HomeMy WebLinkAbout14159 (17) 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 ' � . I _ �i 1 .:'1 k t.. .
}- ,I k ' i.€ �"t t I s�i; . .
. � �:: ^ �.. ,
4€ M k . � I . i �. _ �.. � . 1 �:� �9 ���
3, i.
5
F�' r C � I , 4 .. ..j � � ; i -I ` _' I ?I I I �` � � y ; _. . �
� �r� s . ���; I e ' �, i � f �� � i v i ,- ���� .
t � ; � � � � � I � �
� ���� t � i � � ��
d � � �.>' ,S� ;... ., � ' �� I i ' !' II # f...._ y,iYl . i � � .... �.__1 ...__ ,. ' ..JI_ �I "".' � �� �'�.
t.;�,� i � � �, � "� � ! , '' I , I ����
r � ,
� �' � ; I' I i � :,... . �Q.; � . I _�_._ � �' �f���
I � ��
$ , I ' i I
, ,
� i � . � " ,� , � i f. ` _ _ � �
� , .�; . , i �.. . � � ' . �_. ' f -- i �,��, � .
� � . . �..
� � � j � i ; ' I f � j � �i � r,
1 �� i , � �� � �� � �� � � �j i i '� i j� i � � i �
� , i , � � � . . i �� . ' .. , � � ( ��j I ( .„n
, ! ' i � :; :� I - � � � � � � ' � �. � � , , � � '�
� I � � � , � � � � � � j � � ; I� � � ,� � ��� ��
7 � � � � + ' I � � ' i i �a ( � ' ; � �i i ' i �' �'� °
� ' , � ' � I ; j � i �,; � �
;
j i � 'I i i I � i i I � _� �. 1 � - i - � I ) '� ��� � ,
' { ' , 'I � k ` i ..j r � � - c q t,i i i -..ri k i :
� � � � � � �49 ,7� � � ,i ,��� i �� r,�� {,,
, ', ,' : i ;F -, ' � � �
, " I:� ro .
` I ` I ' 1 I! f.. � A ' � k.
� I � � ' � : �� r � i � �� i � � � r � �� �� -
� ! � �( � � �I � i i � ,t ' � � i ` ' ' I � ��" �
� �n �. �
I ' � I � s.�, , (' i i_ �� � p, k �
i , ', i � i � . � � .�, ,,, �' � 4 c;i � j I I i'��� �i.. - ' i' ir 1 � ��� � r��, .
� ',� i, I �.��� i ; ,� i � - �.� �1� i �'-�� � ��.
�' i I � � � '.�, � � f'��� I � � � � '� � ,� � i � �, � �fia
� i � � � I � , � �#{� � �� � � � �� , i I ... ( . � I t ( i �. i �'�'�; .
�,,, ' � . � ���
� � i � ( � � _ � � � _ � � ���
t ,�', ;
� , ��, , i � � .. � 'i r�R� ' I , �.,_' '' i'_ I ; � ��
� j ' ; � ' I, E I ' I � ' ; ! ��. I ._. � � ' � I � ; I 1 I' �
Y I � � � F ( � � ' � ` ; � ,�
Y � � � � � ` .. � � , i � � � ; ' � � ' ! I I ' ��� �
� I ' I � i ' j � � I � ' i � � � � � � � I � � ��
� ; ; �
'- ` , I � � il i � f_ � �,.__ i �f. � _�...�— , — � � `—_� l i � � ��,
i 1 ; f , i �
� i � i � ( , ' i j � '; j � i ! � ��
+ � � I % , � ( E � � I � � 1 I ��
' ` i i i ' . �� 1 � � I �' ' � . � ,. I I : ( 5�R�
� �I i i ' � � I �, � li f � ' .. i � j f I ' I� i �� f�
' i ' ; � ; I � ' I � 1 k � i i i { i '' i : � '' � �nY
d I I i � � I � k � I , ( ' i ���,'�
, ,
. �
I
, , _�.. . „F _. , ..._ ._ ._ ..... .... ....._. ... ....
, � �� � ._ _.. __ .
, �__ ._.. �.._ ___�
��_.:___ � I i 1 �.
i '