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HomeMy WebLinkAbout17120 (17) �� CITY OF DIAMOND BAR � � DEPARTMENT OF CO[vIIvtUN17Y&DEVELOPMENT SERVICES 21825 E.Copley Drive Y (909)860-3195 Fax(909)861-3117 PRESS ��%::� BUILDING PERMIT APPLICATION FIRMLY o ADDR'ES5�3(�I� fl�C C1�L.A/� DATE CATION � `� D� NUMB R �J ( 2 D N�� � ISSUE D TYPE OCC APN LOT TRACT DATE � CONST. GROUP p OWNER LtZ/Ql f�/� a p ADDRESS��I�S D�r�/��1 20NING SETBACKS z CITY � ZIP • TEL4e4�D S�)s' FRONT RW ❑ g APPLICANT �' �^' TEL. REAR ❑ � SIDE/SIDE STREET RW O � CONTRACTOR -O C�,o SIDE ❑ � ADDR SS PROPOSED USE o CITY �• - ZIP �'�' TEL o ARCH/E �S''S � DESIGNER NO.DWEL NO. NO. n_ ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFWADD/REM O p I HEREBY AFFIPAI UNDER PENILLiY OF DERIURY 7iiAT I AM ExEMPT FROM iNE LONTMCTORS LI• C82Qe/C81pOR W CENSEUWFORTHEFOLLGW�NOREASON(SEC.70]1.58USINESSAND7NOFESSIONSCAOE:ANVCITYOR (f� U pp�JNTYWHIpIPEWIRESAVERAl1TTOCONSTRUCT,ALTER�PA�E.DEMOUSN,ORNEPNIiANYSTRUC� W �81i0/DBCk w IURE.ORIDR TO RS ISSIIANCE.�L50 REWIRES TME APV�ICAM FOft SUCH PERMIT 70 i1LE A SIGNEO W � STAtEM[NT THAT NE OR SHE�5 LICENSED PURSUAN7 TO TNE PROVISIONS OF i11E CONTRACTORS LI� � CENSEUW(CHAPTER9(COMMCNCINOIMiMSELTqNT000�OFDIYISiON]OFTHEBUSMESSANDFRO� � PooUSpa fESS�DNS COOEI OR T1uT NE 00.SHE IS EXEUPTTHEFEFROM ANO TME BASIS FOH THE ALIEGED EXEMP• gTpN.l1NYV10UTqNOFS[CTION70.71.SBYANYApPLICANTFORAPFRMITSUBJECT57HEAPPLICANTTO Z Re-Roal � A CN47ENALTV OF NOT MORE THAN FIVE NUNDRED DOIU(i5�3500�)', 0 O�ASOWNEROFTHEPROPERTV,OR4YE11�LOVEESYATNWAGES�ISTHE1R50LEfaA1PENSATION, � CpmT0fCi21 Z YALL DO TME WOR1(AND TNE STRUCTURE IS HOT INTENOED OH OFFERED iOfl SALE�SEC.7W�,BU51� J NE55 AND VROFESSIONS CODE:THE CONiRACTORS LIGENS[LAW DOES NOT APPL�TO AN OwNER OF N PROPERTYVAIOBVILDSORIMPROVESiNEREd1ANDWNODOESSUp/WORKM45ELFORNERSEIFOH � � TNROl1GHM150RNEROYMEMi�0YEE5.PPONDEOTHATSVCHMPROVEMEMSARENOTNTENDEDOR m � OFFERED�OASALE.IF,HOWEVERTMEBUILD:NGORIAIFROV[MENTISSOIDWITNiNONEtEAfiOFLOA1VlE• Z T10N.THE OwN[R-BUILDEfl YALL H�VE THE BURDEN OF PROVIN�TH�T HE OR SHE D�D NOT BUIID OR = WPROVEFORiNEVURPO5EOF5ALE). �l AS ONMER OF THE DROPERTV,AM E%CU1SNElY CONTRACTING K'fTH UCENSED CONTMCTORS Q TO CONSTRUC'f THE PPQIECT(SE4 f0a�,BUSINE55 AN'J PROFESSIONS COOE:TNE CONTMCTORS Ll� V81U8t1Of1 ADJ.AREA W CENSE UW DDES NOTAPRY TO AN OYR�Efl OF A PROPERTY NT10 BUILDS OR MPROVES MEREON,AND � WFIOCONTMCTSiORSUCNDRQIECTS'MINACONTRACTOR(S)LILENSEDPU0.5UANi70TMECONiMG QUANTIN DESCRIPTION FEE Y TOaS UCENSE UW). � ❑IIUAE%EMPTUN�ERSEC. B.iV.C.FORTNISREASON U � ¢ � OATE OMM[R V W FQ LICENSED CONTiaACTORS DECLARATION W CC 1 NEREBY AFFIRM UNOER PENALTY OF OENURV TNAT I�u�ICENSEO UNDER OROV1510NS OF CHAPTER � d q(CpAMCNCINOWITMSELTION70W�OFD��510N�OfTHE0U51NE55ANDPROFES510NSCODE,MID Z ►/Y UCENSE IS N Fl1LL FOHCEAND EFFECT. m � UCENSE CUSS� LIC.NO. � Z v � F- � J V DATE CONTMCTOR ' f V P. v � w 1 � aD � � WORKERS'COMPENSA710N DECLARATION � ��462 ¢ � %O �j C � ,� S � � U � INEREBY�FFIRMUNDERFENAL7YOFDE(iIURYqJEOFTNEFOLLO'i`�NGDELUMTqNS: Q �J��Z � G ��INAVEANDWILLG1AiNTA1NACER7iFICATEOFCON5EN7TO5ELF-INSUREFORWDRNERS' _ � CpAPENSATION,LS FROYIDED BY SELTON 77000F TME UOOft COOE,FOR THE PERFORMANCE U Q OF TME WORK FOR WHICH iMiS PERMIT IS�55UED. � O w �IHAVEANDWILLAM'NTAINWORKCRS'COMPENSATqNINSUFUNCE.ASRCWIRED8V5ECTqN Q ]7000FiHELABORCODE,FORTHEPERFORM�NCEOFIHEWORKFORYMICNTN15PERMiT15 ISSUED.MYWOFKERS'fAMPENSATqNINS�URA•NCEWRRIERANDPOIICYNUNOERARE: CONSTRUCTION j CARRIEN �n m � ^�` �'�� PLAN REVIEW Z PawYNuiaBER � �a?��IL EIECTRIC ¢ 0 (TM65EGTCNNEmNOTbECOM'LERUOFMPERt.f'6�Oi1CNEHU,Of�EDDOlUilSp+oo1�LE55? PLUM6ING W A7ECHANICAL Z I CEFlTIFYTMIIT PlT1+E PERFORM�NCE O�TTiE N'�RK FORwHidl THIS PEAMi7151S5UE0,1 - (,�} SHALLNOT EUPLOV ANv GERSON N ANY MANNEH SO AS i0 B[CCME Sl18JECT TO TXE N WORKEftS'COMPENSATIDNUWSOFCAUFORNIqANOAGREETHATIFISFqULOB[C04E INSPECTIONFEE S SU0.1ECiTOTNEWORKERS'COI.��ENSATqNVROV1510N50F5ECTION]1000FTHEU�BOR ISSUANCE COD�FOFlTNWITHCpAPLYWITHiN05 PRONSIONS. � SMIP p DATE: � AFPLICAM: �71..r � �1 J �� ENERGY P/C - WARNINC:fAILUAE TO SECUAE WORKERS'COAIVENSATION fAVERAGE IS UNU��1L�N7D SM�t1 BE � SUOJECTANEMPLOYERTOCW�INALPENALTIESPNDCNILFWESUPTOONEMJN'JRE�TMOUSANO ENERGYPERMI7 DOI.URS(S 10D.000).tl/DDI7�ON TO 7HE COST OF COMPENSATqN.OAMRGES AS FROVI�ED FOfl IN � SECT�DN970eOFTH[LACORCODE.WTEREST,M1DATfORNEY5iEE5- FlETENTIONFEE: / a CONSTRUCTION LENDING AGENCY PR[-ALT FEE: 0 � IHEREBVAFFIRMUN�ERPENA�TYOFPENUMTHATTNEREISACDNSiRUCT10NlENDINGAGCNCY fOP Tn[FENFORMANCE OF iHE WORN FOfl WNICH THIS PEflMIT IS�SSUED(SFC.7ao7,CN.C.�. Z W � LENDERS NiwE S H LENDERSN'DRESS � WICERTIFYTHATiHAVEREADTHISAVPLICATIONAI:DStA7ET1UTTHEABOVEN�ORMATION15CORPECT TOTAL FEES ��� � p� 1 AGHEE TO COMPI�WITH ALICfT'/AND GOUN7Y OFD�NANLES ANO STl�TE Uw5 REUTNC 70 BUILDiNC �ONSTRUC710N.AN'J NEREBV AUfNORRE PCPRESENTATIYES OF TMIS LOVNTY TO ENTER UPON TME Z ABOVE�MENTqNEDGROFERTYfOAI SPFCTIONPURPOSES. COMMENTS o �.�. .J . � Q GERMi7TEEN�y[( T� ^ / �� � �_1n^-� Y E N i URE ERMITTEE DATE � RECPT.�O. _PAID BY VALIDATION WHITE—DeDartment Ccpy.YELLOW—finance Copy.PINK—Assessor Copy,GOLDENRO�FiIa Copy,GREEN—Appl�eant's Copy , ..._..-'-•-.., ........._._. ....,..,......._ -... .. . - �r___ ,r--- .---,r< ....._- •— ' ----......- .._. ,. ._. _ .. .__ . tst { •i, �i' ��f.IniL/l��iy I.JI-SL'i !I�'�%.�L� s'it�I�' �E_vu:=L+ 1►��'a=c;.t[f];yl�_T__"-5y�� ..__ IA����c�=;�'�"�1.,.------�---1�,-f;i.��=.c ,�lc�►'..._--__.----�.y^��-_�----li��.'i:l�e-�c).i � R' . ... . ' . . ... ;._.. .'� � '..� . _ ... _'_ ..... ... 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