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HomeMy WebLinkAbout14159 i � 1� CITY OF DIAMOND BAR � DEPARTMENT OF CQMMUNITY&DEVELOPMENT SERVICES �' � 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)661-3117 PRESS �����°�� BUII.DING PERMIT APPLICATION FIRMLY o DDRESS � `� �ATE CATION,� 1 ���NUMBER�� I � #`C ISSUE TYPE OCC � APN LOT TRACT �7�� DATE CONST. GROUP p OWNER �4 Q �-�_, " ADDRESS `' AlGE .� ZONING SETBACKS Z CITY l ZIP Q�� TEL3/CYS�tO`�a tIC� FRONT _ RW ❑___ g APPLICANT TEL. REAR ❑_� SIDEISICE STREET RW CI � CONTRACTOR L� � �- �Ce SIDE ❑ � ADDRESS,1��-'3 aC�3""���=T � ✓ � CITY���'i���� ZIP�I�.� TEL. �Z(r� y�P'/� PROPOSED USE � w ARCH/ENG/ �,,� i '- z DESIGNER ��� � �''� �� -,,�-- NO.DWEL. NO. NO. a ADDRESS ° `� p 4'C`� UNITS__ STORIES _ BEDROOMS y CI7Y'�I`�i�0E1 AI C.�_ ZIP�'�.'�'TEL. y - DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUA710N QOWNER-BUILDER DECLARATION SFR/ADD/REM �j���7� 0 1 HEREBV AFFIRM UNUER PENAIT'OF PEFUURY THAT I AM EXEMPT FflOM THE CONiRACTORS LI- GBf8Q0/C8lPOR W CENBEIAWFOR7HEFOLLOWINGPEA50N(SEC.70.91.6BUSINESSANOPROFESSIONSCODE:ANYCITYOR . (n , � COUNfYNHIpIREWIRESAVERIAITTOCpN3TRUCT.ALTER,IMPROVE,OEMOLISH,ORNEPAIflANYSTPUC• �.J,J Pdi10/�BCK W 7upE,PFIOR TO ITS ISSUANC�ALSO RE�UIRES YHE APPl1CANY FOR Sl1CH PERMIT TO FILE A SIGNED w S. STATEMEN7 iMA7 NE OH 3HE IS LICENSED PUR91JANf TO THE PROYISIONS OF 7HE COMFUCTORS LI- CENSE UW(CFWPTEfl 9(COMMENCIN�YlITH BECTION l000)OF DIVISION 40F THE&1SINF55 AND PRO- � PooUSpa � FE6310NSCOOQORTHRTNEORSHEISE%EMIPTTNEREFR0IAANDTHFBASISFORTHEALLEGE�EXEMP- (� �) TION.MIYVIDLATIOHOFSECTION7a31.5BYANYAPPLICANTFORAPEPMITSU&lECTSTHEAPPUGANTTO Z Re•Raof � RGML PENALTYOF NOT MONEtHAN FNE HUNDflED DOLU1fl5(750D).): ❑I,ASOWryEROFiHEPflOPEF1TY,OflMYEMPLOYEESWITHWAGESASTNEIfiSOLECOMPENSAiION, ❑ CommBfCifll ' �.: WILL UO THE WOH1C,AND THE STRUC7URE IS NOT INTENDED OR OFFEFED FOR SALE(SEG]Odd,gU51- J NESSAND 7ROFESSIONS GODE:7HE CON7RACTORS LICENSE LAW DOES NOT APPLY i0 Ml OWNEfl OF � PROPERTYWHOBUILDSORtMCROVE3TIEREON,AN�WHO�0E3SUCHWORNHIMSELFORHEFiSELFpq m �' iHROU6HHISORHERQWNEMPLOYEES,PROVI�E�THATSUCHIMPROVEMENT8RRENOTINTENDEDOR QOFFEREDFORSK6IF,HOWEVERTHEBUILDINGORIMPROVEMENTISSOLDW7THINONEYEAROFCOMPLE � Z; TqN,iHE OWNEREWLOER WILI HAVE THE 9URDEN OF PROVING THAT ME Ofl SME OID NOT AUILU OR �. IMPROVE FOW THE PURPOSE OF SALE). , W f.11,A50WNEflOFTHEPROPERTY,�MFXCIUSIVELYCONTHACTINGWITHLICENSEDCONTRACTORS � TO CONSTRUCT THL PHOJECT(SEC.7U/4,BUSINESS PND PHOFESSIONS CODE:THE CANTRACTORS LI- V2111d�iDf1 __ __ ADJ.AREA ___ ___ _ W CENSEIAWOOESNOTAVPLYYOANOWNEROFADflOPEFTVWHOBUILD50RIMPROVESTMEREON.rWD �' WHOCONTMCTSFORSUCHPRQIEGTSWITMACdJTRAGTOR(S)LICEN9EDPURSUANTTOTHECONTM0. QUANTITY DESCRIP710N FEE �� TORSUCENSELAW.} -y ' ❑IAM EXEAIPTUN�ER5�C.� B.b P.C,FOflTH15 PEASON U },� ��v��� ' � � --- -- cc � �, �-'!"�' - .� Z, �ATE_ OWNER_.____' '_'__-" W �f � � �, UCENSEDCONTRACTORSDGCLARATION W � � . �' { �� IHEFE9VAFFIRMUNOERPENALTYOFPERIUHYTHaT1AMLICEN5E0UN0ERPHOVISION50FCMaPTER � �. B(GOMMENCINO WITM SECTION 7000)OF DIVISION 30F THE BUSINESS AND PROFESSIONS CODE.AND Z X. MY UCENSE IS IN iULL FOftCE AND EFFECt �. m �9 L,. � �� IICENSECLAS �'� � LIC.NO.���_ � � 4Y �'�'" �^ � r�r s � W�� DATE I Cj I S � CONTRAC70R�]_,� �� J _L,!V'� d . � ,�.. �� WORKERS'COMPENSA710N DECLARATION d - _ �.. � I� � 1 HEftEBV AFFIRM UNDER PENALTY OF PEiVUHY ONEOF7HE FOLLOWING DFCLARATIONS a � ,�f„ N. i� A _Il/AVEANDWILLMAINTAINACERTIFlCA7EOFCONSENT'fOSELFINSUlIEKORWORKERS' ;7: Z C�MPENSATiON,ASPROVIDEDBYSECTION3'looOF7ME4A80HCO0E,FORTHEFERFORMMCE C� Q OFTHE WOPK FOR WHICH THIS PFFU.IIY IS ISSUED. � � a/ - � jl HAVE M!D'�VILL MAINTAIN WORKERS'COMPENSATION INSl1RANCF.AS REOJIqED BY SECTION Q 3�OOOF THE LA60R CODE,FOR THE PEFFORMANCE oF THE WOPK FOR WHICH THIS PERMIi IS �. ISSUED.MYWORKERS'COMPENSATIONINSl1pRlU�JC[CARRIERAN�POLICYNUMBEflAHE: CONSTNUCTION __,,.__,__ ._..._—. _.___ j '�T�� .!�� � PLANREVIEW ....._-...- --..._----.._....--- � CARRIER___ � *� � . .._.....— ., � POL�CV NUMBER__Z G Q ��_lt--.-- ELECTRIC �i- . .-- ---��---- ---�+Y'_l .. 0 (iHssECfqNNE�N0T6ECQ�LErE00F'M1EFERIMISFofloNeHunnfiFroDOluRs(Stoo)oRLESS} � PLUMBING -"- ..__. ..---- Z i CEflTIFV THAT IN THE PERFORMPNCE OF YHE WORK FOR WHICHTHIS PERMIT IS ISSUEU,I MECHANICAL .—_ _-_ .__—_._..- (7 SHALL NO�EMPLOY ANY PERSON IN ANY MANNER SOAS TO BECAM[SUBJECT 7olHF � WORKERS'COMPENSATIONLAW50FCPLIFOflNIA,ANUAC:REFTHM17'IFISNWLDBECOIdL INSPECTIONFEE __ .__ ^�- S1161ECTT0 THE WORKEflS'COMPENSATION PqOVI510NS OF SECTION 970oOF TH[lABO(1 ��/ OCAOE.I SHALL PoR7HlMTH COMPLY WITH TIiOSE PROVISIONS. ISSUANCE �py�����,�____ ��,�(�'- � ' DATE: � APPLICANT. _.._ _ SMIP 5.1 '__ y -" .____ '. W' -_' �ri �;�. � ENERGY P(C �I i�����-1.�-+fsL�I s��:--� -------- � ' WARNINO:FAILURE TO SECUFiE WOFKEflS'C01.1PENSATION COVERAGE IS UNLAWFUL,AN�SHALLBE y � !' �y SUBJECTANEMPLOYERTOCRIMINALPENALTIES/W�CIVILFINESUPTOONEHUNDREDTHOUS/INO •� ENERGYPER y' {j.��"yL��-5��=���"'°�.�.. DOLLAf15(flaa.o�o�.INAODITIONT07HECO5TOFCOMPENSATION,DAMAGESASPROVIDEOFORIN �y�'+'= ' "'-'"'--' �� �. .}_I SECiION 3�oe OF T11E LAOOfl CODE,INTEHEST,AND ATTORNEI^S FEES. RETEN7ION FEE: � i � _—'.. ..-" ."'_—__'-- O� CONSTRUCTION LENDING AGENCY pRE•ALT FEE: _ __.. __ _.— I � IHEREBYAFFIRMUNDERPENALT'OFPEFiJUR`/THATTHEREISACONSTRUCTIONLEN�INGA�ENCY _____ ___ _,__ FOR THE FF.fiFORMANCE OFTHE WORK FOR WNICH TMIS PEHMIT IS ISSUED(SEC.]087,CIV.C.). Z ---'__ _ ""-_ _"-_ � W I � LEN�ER'SNAME- �.."'_-_" "---- . '_'_ ' _____ F_ LENDER'SADDRESS ` /// ���""" I w ICERTIFY7HATIHAVEREA�THISRPPLICATIONAN�STATETHATTHEABOVEMFORMATIONISCORFECT. TOTAL FEES �,J•� .��.-/ I.� � IA(3REETOCOMPLVWITHFLLCITYANDCOUNTYORDINANCESANOSTATCLAWSFEUTINOTOBUILDING � / � CONSTRUCTION,ANU HEREBYAUTNOflIZE REVRESENTqTIVES OFTHIS COUNTV TO ENTEfi I1PON TME — -- — A80VE-MENTIONED PPOPERTY FOfl INSPECTION PURPOSES. COMMENTS � ��M1 •►"IV� 1.n 1_`��Q�1-c•,�l�"" _ _�' _ _ m PERMITTEE E(PNN7) _-...-" -' -- Q !) . V) (J '_ _" � SI� iiE F PERAIITTEE �ATE �, = RECPT.NO. _ PAID B� VALIDA710N� I �'- �.,� WHITE-Deparlmrint Copy,YELLOW-Finence Copy,PINK-Assessor Copy.GOLDENROD--File Copy,GREEN-Applicant's Copy {', �; .__..� _W �_. _ .. � , ."_ ; r r r � i ��. � , io � '�Y z�- � . ' r � ., i � � - 1 r' :.i � �� � � �; � s € � i ��� ' � wt . - �3 '..i k � � �E., ,�i i � � � .� I � � � � - �� �w ,� . _ $y�.� i E i , i i ' � . 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