HomeMy WebLinkAbout10369 f,; � �:
i ��
----/�`�- CITY OF DIAMOND BAR
COMMUNITY DEVELOPMENT DEPARTMENT
.,,.� . 21660 E_Copiey Drive Suite 19D PRESS
(909)860-3195 fax(909)A61•3117
; �'""'� BUILDING PERMIT APPLICATION FIRMLY
i N JOBSITE ,` ��j,/� l-;y,�j APPLICATION � PERMIT 7 P/C
� � ADDRESS�`���� U•��:W 1�V {/Y)�?� _ DATE NUMBER �t./ #
" o ISSUE TYPE OCC
� °D �APN LOT TR{�CT _ DATE_ _CONST. GROUP
� p OWNER L C.SO iJ
o ADDRESS b AI�� � ZONING SETBACKS �XP1�7��
z ,CITY ZIP TEL. FRONT �f� ❑ _
i� `APPLICANT TEL. REAR LI__
�' S SIDE SIDE STREET • �,�j,W ❑
� ¢. l�l! C:1_
CONTRACTOR
" � ADDR 5 �
� � CITY ZIP TEL. PROPOSED USE
� w ARCHlENG -
0
j� W DESIGNER NO.DWEL. NO. NO.
'f a ADDRESS_ UNITS STORIES BEDROOMS
� � CITY _._ ZIP TEL.
' � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
J pC OWNER-BCILDER DECLARATION SFWADD/REM
O
p I HERE6V AFFIRM UNDER PENALTY OF PEFJURY 7MRT I AM E%f.MPT FROM THE CONTRACTOqS ll� Gef3J6lCdfpOli
f W CENSELAWFORTHEfOLLOWINGREASON(SEC.7031.SBUSINESSANDPROfESSIONSCODE�ANVCITYON (n
' U COUNTYWFiiCHREDUIRESAPERMITTOCONSTRUCT,ALTEH,IMPHOYE,DF.MOUSH,ORREPAIRANYSTRUC- W PatiO/DBCI(
�;{ w TURE.PflIOR TO ITS ISSVANCE.P150 FEQUIFES TNE APVI.ICANT FOR SIICH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PI1RSl1ANT TO THE PROVISIONS OF THE CONTfiACTORS LI•
�3, � CENSE lAW(CNAPTER a(COMMENCING WITH SECTION Iaao)OF DIVISION 3 0F THE 6USINESS AND PR0- � POOUS(I8
p � FESSIONSCODEJORTHATHEORSHEI5EXEMPTTHEflEFROMANDTMFBA515FOflTHEALLEGEDEXEMP- (�
� � TION.AkVVIOLA7lONOFSEC7I�N7a31.59VANVAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANiTO Z RB-R00}
� AGVILPENALTY OF NOT MORE THAN FNE HUNOpF.D DOLLARS�SSoo)J:
� ❑I,ASOWNEHOFTNEPROPERN,ORMVEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, 0 Commercial
Z WILI DO THE WORK,AND THE STRUCTURE IS NOT INTENDEO OR OFFERED fOR SALE(SEC.7044,Bl1Sl- J
H NE&S AND PqOFESSIONS CODE:THE CANTRACTORS LICENSE LAW DOES NOT ACPLY TO AN OWNER OF
l � PROPERTYWHOBUILDSORIMPflOVESTNEREON,AN�WHODDE55UCHWOfiKHIMSELFORHERSELFOR �
j 2 THHWGHHISORHEROWNEMPLOYEES.PROVIDEOTFIATSUCHIMPROVEMENTSARENOTIN7ENDEDOR m
� Q OFFEREOFOHSALE.IF,HOWEVER,THEBUILDIN60RIMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE-
� Z TION,TNE OWNER�BUILDER WILL HAVE THF Bl1RDEN OF PROVINO THAT HE OH SHE DID NOT BUIID OR
� IMPROVEFORTHEPURPOSEOFSRLF.).
f.l l,AS OWNER OF THE PflOPERTV,AM E%CLU5IVELY CONTRACTING WITN LICENSED CANTRACTORS
� TO CONSTHUCT THE PH0.JECf(SEC,7oaa,BUSMESS AND PFiOFESSIONS CODE:THE CqJTRACTORS LI- VdI112110f1 ADJ.AREA
� W CEN5EUWUOESNOTAPPLYTOANOWNEROFAPROPLRTVWM09UIlOSORIMPROVESTHEREON,AND
� WHOCONTRACTSFO�iSUCHPRQIECTSWITHACANTqACTOR�S�LICENSEDPURSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FE
Y TORS LICENSE LAW.�. ,p��
� �I NA EXEIAD7 UNDER SEC.__ B.8 P.C.FOR THIS REASON Q _ 'LV!. jI�
� � _._". ¢ '0� � /'[! �
.3 � OATE"'""_ OWNER —"_y___'_'_"_' V
Z
+ � LICENSED CONTRACI'ORS DECLARATION L
f � 1 HEREBY AFFIRM UNDEfl PENALTY OF PEflJURY THAT I AM LICENSEO UNDER PROVISIONS UF CHAf'TER �
� 9(COMMENCING WffH SEC"fION%000)OF OiVI510N 30F TME BUSINESS AND PROrcSSiONS COuc,iJrD Z _
' X MY UCENSE IS IN FULL FOFCEAND EFFECT.
� � "_' �
�._, LICENSE CLASS_,___ IIC.NO. J
7 V DATE______.___ CONTRACTOR ______ 0.
W
j � WORKERS'COMPENSATION DECLARATION Q
; = U
� IHEREBYRFflRMUNDERPEHALTYOFPEiUURYONEOFTHEFOLIOWINGDECURATIONS:
,.� � Z
Q
� � __IHAVEAN�WIILMAINTAINACEATIFICATEOFCANSENTTOSELF�INSl1REfORWOPKEPS' � � '
y COMPENSATION.ASPROVNEDBYSECTION31o00FTHELABORCODE,FORTHEPERFORMANCE U
d OFTHEWORKFO(7WHICHTHISPERAAITISISSl1E0. �
3 W
I HAVE AN�WILL MAINTAIN WOHK[HS'COMPENSA710N INSURANC'c,AS RE�UIRED BY SEC710N
� Q vaoOFTHELABORCODE,FORTHEPERF�RMA'JCEOFTHEWORKFORWHICHTHISPERMITIS _------
ISSUED.MY WORKERS'COMPENSATION INSURANCE CARRIER PND POLICY NUMBER ARE: CONSTRUCTION
— .�
j cnaaiea_..._.........__ PLAN HEVIEW
� z POLICV NUMBER . _._ ELECTRIC _— L
Q
� 0 (IHISSECf10NNEmNOTBE00MfiEfEDOF7HEPERMfTISP7RIXJEMN�DFiFDD0UM5(StOo�ORLE55} PLUMBING . ---
W� MECHANICAI
Z ICERTIFYTHATINTHEPERFOflMANCEOFTHEWORKFORWHICHTHISPERMITI5155UED,l
(}� SHAIL NOT EMPLOY ANY PEfl50N IN ANY MANNEF SOAS TO BECOME SU&IECTTO THE [�,•'_;+. f�� �� ,j �.; �
'� � WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGfiEE?HAT IF I SNCHILD BECOME IN5PECTION FEE . d .m•���
SUBJECTTOTHEWORKERS'COAIPENSATI�NPflOVISIONSOFSECTION97000FTHElABOH �''� � I'�
4 � CADE,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. ISSUANCE �' __, �
� SMIP
� p DATE:___ APPLICANT: _____________. �y�p ---'—
w ENERGY P/C �A dl [1 Il 1�TM4/
J WARNING FAIWRE TO SECURE WORKEfiS'GOMPENSATION COVERAGE IS UNLAWFUL,AfJD SHALL BE ��y��+
LL SUBJECTANEMPLOYERTOCRIMINALPENpL71ESAN�CIVILFINESUPTOONEHUNDFEUTFiOUSAND ENERGYPERMIT '" � '
OOLURS(5100.oW),INADDITION TOTHE C0.ST OF COMPEN6ATION,DAMAGES AS PROVIDED FOR IN
� 5ECTION37080FTHELABORCODE.INTEREST,�N�ATTOflNEV'5FEES. RETENTIONFEE:
d CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� IMEREBVAFFlHMUNDERPENALTYOFPEflJURYTHATTHEFEISACONSTRUCTIONlLN01NGAGENCY
d FOR THE PER(-0RMANCE OFTHE WORK WR WHICH 7HI5 PERMIT IS ISSUEO(SEC.3097,CIV.C.). -���- —
Z
W ---------
� LENOER'SNAME_ ___.____ ____
F— LEN�EIYSADDRESS ._._.,___ _._.-
W ICERTIFYTHFTINAVEREADTHISAPPLICATIDNANDSTATETNATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES
� I A6REE TO fAMPLV WITH ALL CIT/AND COUNTY OROINANGES AND S7ATE lAWS flELATING TO BUILOING ��
CONSTRUCTION,AND NEREBVAUiHORRE REPRESEMATIVES OFTHIS COl1NTV TO[NTEFl t1PON THE
Z ABOVE�MENTIONED PROPEflTV FOH INSPECTION PUPPOSES.
COMMENTS_._,___
� N C UL or� --
� -
m PENMITTEENAM INT) _
Q ^ —___
� y //[..— ...
/��i14 WvV r
f/) SIaNR7UR ERMITTEE DATE
� � RECPT.� C _ PAID BV ___ VALIDATION, _
I ~ WHITE--0epartment Copy,YELLOW—�inance Copy,PINK—Assessor Copy,GO ENROD—File Copy,GREEN—ApplMant's Copy
�
�
,. w.. .�.�.�_..._.
_. .___ �--�-� e
r � � .. . -� � "�' I I I
us.n, � -rs �+,� -n � in v>E � � ca � m :n�a � � ss -n �y��i--i va �y m c�
� �� � z�2iz�� ,°Dn m � r"�� � T+ � al0 DIO Gla Q'� T�ID �s�m G�,, a
n'�� n�� rla �. r- . G�c c o o -, ��
Tl_il � � � rir D ti � m�� r I� m �ios ��C r=
-o C7 � -�u m xlc'> z %�c�l�'n � ��� mfi�? s_��'z � � -o G� z�9 T�a
r � _ O�p �e
, �- m , . . r � . -'- .�
a -� -, _ v, i � y � c �
� � � �r r 2 �� � S.O � I
`t-i I� � �I C tri� � D� .� t� 7J X
� i '� Z f= y �-� I ` r 7't <:� f71 i� S`
C� � � � I i � �i� -�Ic�'lumi�� I I� n r cnicl� m a m D4� m p!r G� � ,
'.G�7�: � ,W�� z ".� � . .�� �D c 3'�� a ca�� n -i 73 z -I C � m.c z, cn �.
�N G7 I - � �� G7 � � r1� L� ,y D O �i^,�'t���-9S',� �.7 I Pnn '�� ,w p � �. � .....,,,„� ... .
`a.�
�ty 1, � I � . � � z cn � n� ' ca � zm
'ml � 1 � I � ��i I � � I ; � .� '�I �
�
i I i � � _�- �T I— {- I �', d � r� � ,�.�
_ f � � ' , ; I � � ; , � - i -� I _ � a --
: i -� � i i ' ; � ; i 1 _� � ' � I i �: �=;I �, a _ ,.�,.
� � I ' if ' � .
,
I � � � , - -- - � ' "
-
i i ..1 , r. � � � � - � � �
� "� � � � � � ,. ;- � -. � I --��- -�- --
��
I ( '' � � I ' ' I - ��
'� � ;:�' �� I ! ;� 4. � _ I ! i ; '� , �� i � � �� �
� ; � � � � �� � ��k � � � , ,.
� � � ' � � �
� � � , � � � i '� -
' I � j � ;. .; , � f ; I � I fl o
' � � ' � � � ( :� �' ( �� "�a�
I � i i . i , i � �
� .I If I � I . � : i' �' I I I � � f E a� —o .
- � ( � � ' I � ;j I ( i ` -�-i$��"----_ —, T _ I " -.� __��_ _ _ � �
i ' � � ,� ,,,I o�_ -n ?r.p�-n�� � �,v(�i�� , i . _+-, � '�S �.
� I � i i . � z r-� m I�.� o � m -n�0 OIO Ip!�m ������� 'n �i�iz�=�� °� �
i
� �
1 � �
� ' I ! � ° Imf r. m D � D�_I TIO O10 '_'� mIz'� t7 �i� i �. ;
I � � � � <�����'��� z �lo . ��Z' n rn �, a o�>;o� Ja
{ I .� . I � I - � Ti-9� '� 7 r� r r�r- J''G)�� r�� Z T3�� 'r1 f1T�7J- � � ��.,� s'
I 7 � �� G� i I �S -r L7� 'J7 i I A �
I � � i� rniz iti -nD,-� � �+.m y � -+ � r � x�m
i ( . , ; i rr�i i.p�� ��c� � �im r-i�r���i �Z!a oI�I� D���-n ���I� � O
i ; i � ! i i � � v; m�-��� � v c'> �I� a nin���s�a�G)lo z�o O mimir' '_i� p � .,�
� I i ( ���� I� � I s �IvjriZ m �2j r .p ID� �7 � �.r � i i0 Oi�:� 2�
i I � � � ����Z � cnl�i !u?��� z��I o� � [a m O m �n Q O Cnj=i � �� ;
i i I o c�' z -, �O i o � �j , �'"� ;
� i ,�. , � i � i i--"�� �� i' I � ��-� G�Iz'� I�:� ,•�n � �o o �
II ! i � '� ' z _� , ^� I ' � I I�I n I� z io c� I ' � � � �
' � �'� �� � � � ' �' I � �:� � � '�_� � i I � ��alo.��; � ��
� � I I I ( I - I ; I' ( I � � '� �si�l�l I
��� I I I � - I i i �. . II � '- � i` � �;- - � - - .I � r � .
�I ; � I � ��� ,
I � � � � �� I �� i � ' _ .
� I � � I :i_ i r
�, � � � � `I � I.; � � � � ��w
; � � � � � � � � �� Ii � I` �
; . , � ' ..'` : f � :.' i � � ' � . ' - ' i �i. '
� : I � I ::� �I I',,.I- � . ', j . -----���---���� -� . ��
� 4� 1 ' ¢ ,: I � i � i I- I � ! _ I ;
I � I � `
.
;
-
; � � 1' I , � ' ' ' -. � i � ; � . ; � `:. , - . -
, � . ; : I �. ! ! t-� � � .i= I � : ! � � i
� � , . _! � : � �, � � . � � ; , � � ; G :,
' �J.� _ � .!����.�__���r�'_1_. __.�_.�_��w�:�!� � ! I �
_ .� ���_. . _���.mm__�
�
__.____ �.. s�