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HomeMy WebLinkAbout14067 (16) � I _�.� CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � _ 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRE$$ ���'A�' ' BUILDYNG PERMIT APPLICATION FIRMLY o� JOBSITE �'��� ,L�f�""�� DATEICATION �-�` � NUMBER , V ' #!C ADDRES $ ISSUE TYPE OCC APN LOT � T CT DATE CONST. GROUP °C OWNE / fi� �1� ` O p ADDR S i� ZONING SETeACKS Z CITY ' !�� IP T FRONT RW ❑ g AP CANT / e� /�C" TE ' REAR ❑ Z SIDE/SIDE S7REET RW C � � CONTRAC � '/,/ ,y' .` SIDE ❑ � ADDR S / �-- � C! IP TEL PROPOSED USE oARCHJENGI DESIQNER I� �� � � �: ADDR S NO.DWEL. NO. NO. � CI � " � T UNITS STORIES BEDROOMS � � DESCRIPTION SQ.Fl: FACTOR PSF ADJ.ARErWALUATION Q OWNER-BUILDER DECLARATION SFFVADD/REM O � I SiEflEOY AFFIPAI UYDER PENAITY OF PERJURY THAT t pM EX'cMPT FROM TME CONTFiACTORS LI- � GaragelCarport W CENSELAWFOH111EFOLLOWfNGREASONjSEC.7031.5611SINESSRNOPROFESSICN5CO0E:ANYCITYOR U CWNTyWHICHRE0UIRESAPERMITTOCONSTRUCT.ALTER,IMPROVE,DEA70!ISH,ORREPAIRANYSTRUG W Pgti0/DBCk -Z 7UR�PFIOR TO 1T9 F99UANCE,ALSO FE�UIflES THE APPLICANT FOH SUCH PEflMIT TO FILE A SIGNED W STATEMENT THAT HE OR SHE IS LICERStU PURSUPNT i0 THE AROVi510N5 OF THE CONTRACTOFS LI- W �.�-_ �NSEUW(CHAPTER B(..'�OAIMENCING WITH SECTIOY 7000)OF DIVISION 30F TH�BUS:NESS AND PR0- � POOUSPH FESSIONSOODEJOflTHA7HEOflSHEISEXEFAP7THEREfflOMANDTHEBASISFORTHEALLEOEDEXEMP- (�- V: TqN.qt1YVIOLATiDNOFSECTION7W7.58YANYAPPUCANTFOPAPERMITSU&lECTSTHEAPPIICANTTO Z RB-flOOf � �_ ACINLPENALTVOFP:OTMOFETHAqF14EHUNDREDDOLLARS(f50o).): - .�. OI,ASO4MEROFTHEPROPEHTY,ORMVEMPLOYEESWITHWAGESASTHEIfiSOiECOMPENSATIOk, � COfI7rt18fCld1 - ' - WILL DO THE WOHI(+WD THE STRUCTURE IS NOT INTENOEOOR OFFEREO FOR SALE�SEC.7044,BU51- J ; �_ NESS AND PpOFESSIONS CODE:THE CONrRACTORS LICENSE lAW�OES NOT APPLV TO AN OWNEH OF � _- - PpOPEf37YWtiOBUiLDSOqIMPROVESTII'cPEON,ANOWHODOESSIICHWORKNIMSELFOFiH[flSEL(Oq � t� _W_ iHROUOMHi50RHEflOWNEMPLOYEES,PflOYIDEDTHATSUGY!IMPRDYEMENTSAREfVOTINTENDEDOi _ _�_ ,OFFERE�WRSPLEIF,HOWEVEiLTHEBUiLDINGOR!MPROVEMENTISSOLOWITHINONEYEAfiOFCOMP'iE- -TION,?'HE-OWNER$UIIAEfi WILL MAVE THE BUROEN OF YROVING TMAT HE Ofl S4E DIO NOT BUItD OR- _ .__ iMPROVEFOfl�}fEPURPQSEOFSALE). - .�- C7.ASOWNEROFTHEPROPEFZTY,AMEXCLIISIYEIYCAi.'iRACTINGWI7HLICE'ISEQCONTRACTOA3 -�- TO CONSTHUCT 7HE PqOJECT(SEC.�04t,8US1aE55 AN�PROFESSIONS CODE:TNE CONTqACTORS LI- VHI119f10l1 A'JJ.AREA �.W-: CENSEUWDOESNOTAPPLYTOhYOWNEROF0.PROPERTYh'FIOBUfD50A1MFROYESTH[REOIJ.RND :�� WFfOWNTRACT5PoR5UqiPROJEGT5WIIHAC�N�ftACTORIS)LICeNSEDPUR3UANiTOTMECONiW1G pUANTITY DESCRIPTION FEE Y-. 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B.&P.C.FOR 7MI5 ftEASIXJ ,�: � �G7 �/c,�. .Z_ �ATE CYlNER U ��'L 5�+�� / + � � W- ;o- LICENSED CONTRACTORS`JECLARATION i j ,- t, _i'-K� -�� IHEREBVAFFIRAIUNDERPENALTVOFPERJURVTHATiAMLICEhSEDUNDERPROVI510NSOFCHAPTER �� - �'- - 'a� s(COMMENGNG WITN SECTION�a�o)OF�IYISION 9�HE BUSINESS AND PROFESSIONS CODE,AND 7 - :X._ MY LICEN5E IS IN FD AND EFF�CL m -- LL! 2� �,. . � "�: �ICENS ���+ISsL.IC.NO. 1 � <F—__ � ' � �� J _-V_ OATE CONTRACT� �} d W- 11�t�'//�'/ . . . . . . . . . t�- WORKERS'CUMPENSATION DEQ RP.TiON �� �� �;: 1HEFEBYAFflHklUNDERPENALTYOFPERJURYD'JEOFTHEFOLIOWMGDECLAHA7104S: J z , -�`- _IHAVEANU'NILLFUiWTAINACERTIFiC11TE-UFCOY3ENTTOSELF-INSUREFORV�ORKEflS' _ - ��.-.-: C0IAPENSATIO4,AS GROVIOED BYSECTON 37:A oK THE LA00R CODE,FORTHE?EAFORMANCE W � -- OFTHEWOflKFORWNICHTHISPEfUtI7�515SUE0. � � �. _ '..�;_. _IHAVEANDlMLLMAMfAINWORKERS'COMPENSATIONINSUIiANCE,ASREQl11REDBVEECTIOri ��Q_- 37M4FTHELA90RQ?�E,FORTNEP�flFORMt4CEOFTHEWUPKFORWNICHT SPERMITIS �-0< ISSUED.MY WORKEP' Fl6M•itjSI�ANCE CAf1Rl -��Dt PO:ICV�R AflE: CONSTRUCTION :��?�-. caapiEa -� � l� PLAN REVIEW / Z; aa�cr NUMeeA _ ELFC7RIC �. - _ 4� ¢; _�.- (tt4SSECtKY�Ir��No7AE(X7MRE7EDOFn cP6'JMI'ISwaarvEtNnDfiEOCalaas(StaoIORLEss} PLUMBING r.h-qi :,"-=A 'Z- �CEATIFI'THAT W THE PERfORMA.NCE�F TY.E�YORK FOR KHICH h115 PERMIT IS ISSUEq I` MECHANICAL :s�L"-'"`""�$ „�T- SHPU_NOTEMPLOVANVPERSONINAMfMANYEREOASTOBECOMESUBJECTTO?HE '�-: WORKEflS'COMPENSTIONLAWSOFCALIFOFYIA,ANO�EETH FhBHOUhDpECO—ME�VO INSPECTI6NFEE -F' Sl18JECTTOTHE -.KEPS'COMPENSA VI51915 FSE A �EL�UR - � ,��.. f� :�: E,1 AL{. O COMPLV THOS HOVi � B. (J'SUANCE �� �r _ .. �-�pi DATE: AAPLICANT:� SMIP �� f .^ — _.._.._._ . �' ENERGY P/C `—�-° WARN :FAIIUA O SE RE VJOHKER ENSRTIO�COVERAG IS 11Nt�1WFt1L.A� L BE 'r ;J:, F - r�- SU CTANENPIOYEHTOCRIMiNALPENALTi ANOCIVI�FlNESUP ONEHU4DREOTHOUSAND ENERGYPERMIT " � - S(i100.000),INAO�ITIONTOlHECOSTOFCOMPENSATION,O AGESASPflOVIDEDFORIN —�1- . --J< SECTION370BOFTHELn80RCO0E,INTEf7EST,ANDAttORNE1"SFEES. RETENTIONFEE: -£�� '� �'. �;d; CONSTRUCTION LENDING AGENCY PRE-ALT FEE: d; �-.��-- i HEPEBYAfFIRM UNDEH PENALTY OF PEfiJUHY THATTHERE IS ACONSTRUCTIDN LENDING AGENCY -n-- FORTHE PERFORAI F TH W K F�HI �MITIS ISSIJED(SEG 3097,CIV.CJ. Z-. .W_ — -�. LENDER'SNAME C� . -� LEN�ER'SADOHE55 :.W� TOTAL FEES �,.j. �' I CERTIF'!TMAT I MAVE REAG TNISAPPLICATiON AND STATE THA7THEABOVE INFORMA710N IS CARRECT. ::� I AGRFE TO CAMPLY WITH ALLCIiV M1D COUNTY ORDINANCESAND STATE LAWS FEUITING TO BUILDIN6 _ :� CONSTFiUCTION,ANDHEREBYAUTHORIZEHEPRESENTATIVESO:THISCOUNTYTOENTEiiUPONTHE -� ABOVE•MENTIONED PROP�tt FO SPEC710N PUflPO3E3. COMMENTS � ' C alfS .���C , � — m �� ,� ��, ¢ � EE DF7E `_ - RECPT.NO. PAID BY VALIDATION -~ WHITE—DepartmeM Copy,YEILOW--Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanPs Copy ` � _' _ .f �_ _ _ 4 _ F _ r.. . t I�_ 4 [ i ��, 3 ��` � .�� 4�� �! �, i y ij (s � ��� . '���� ��,.p� f I ,+ _ F -.3¢ - � ,. $� . a, ; C _ "*: ' � � r � - 3 � ' I TI �.� r a�-� � e��;.� S` E j � i _ € _ , � ��§���, a����:� � ' � i � ' �� ` - �i ��- ���..� t € � � ��... 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