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HomeMy WebLinkAboutNo Permit Number (27) � . �t! _ CITY OF DIAMOND BAR , � DEP�4RTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21660 E.Copley Drive Suite 190 ��w (909}860-3195 Fax(909)861-3117 PRESS ��'��"� BUII.DING PERMTi'APPLICATION FIRMLY JOBSITE � APPLICATION PERMITf L P/C ^�� o ADDRESS���E��� ��� DATE '' �'� NUMBER"'� # - �O' � ISSUE TYPE OCC ; °r APN LOT TRACT DATE CONST. GROUP � � OWNER O � o ADpR S ZONING SETBACKS � Z CiTY � _ ZIP TEL�IJ ^ FRONT RW i.I---, � g APPL CAN't _'S���a. TEL. _ REAR n_____i � CON7RACTOR.�. SIDE SIDE STREET RW n � � CI7Y S ZIP TEL. PROPOSED USE � � - --- � w ARCH/ENG/ _ - zi DESIGNER ' � � �9 "�� � w. ? NO.DWEL. NO. NO. n, ADDRESS cn UN17S_ STORIES BEDROOMS �;. CITI' ZIP TEL. ,j �n; DESC TION S .F�: FACTOR PSF ADJ.AREANALUATION �� ;��0: OWNER•BUILDERDECLARATION : SFR/ DD M 1 HEREBY AFFIRM UNDER PENALTV OF PERJURY THAT I AM E%EMPT FROM THE CONTRACTORS LI- { 'W�� GENSEUWFORIHEPDLtOWINGREA30N�9EC.TWI.5BUSMESSANDPROFESS!ONSCODE:ANYCITYOR � � Garage/Carport .C.�'�. CCUNfVWHICNRE�WRESAPERMITTOCCNSiFIJCT.ILLTER,IMPROVE,OEMOLiSH,OI1FiEPA1RANV9TRUC- � ��Z• T1RE,PRIOR TO ITS ISSUANC6,FLSo REOUIRES fHE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED ` W Nd1i0/D6Ck W�� S7AiEMENT7HAT HEOq SHE IS LICENSEO PURSUANT TO THE PROV'S101JS OF THE CONTRAC70P5 LI• '� W ��'�'� CENSELAW(CHAP7ER0�COMMENCINGWITHSECTION7000)OFDIVISION30FTHEBUSINESSANDPflO- `' � POOUSP2 FESSqNSCODE)ORTHATHEORSHEI5EXEA/PTTHEREFROMAN�THE9ASISFORTHEALLECEDFXEMP• ,. (� TION,pNYVpLATqNOF5ECT10N7a3t.5BYANYAPP�ICANTFOqAPERMITSUBJeCTSiHEAPPLICANTTO �.'. Z Re•Foof '.•��� ACML ENAI7YOPNOTMORE7}iANFlVEHUNORE000�1AR5(is�).7: ASOWNEROFTHEPROPERNORMYEAlPLOVEESWITHWA(3ESASTHEIRSOLECOMPENSAiION,� % C] CpmmgfClBl ' -� :��::- WI YVORK,AN�THE STRUCTURE IS NOT INTENDED Oq OFFERED FOR SALE(SF.G�aa4,Bl1Sl- 5. _1� ..,'� NESS AND PROFESSIDNS CODE:THE CqYiRqC70RS LICENSE IAW DOES NDT APPLV TO AN OWNEH OF� �.,�..�� , � � PAOP6RTYNM00UILD&ORIIAPAOVESTHEREO4.ANDWNODOFSSItCMWORKNIMSELFORHEFlSELFOq 9 '�'CG�. THflIX10HHiSORHEROWNEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMENTSAqENOTIN7EN�EDOR'� �: m " � .�O OFFEREDWRSALEIF,NOWEVER,IHERUILDINGOqIMPPOVEMENTISSOLOWITHINONEYEAROfCAMPLE . 'TION 7Hf OWNEqAUiLOER 1MLL HAVE TNE BURdEN OF PqOViNG TtiAi HF OF SHF DI�NOT 6�IlD Oq '= IMPROVEFOqTHEPURPOSEOFSALE). U 1,AS OYMER Of THE PROPERTY,AM EXCLUSIVELY CONTRFCTING W�TH LICENSED COMRACTORS :��Q�, TO CONSTpUCT THE PR0.IECT(SEC.70M6,BUSINE55 PNO PROFESSIONS CAUE:THE CONiRACTOflS ll VdIU81i011 j_.___ rADJ.AREA... I iW`� 'CENSELAWDOESNOTAPPLY70PNONMENOFAPPOPERTYWHOBUII.DSORIMPRDVESTHEREON,AND " —�'- - i '�.'�,� M1IDCANTMCTSFORSUCNVR0./ECTSWITNACONTMCTOR�S)LICENSEOPURSUANTTOTHECONTRAG QUANTITY DESCRIPTION � FEE � . . 70f151lCENSELAWJ. j r�h � � J - ' ' ❑I AM EXFMPTUN�EflSEC. B.a PC.FOR THI5 NEpS�IJ Q /'7 .;i .'.Q�S; '_ '_ U { - �f � , � ( . �;Z� OATE _OWNER _ ;:.; U' � J . W v ,:`�Q,,,, LICENSED CONTRACTORS OECLARATION �;;� W �� ���.r: IHEREBVAFFiR11UN0ERPENqL7yOFPEH.1UflYi/iATIAML7CEN5eDl:Y.O[RrROV15'ANSCFCI.A EP .' � j4 � 9(GOMMENClN(�WIhISECTION7(q0)OFDIVISION30FTHEBl151NE5SANDPROFES510NSGODEPNO :., Z N f . MY UCENSE IS IN FU4L FORCE AND EFFCf,T. .,_ m � �. ,�� LICENSECLASS___ LIC.ND. _,__ u�n`�j 9 �; J ;3 ,?'�j" DATE _CONTFACTOR__ ._ _.... , y;:. a � `� � r.::,�} WOHKERS'�OMPENSATION DECLARAT�ON ,,: ¢ � ������,� I NEREBY AFFIFM UNO[R PENpLTY OF VE0.NRY ONEOF TI1E Fp�LOWING OECIAFATIONS: .`; Z ��L7! „_iMAVEANDW!L[MAM7A4NACERT�%:CA7EOFCONSEN7TOSELF�IHSURFFDRWORKEPS � � ; .`.. Z ., � . p -;�i,�: CqMPENSATI0N,A5PROVIOEDBYSECTION3�000FTNELIBORCOOE,FOqTHEPERFOqFAMlCE 'N .W ' � OF THE WORH FOR WHICH THIS PERMIT IS ISSUED. � ; L' � "� _I HAYE AND WILI MAINTAIN WORKERS'COMPENSATION INSURAtJCE,AS fiEQUIR[U BY SECTION �� ;4 37000F THE LABOR CODE,FOR 7f1E PEfl WRMANCE OF THE WOAN:OR Y/1{�CH�WS PERMIT S " � .'��. ISSUED.MY WONK[RS'COMPENSATION INSURRNCE CARiiIER AND POLICY NUMBER ARE � CONSTRUCTION � • O� �' -_-' ' ..... � � -��. CASFIER—'_' _""_' '"—' '� PLR� —. -.�...— �. r.�.+. s� ......... �� POI.ICV NUMBER____ � � Q - ---- _...-- -------�-� . � � (IHtSSE(,'11GWNE�NOTBEOCP.�I.ETE�OF'fF�PE0.WTISfORONEMJI�AREDDIX.L4Fl3(S��)ORLESS). PLUMBING ___,_____ ^., 1 C .�.���Z-. Ir.ER71FYTHq71NTHEPERFORMIWCEOFTHEWOfiKFORWHICHTHISPEFlMITISISSUEDI MECHANICAL __,.._ '<'�`"i t! � �S'i� __ "'�:(j"' 'SHALLNUTEMPLOVANVPERSONWANYRIANNERSOASIUHGGUMESUBJECfTOTHE :�(/)'_ �WORKEqS'COMPENSATION UWS OF CALIfOFNIA,ANO AGkEE 7HAT IF i SHOULD BECOME :���� � �NSPECTION FEE _,__ � �. ;' SU&IECTTOTHEWaRKERS'COMVFNSATIONPROYISIONSOfSECT10N9�uoOFTHEL480R QT /�-' ^�� �J .-. q � .� CODE,I SHALL FOATkWITH COMPLY WITH 7H0.SE PROVISIONS. . � ISSUANCE _.._ ' �� " " �-�-i" J F' v _ �--�'--.'�T--.._"__' rz_'"'_ O �LJ I �. . :. .. SMIP ...�. .. �.�..� ... ._ ��.�.J Q. ..::.p, �AiE:_ __ APPLICANT: _. .;:-. . ..- " .._ �.,. J. WARNING•FAIWRE TO SECURE WORKERS'GOMPENSATION COVERAGE IS UNU'NFUL,AND SHALL BE ENERGY P/C _,__� ___ __ _ � .':��LL� 9L1&IECTAN f:MPLOYEq T0 CRIAAINAL PENALTIES AND CIyIL FINES 11P TOONE HUNOFEU THOUSMD ENERGY PERMIT . �,,;, WLIAHB(5700.a00),INADDITIONTOiT1F.CO5TOFCOMVENSATION,�AMACESASPpOVIDEDFOHIN . r �-���-- ..-�--.. ---. --..- :�,� SECTION 3�OB OF lHE LABOR COUE,INTEREST.ANDA1 TORNEY'S FEES. � RETENTION FEE: ' :.d� CONSTFUCTION LENDINGAGENCY P E-ALT FE �•� �y �_ �::O. �/9-`- -- — ---- :.�.. IHEflEBVAFFIflMUN�EHPENALTYOFPERJUflYTHATTHEHEISACON51'RUCTIONLENDINGAGFNCY p J� _ __ __ GOH THE PERFORMANC[OF THE WOFK FUR WHICH THIS PERMIT IS ISSUE�(SEC.30a7,CIV.C.). . — Z .' lyj _"" _'_ "—.... ._.__ . :'>.�� IENDEfi'S NAME' _ ' __'_ —. __' ___ ' _ ' ':: /i� �r ' 1-' LENDER'SADDRE55__,.,. _.,_ __.. _,__ 'n � � I CEflTIFY TMAT I HAVE READ THISAPPLICATIONAND STATE THAT TNE ABOVF INFORMATION IS CqRFECL TO 1 AL F�ES ��:7�f�y 'm'" �Y �� V .':� IAGflEETOCOMPLYWITMALLCIlYANDCqUNTYORUINANCESANDSTATEIAWSRELATINGTORUIL�ING ��'� � � �� ,- � CONSTPUCTION,pNOHEflEBYAl1iiK7HIZEHEPflEScNTAT7YESOFTHISCOUMYTOEN`ERUPONTHE � /�`' �t� �+ �� � •�I' .�Z AtlOVEMENTIONEDPROPERTYFOqINSPECTIONVURPOSES- �'�� �-„(lf�.�i���� !r/ �� � �N ; � COMMEN � '-� v v J _ ��� y, �� '- _ - - ' m PERMI AME(PFIMj / Q / \ - � _— � � TUfl FPER �E AT ��_ . �L _ _ ` . �.S RECPT.NO._ _PAID BY _ ALIDATION, � F� WHITE-Depertment Copy,YELLOW-Finence Copy,PINK-Assessor Copy,GOLDEN OD-File Copy,GRE -Applicant s Capy /1... , � C���.t,e�.s c�. ��.2�' �tZ.twL ��.sz-� �'2'� 'FJ'� �.�; ....w „�,.�.ry, t W �. 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