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HomeMy WebLinkAbout13667 (14) � �� �.� CITY OF DIAMOND BAR DBPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES > 21660 E.Copley Drive Suite 190 PRESS (909)860-3195 Fax(909)861-3117 ��'°�' ` BUILDING PERMIT APPLICATION FIRMLY � JOBSITE i APPLICATION ��' �/ PERMIT 1--I�.�n P/C o ADDRESS_� !��� ����'1^ � � DATE NUMBEIL � I_ # � ISSUE TYPE � OCC �- APN LOT TRACT DATE CONST. GROUP °C OWNER � �:� O � ADDRES ZONING SETBACKS � CITY ZIP�:�� TELS � FRONT RW U APPLICANT TEL. REAR ❑ � SIDE/SIDE STREET RW ❑ � CONTRACTOR 'S► SIDE n___ � ADD SS ' � CI7Y ZI TEL. - - (^j PROPOSED USE_ �'�-""'6 "� � ARCH/ENG/ �z DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. �. u� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADD/REIv1 O � I HEREBY AFFIAM UNDER PENALTY OF PERNRY THFT 1 AM E%EMPT FF70M THE CONTRACTORS LI- Gdf9A0/CBfpOft W CENSEIAWFOHiHEFOLLOWINGHEA50N(SEC.7o31.5S11SINESSANOPROFESSIONSCODE:ANYCITYOR (n C.�� WL1NiY41MIq1HEWiRESAPERMRTOCON5TRl1CT,PLTER.IMPpOVE,OEMOLISH,ORREPAIRANVSTRUC- �j,� pyi10/DBCk Z 7URE,PFIOR TO ITS ISGUANCE,ALSO RE�UIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w' STATEMENT TI1AT FIE Ofl SNE IS LICENSED PUflSUANT TO TME PROVISIONS OF TNE CANTRACTOR$U• W :�. CENSE UW(CHAPTEH B(COMMENCING WRH SECTION 7000)OF OIVISION 3 OF THE BUSINESS ANO PRO- u" POOUSpB � FES8qN4CODE�ORhIATHEOH5HEISEXEMPTTHEFEFROMPNDTHEBA3ISFORTHEALLEGFDEXEMP- � y� .V TpN.ANYVKKATpNOFSECTqV70.s1.5BYANYAPPLICANTFORAPERMITSU&JECTSTHEAPPLICANTTO Z fle-Roat Y � ACMLPENALT'OF N0T MORE THAN FNE HUNDRED DOLLARS(5500).): ❑I,ASOWNEROFTHEPROPERTY,OFlAIYEAiPLOVEE6WITHWAGESASTMEIFSOLECOMPENSATION, � COrtlrtlefC121 ' �g� YIILLDO THE WORK,AND THE STRUCTURE i5 NOT INTENDED OR OFFERED FOF SALE(SEC.7044,BU51- J NE53 AND PFpFE531IXJ3 CODE:iHE CONTflACTORS LICENSE LAW OOES NOTAPPLY 70 AN OWNEN OF �� DqOVERTYWF108UILD50RIi.9PROVESTHEREON,ANDWHO00ESSUCHWOPKHIMSELFORHERSELFOq m i ,CC� hIHOUGHHISORHEROWNEMPLOYEES,PAOVIOEDTHATSUCHIMPROVEMENTSARENOTINTENDEDOq W�. OFFEREDfORSALEIF,HOWEVER111E8UIL01N60RIMPROVEMEMI550LDWITHINONEYEAROFCOMPLE- ��� '710N,hIE OWNERAl/1L�ER WILL HAVE THE BUR�EN OF PROVING THAT HE OR SHE DID NOT BUILD OR ��� �IMPROVEi'ORTHEPURPOSEOfSAIE). � � ;�y,�; ❑I,ASOWNEROFTHEPHOPERiV,AMEXCLU5IVELYCOMflACTINGWITHLICENSEDCONTRACTOR3 ��� �70 CONSTRUCT THE PRD.IECT(SEG.70M,&1SINESS AN�PROFESSIONS CADE:THE CANTRACTOHS LI- VelUet1011 ADJ.AREA 'W. CENSEUWOOESNOTAPPLYTOANOWNEROFAPROPEflTYWHOBUILD50RIMPFlOVESTHEREON,AN� — --- .� WMOCOMRACTSFORSUCHPROJECTSWiTHACONfflACTOR(S7UGENSEDPURSUANTTOTHECONTflAG QUANTITY DESCRIPTION � FEE Y- TORS LICENSE UW.). � L'J IAM EXEMPT 11NDER SEC. B.8 P.C.FORTHIS REASON � Q � U � — ----'----'-----�—�---------.'-..............'-- . � . � DATE OKTlER � V � LICENSED CONTRACTORS DECLARATION W �� IHEflEBYAFFIRMUNDERPENALTYOFPE0.IURYTHATIAMLICENSE�UNOERPROVISION50FCHAPTER � I � d•, 9(COMMENCINOWITHSECTION7000)OFDIVISION30FTHEBUSINESSANDPROFESSIONSCADE,PND Z �.['. MY LIGENSE IS IN FU OF EFFECT, ,+., � � W' 0:. LICENSE CLASS LIC.NO. � " �V � �� :UT pATE r _CONTRACTOR_ L L�f� W4 �.[� WORKERS'COMPENSATION DECLARATION a = U ��� IHEHE9YAFFlRM UNOER PENpLTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: :�� Z 0' �IHAVEANDWILLMRINTAINACEiifIPIGATEOFCONSENTT03ELF�INSUHFFORWORKEfIS' _ '.;�'. COMPENSATION.AS PROVI�ED BY SECTION 3700OF TME LAB�R COOE,FDH TH[PF:RfORMANCE W OF 7HE WORK FOR WHICH YHIS PF.flMIT IS ISSUED. � 0 I HAVEAND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS FEOUIHED BY SECTION / �Q.'� 37000FTHE IABOR COUE,FORTME PERFORMANCE OF 7HE WORK FOR WHICH THIS PFRMIT IS r j `0: ISSUED.MV R�ERS'COMPENSATION INSURANCE CARRIER AN� ucv NUMu�n aaE�. CONSTRUCTION �� _____ a+ -- — ;�. CARHIER � �1 -,f PLANREVIEW ----.._._. ..----------------- O., �icvNUMeed�x.� " ELECTRIC _._...._..--------- --------.---- ��'� (fH1S5ECiqNNE�NOTBEOJMPLEfIDCFTHEPERWTISFORIXJEMNDRED�OI.LAR5�5100)OfiLE55} PWMBING ,p� —.____—_.—._____._.. _—___-- -,Z�� I CERTIFY THAT IN TME PERFORMANCE 0 E WORK FOR WHICH THIS PERMIT IS ISSUEO,I MECHANICAL ______.__ __ ___ _____ ���' 6HALL NO7 EMPLOY ANY PERSON IN ANNER SO AS TO 9ECA E SUBJEC7 TO TNE �,(n'" WORKEflS'COMPENSATIONLIWSOF FOflNIA,ANDAGREET �If"ISFIOUIUDECOME INSPECTIONFEE __________ _ � SUBJECT TO THE WOfiKERS'COMPEN ION PROVISIONS OF 5 ON 37000F Tf1E Ln�6F� ' ;� DE, SH IFOR WITHCOMPLY T l}WSEPROVISIONS. / j ISSUANCE _.___.______� ,_„�,__ �;:� '— .�= SMIP � ;:;`p' DAiE: � APPLIC � "'---1' '--'- . i� ENERGY P/C ,:� WAFlNING FAIWR[TO SECl1RE WORK 5'COMPENSATION CO EPAGE IS UN UL,ANO SHAIL E ------�------���------ ` SUBJECTANEMPLOYFRTOCRIMINALPENALlIESANDCIVILFINESUPTOONEHUNDREDTHOU ENERGYPERMIT � DOLLARS(51ao.oW),IN ADDITION TO THE COSTOF CAMPENSATION,DAMAGES AS PROVIDED FOR IN --- •�'J�: SECTION9'laeOFTHELABORCOOE.INT[REST.ANDATTORNFY'SFEES. RETENTIONFEE: � _.Q.. -. ;'d' CONSTRUCTION LEN�ING AGENCY pNE-ALT FEE: __,._. _ � ;;O; '��P IHERFBYAFFIRMUNDEPPENAL7YOFPERJURYTIIATTHFREISACONSTflUCTIONLENDINGAGENGV FOF THE vERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED ISCC.3W7,CIV.C.). Z. ':�W.. '_—""._.__—'._'_'___'—_ _ •�t LENDER'SNAME_.__. .. _"_' "'_— F_—� LENDER'S.ODUR[SS ________—.—______._ �' TOTAL FEES + �` 1 CEfiTIFYTHAT 1 HAVE flEAD TNIS APPLICATIONAND STATE THATTHEABOVE INFORMATION IS CORRECT. �� �,Q.' IAGHEETOCOMPLYWITHPLLCfiYANDCAUNTYORDINANCE5AND5TRTEUWSREUTINCTOBUIL0ING ;,Z, CONSTRUCTION,ANDHEREBYAU��7}WWW HIZEREPRESENTATIVESOFTHISCOUNTVTOENTERUPONTHE �E-MENTIONEO PROPER OI�INsaECTwH ruAcosEs. COMMENTS ___ _ �9' �� 4 ��--- ------ -- _ -- m P ITTEE NM1E(PflINT) � � Q _' C!� � NANHEO EFM E � E ,= RECPT.NO. PAID BY VALJDATION ��~ WHITE perlment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROQ—FileCopy,GHEEN—Applicant's Copy � ._. .... .. .. �_ _. _ - - ���� �� � �ti r�� �� � � , - , , I= e �, � ` 1 '� _ � � ��� ���� � �� � k ��1� a . i + � " � .r ��#"fq�����{�`�F � t ! ', �.. 3 M j ( j�..y f �. t �.� e��� � . �7 a r �. 5��p pC�� �f �' , i � _ � I t " i I 4 � � ��' ��++� `"����k�^��.�� � , ' � � � � t� ���, ��� � � , i�`� 1` M�„� � +��.xas�raa .: a� �� ; ( - j , � a � �. I � S� y a 5'�.-��.� E �,#r e < l ` S i i : j � � � � ' � � d.�^��;. g �������� , � �� �� b: , �� � �� „ , � E � '`�Fh= r�3 �&�i '�r a ,`i � ' I 1 � ;�-s i i r ! 'F'x �'' � ���� �'i r'� � Y'�i r�'�3�q �� � � i i �� ! x� t � t� � ' _ . . J��� ��.� ��. �,..�xn r . � r.^ , � � . 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