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HomeMy WebLinkAbout12085 � j JF�_ CITY OF DIAMOND BAR ,;���.� j ��DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVTCES �%' � ('j� 21660 E.Copley Drive Suite 190 � �� (909)860-3]95 Fax(909)861-3117 PRESS � � ���`�^°���W '�', BUILDING PERMIT APPLICATION �,�• FIRMLY � o ADDRESS ' � C.���� � �l" + DATE CATION a � � [. ?5/ NUMe R� =��� `� #/C � � ISSUE � TYPE OCC � APN LOT �-+� �jC�T�, C�`�� DATE CONST. GROUP p OWNER �G� 1 aF.i✓�t:w D0.'1r �4 ,L�- • �` ADDRESS � '� Y ZONING SETBACKS I Z FRONT RW f!_._.___ CITY`(��,{P1qL_C?� ZIP�I�, TEL. S'���^�cl� REAR LJ___ g APPLICANT TEL. SIDE/SIDE STREET RW I I � � CONTRACTOR � (� SIDE __,__. ,__ I l � ADDRESS C - ` ', O CITY�� ��y�_ ZIP��� TEL.�"Z.�p� PROPOSED USE --- �� o ARCH/ENG/ � z DESIGNER - — W NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � � CITY ZIP TEL._ u� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION O. OWNER•BUILDER DECLARATION SFWADDlREM � ' Q I HEREBY AFFIRM UNDER PENAI.TY OF PERJURY 1HAT I AM EXEAIPT FROM THE CONTfiACTORS�I- � � Garage/Carport W CENSEIAWFOR7HEFOlLOWINGREASON(SEC.7031.SBUSINESSRNDPflOFESSIONSCODE:ANVCIiYOR � U COUN7yWHICHRE�I.IIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANVSTqUC- �J,J� pgti0/DBCK ¢ �Z' TURE,PRIOR TO ITS ISSUMICE,AL50 REW IRES THE APPLICANT FOR SUCH PERMITTO FILE A SIGNED � W STA7�MENT THAT HE OR SHE IS UCENSED PURSl1Mlf TO THE PROVISIONS OF THE CONTRACTOR3l1- ' � � � CENSE lAW(CNAPTEH B(COMMENCING WITH SECTION 70W�OF OIVISION 30F THE 6USINESSANO PRO• � POOUSpd V FESSpN5000E�ORTHATHEORSHEISEXEMPTTHEREFpOMANDTHEBASISFOFiHEALLEGEDEXEMP- (� i TION.pNVV10LAT1ONOF5ECT10N7037.5BYANYRPFLICP.NTFORAPERMIT5U31ECT5THF.APPLICANTTO Re-Raof I 'V ACM�PENALNOFNOTMORETHANFIVEHUNDFEDDOILARS(Ssoo).): ' z � ~ ❑I,ASOWNEROFTHEPROPERN,ORMVEA7PLOYEESWITHWAGESASTHEIRSOLECAMPENSATbN, COrt1rt16fGial � .g.:, WILL DO THE WORK,AND THE STRUC7UflE IS NOT INTENDED OR OFFEHED FOR SALE(SEC.�o4a,BU51- �J NESS AND PROFESSfONS CODE:TXE CAMMCTORS LICENSE UW DOES NOT APPLY TO AN OWNER OF j �� PflOPERTYN1i08U11A50fliMPflOVE57HEPEON,ANDYIHODOE55UCHWORKHIMSELFORHEH&ELFOR " � ��CC�. iHNOUGHHISORHEpONT1ElAPLOYEES,PFOVIDEOTHATSUCHIMPROVEMENTSAqENOTINTENOEDOH m � �W� OFFEREDPoFSNLE.IF,FiOWEYER,7MEBU1L01NGORIMPROYEMENTI55olDWITHINONEYEAROFCOMPLE- �0� �TION.THE OWNER�BUILAER WILL HAVE THE BURDEN OF PROVING THAT HE OH SHE DID NOT BUILD OR Z�" IMPROVEWflTMEPURPOSEOFSALE). � ',;w'�, ❑I,�SOWNEROF7HEPROPERiV,AA1EXCLU6NELVCONTRACTINGWITHLICENSEDCONTRAC70RS ; '��. TO CONSTflUCT THE PqO,IEGT(SEC,70t0,9USINESS AND PROFESSIONS COOE:THE CONTPACTOflSII� VeltlflllM .,_._,__ _ _ADJ.AREA ___,_________ � '�W CENSEUWDOESNOTAPPLYTOANOWNEROFAPROPERTVWHOBUILDSOFIMPROVESTHEREON,AND { �:�.��' Wr1000MRACTSFORSUCHPROJECTSWITHACONTRACTOR(5)UCENSEDPLIRSUANTTOTHECON7RAC- QUANTI�' DESCRIPTION FEE TORS LICENSE LAW.). ��� Lt l AM IXEMPT UNDER SEC. B.8 V.C.FOR THIS HEASON, � a .� f' � ) � ___'_'-___'""_"'_ ¢ � � ' [ i 'LL�� DATE OWNER"_--' '....--_- ��� U �j��C��.C ' S � W ( �,� LICENSED CONTRACTOFS OECLARATION �`,'�W :� 1 HEflE6YAFFIRM UNDER PENPLTV OF PERJURY THAT I AM LICENSFO 11NDER PFOVI510N5OF CHAPTER .^ � � �'p' 0(COMMENCINO WITH SECTKKJ 7000)OF DIVISION 30FTHE 9USINfSSAND VRO�ESSIO.US CADE,RND .. Z X YY LICENSE IS M FULL FOflCEAND EFFECT. ; � ��� UCENSE CLAS ���'V LIC.NO.�� I��g,-��,�/�^' _� � � :�U DATE CONTFiACTOR�__y,�•"_�--�� '" a I � � i � �• WURKERS'COMPENSATION DECLARATION �j Q � : U � ��� iHEqEBYAFFlHMUNDE6iPENAL7VOFPERJURVONEOFTHE'FOLLOWiNGOECLANATIONS� � Z I ¢ -� _IHAVEANDWILLMAINTAINACERTIFlCATEOFCANSENYTOSELF-INSUREFORWOHKENS' � z - COMPEN5ATION,ASPROVI�ED9YSECTION37ooOfTHEIABORCODE.FORTHEPF_RfORMANCE � C� Q OFTHEWOqKFORWHIGiTHISPF.RMI715i55UEU. � 0 `W �I HAVEAND WILL MAINTAIN WORKEHS'CAIA7F.NSATIO4INSURMCE,h5 REOUIR[D 6V SECT!ON ,�Q 37000FTHE LA90R CODE.FOfl7HE PERFORMANCF OFTHE WOFK FOfl WNICH T1115 PERMIT IS � ISSUE�.MY WOPi(E 5'CA iENSATION IN CE CAft IER AND POLICY NUMBER ARE: ' CONSTRUCTION ,_,___._,_,,...._.___ +��g�,w -..."___'__......_._._ j� CARRIER ��`�C i V yl _ _ � PLAN FEVIEW .... .._...._....—.-,------_— � p s � '.Z POLICYNUMBEfi_'�"� �-�-��.�- FkE'(,T-� ___�.._—____ �/`�� Q Q- (IHIfiSEGIIONNE�NOTBEWR�LEfF.DOF7FEPEfW7TISFOFiIXJEHIMDREDOO.tMS(5100)OHLESS} PLUMBING .....'"'-"""'_"_"_ "_'__ " ������ iCC-NTIFVTHATItJTHEPERFORNANCEOFTHEWORKFORWHiCHTHISPERMIiI5155UFD,1 ,,; MECHANICAL -'_""'-__"'_'_......_..-_'_ "-_ (J SHALLNOTEMPLOYANYPEfl50NINANYMANNERSOASTODECOMESUBJECTTOTHE y WORNERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGREETHATIFISHOUL�9[CAME (NSPECTIDNFEE "'_..__...-__"_'__" SU&IECT 1'p THE WOFKERS'COMPENSATION PROVISIONS OF SECTION 97000FTHE LABOR �} � CODE,I6HALLFORTHWITHCOMPLYWITHTHOSEPRQVISIONS. �SSUANCE ______ ____ .r_ '��u � SMIP � p �ATE:___ APPLICANT: "'___ '.�_- ".._ ..__._- J - ENEFiGY P!C --'- -----------_' . J WARNING:FAILl1R[TOSECUPEWOPKEHS'COMPENSATIOYCOVERAGEISUNL�WFULPN�SHALLBE "�y SUBJECTANEMPLOYERTOCHIMINPLPENALTIESANDGVILFMESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT � DOIURS(f1oD.000�.INADDITIONTOTHECOSTOFCOMP[NSATION,DAMAGESPSPqOVID[�FORIN --""- --------'-'--'--- - -- � SECTION37080FlHELADORCADE,INTEHE57,AN�ATTORNEY'SFEES. RETENTIONFEE: � ' , :'��r.�_'____'-'___'_' -"'____ 1 nW�. PHE-AL7 FEE: . ,i•i; _ ����.., --,---- CONSTRUCTION LENDING AGENCY ������� �1 � �. IHEREBYAFFIFMUNDEHPENALTYOfPERJURYTHATTHE(lEISACONSTRUCTIONI.LNDINCAGENCV "" ��� � ,,��� - µ'�x-��f �. ;� ' d FOq THE PENFORMANCE OF 7HE WOFK FOR WhIICH THIS PERMIT IS ISSUE�(SEC,3oe1,CIK C.). -"�-"'--� ` � y Z ._ �1 , W __'_" '_'_.__ ,�-:..,�.,..r> :::.::-,.,:,�_r.:..... . ,. . �i �� LENOER'S NAME____ __ .__-_ - _ _ •� H LENDER'S.1�DftES3__,__.. '3 �� � ICEHTIFYTHATIHAVEREl�DTHISAPPUCATIONANDSTATETHA�THEABOVEMFORMATKKJISCAflRECT. TOTAL FEES "�! y�� �'�' 'I � I AGREE TO CAMPLV WITH IILI CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING �-� j �� CONSTRUCTION,ANDHEREBVAUTHORIZEREGHESENTATIVESOFTIIISCOUNNTOENTERUPONTNE --_ -- � � ABOVEMEPl�IONED PROPERTY POq INSPECTION PURPOSES. a Z L COMMENTS__ � � �(:��':"`�-�L__� +'�'C�l�r!`Q.- ---- --- G __�L.'t���w�'/ '� m PEflMITTE' E(PRINn _ __'___'_ _ . :,`I .. Q / _ � 7 :I SIO URE FPEflMIiTEE �A 1 � .,�����d= RECPT.NO., ��� ��� _PAIDBY � VALIDATION " � �� r WHITC—Deparlment Copy,YELLOW—Finence Copy,PINK—Assessor Copy.GOLDENROD--File Copy,GREEN—Applicant's Copy i • . . ~.. . _" � • � �..��.r . .._ .... g._�� ._, .."'°.,-�° �� � �., __'_.��-�"' h �r c ` ' i ' , ' �..µ� �. [�.. ' � I -�f �'���� . � �+� �" s��, a�� 1 E � ti :i � z �'.I xM�� � s �K� ' � I : � I ' ( � �� � ��,��t r ��, '� f ; 1 � , , ! .I � � ; I � i t r, i i� � u r � 5 e �,3 ..i . i � $ r � r � � " f � I�:; � �� . r i � r � ��; � t . 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