ti� i t �i'.'t�. _". . 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