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HomeMy WebLinkAbout12178 (14) j. I �� CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �- 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 ; PRESS ���'�^°� BUILDING PERMIT APPLICATTON FIRMLY � JOBSITE >.. 2� APPLICATIQ� a , PERMIT P!C o ADDRESS � 3...�J ��i.l"YiYI �� DATE Y� `�7"'l� NUMBER � u � ISSUE TYPE OCC APN LOT TR CT DATE CONST. GROUP p OWNER ` {�1" �,�'L o ADD, SS � � ' C�YYi 1� ZONING SFTBACKS QCITY ` i IP � TEL._ REART RW u- � APPLICANT 7EL. SIDE/SIQE STREET RW fl. �� CONTRACT SIDE U__V_ ApDRE r �? ! � CITY ) ZI 7 TEL PROPOSED USE w: ARCH/EN / z' DESIGNER w NO.DWEL. NO. NO. a ADDRESS � CITY _ Z�P TEt. UNITS STORIES _ BEDROOMS �n DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DFCLARATION SFFVAD�IREM � p� 1 HEHEBY AFFIRM UNOEfl PENALTY OF PERIUqY TF1A7 I AM eXEMPT FROM THE CONTflACNRs LI- � GefagBlCd�pOfl W CENSEUWFORTHEFOLLOWINGPEASON(SEC.703f.56USINE55ANDPFiOFESSlO;lSCO�E,ANYLITVOR . 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'� COI111110fCidl - �MALL DO THE WOP!(,AND THE STRUCTURE IS NOT IN7ENOE0 OR OFFEflED FOR SALE(SEC.7o4a,BUSI- � J N, NE55 ANO PHOFESSIONS CWE'TME CONTRACTOp5 LICENSE LAW OOES NOTAPPLY 70 AN OWNER OF PqpPERTYWIpBU�LDSORINPRpVESTf1EREON.ANDWHO00ES5UCHWOFKH161SELFORNERSE�FOR ' � � �T}1flOUl3NHISORHFFiOWNEMPLOYEE9.PflOVIOEDTHATSlJCHIMPROVEMENTSARENOTINTENOEOOR LO - Q, OFFEHEDFORSAIE.IF,HOWEVERT1iE8UIL�INGORIMPROVEMENTISSOLDWI7HINONEYEAqOFCOMME- ' � Z TqN,iHE OWNERAUILDEH WILL HAVE THE OUROEN OF PqOVING THAT HE OR SHE DID NOT BUILD OR . �. .IMPROVE FORIHE PURPOSEOF SRLE). W, ❑I,ASOWNEflOFTHEPpOPERTY.MIEXCLU5IVELYCqNTRACTIN(3WITHLICEN3FACONiRACTORS ' ([�. � TO CONSTHUCT THE PflOJECT�SEC.7oe4,BUSINESS AND PROFESSIONS CODE:THE CONTMCTORS LI- '� vdIU811011 ,ADJ.AREA W �.CEkSELAWDOE3NOTAPPLYTOPNOWNEROFAPqOPERTYWHODUILOSOPIMPHOVESTHEREON,AND �' � ---'--- -----� — �-� NTpCONTMCiSFORSUCHPflQJECT3WITMACONTRRCTOq(SJLICENSEDPURSUANTTOTHECONTRAG � QUANTITY DESCRIPTION FEE � TOASLICENSELAW.). p. U TAM E%EMPTl1NDER 5EG __ ,B.6 P.C.FOfl THIS REASON :��� Q �' ' U LL � DATE OWNER _ .._. ..._.,_ . � �, LICENSED CONTRACTORS DECLAqA710N { W �� �NEflEOYAFFlfiM UNDEA PENALTY OF PERIURYTHAT IAM LIC[NSE�UNDER VROVISIONS OF CHAPTER � � .� p.� 8(COMMENCINOWIh7SECTION7000)OFOIYISIOY30FTHEBUSINESSANOPROFESSIONSCODE,AN� Z X {AY LICENSE IS IN FULL FORCEAND EFFECT. m ' LIJ, z r- �� LICENSE CLASS�� �'/.J�G�q,� _ LIG NO._ C �^ V DATE�(v 3tL_S.;l! CONTRACTOH� � ".7_ ���� W � � �. WORKERS'COMPENSATION DECLARATION �i�� v ¢ . �:� I XEPEBYAFfIRM UNDER PENALTY OF PEfiJURV ONE OF THE FOLLOWING DECLARATION5: Z O: __IHNVEANDWILLMAINTAMACERfIFICATEOFCqNSENTTOSEIF-INSl1flEFOHWORKEGI3' S '�d-. /EOMPENSATION,A9 PROVIUED BV SECTION 37000F THE LA90R COD'c,FOfl THE PERfORMANCE `U O i OFT}fE WOLiK FOR WHICH THIS PF.RMI713ISSUED. � w ..�'_IHAVEANDWILLMAINfAINIYORNERS'COMPENSATIONINSl1ftANCE,A5RE0UIREDBYSECTIUN ' Q 370o OF THE LABOR CA�E,FOR 7HE PERFOpMANCE OFTHL WORK FOfl WHICH THIS PERMlYlS . ISSUEO.MY WOP.KERS'�MPENSAT NSURANCE Cl.RRIER AND POLICV NUMBER AR[: CONSTRIJCTION .___,.._,____,_____ � "_ . � � CARflIER_'_ '? � `, ' PLANREVIEW --,---,-_—.-- -_ _---- —_— � Z POLICV NUMBER_. �_ -� �7����//�� ELECTRIC �P�� _—_'_ �_'___._-_' Q r � Q (iHISSECIK7NNEE�NOTOEWI.�IEfEDOFTFIEPEPoVYfISFOROAEHIHJfX1tL00LLNi3 fao)OqLESS�. LUMBING _' __ _ _ __. .. /_��� W � Z I CEflTIFYTHAT INTHE PEflFORMANCE OF THE WO(iK FOq WHICH THIS PEHMIiIS ISSUF.U,1 MECHANICAL ___,___�,_______,_ -. �� ��� � (} SH/LLLNOTEMPLOYANVPERSONINANVMANNCRSOASTO6ECOMI[SUBJECTTOfHE (n ' WORKEflS'COMVENSAT�ONLAWS�FCALIfORN1A,ANDAGR[f:T11ATIFI51i4UL�BECOM[ INSPECTIONFEE ____ __,._,________ � SUBJECTTO'(HE WORKEHS'COMPENSATION PflOVI510NS OF SECTION 37a00F THE LF�OR �q�!� - ~j CO�E.ISHALI.FORTHWITHCOMPLYWITHTH PROV IONS. � AN ^"'_'_____" '_'__'__�.'y�e�J(r1_ � P=-d� -��. W �ATE: APPLICANT. �_'_ S� .- '--.-' _. '._ �� J WARNINGFAILURETOSECUREWORKERS'COMPENSATIONCOVF.RAGEISUNLAWfUL,ANOSHALLBF. ENERGVP/C ..__._______.__,_._._, ' �y '.SU&IECTANEMPLOYEHTOCHIMINALPENALTIESAN�CIVILFINESUPTOONEHUNDfiEOTtbUSAND ENERGYPERMIT � �OLLnRS(f 100.000�.IN ADOITIIXJ TO THE LOST OF COMPENSATION,DAMqGES p5 PRUVIDED FOft IN ��-�---�-�----�—��-� J SECTION37o80F711ELABORCODE,INTEHEST,ANDATTORNEY'SFEES. RETENTIONFEE: (_ _' _ _ '______ "_-- d CONSTRUCTION LENDING AGENCY PHE-ALT FEE �'�, � I HEREBYAFFIpM UN�ER PENALTY OF PEflJURY THAT THEFE IS ACONSTHUCTION LENDINQ AGENCY _ __ ^� _ _^ FOR TNE PERl-0fiMANCE OF THE'NOFK FOR WHICH THIS PEflM1T IS ISSIIEO(SEG.30W,CIV CJ. '-' � -._ ..._ _ � ,_ _ � LENDER'SNAME_-__ ___ ' . ___ ._ .__ . .._ , F_- LENUER'SADDRE55___ _. ._._. ./�� � ICERTIFYTMATIHAVE.READTHISAPPLICqTIOtiqNOSTATETHpTTHEABOVEINFORMATIONISCORRECT. TOTAL FEES ��" • - � IAGREETOCOMPLYWITHALLCITYANOCOUNfYOHDINANCESANDSiATELAWSAELATINGTOBUILDING � CONSTRUCTION,AN�HEREBYAUTHOqIZEHEPHESENTATIVE50FTHISCOUNTYTOENTERUPONTNE Z A90VEMENTIONE�PROPERiV FOR INSPECTION PUfiPOSES. . 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