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HomeMy WebLinkAbout12-2005 ��`_ _ CITY OF DIAMOND BAR � I� � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21810 Copley Drive,Diamond Bar,CA 91765 (909)839-7020 Fax(909)861-3117 Building Inspection Hotline(909)839-7027 PRESS �"'"'. BUILDING PERMIT APPLICATION FIRMLY � JOBSITE / >- %1 ,��,2Q � �N �� APPLICATION �l 2�, �� PERMIT�_Z� p/C ¢ ADDRESS d��o23 �-�1 � //F�II o -, S DATE NUMBE # r' APN LOT TRACT ISSUE / 2� � TYpE p�C DATE �� CONST. GROUP p OWNER o ADDRESS ` p ZONING SEBACKS Z CITY ZIP�� TEL. � FRONT q�/y p � APPLI ANT TEL. /OI � q!,>v REAR p � - � ��` U SIDE/SIDE STREET RW p z ¢ CONTRACTOR i SIDE p � ADDRE � CITY ZIP G O TEL � PROPOSED USE o ARCWENG/ z DESIGNER w NO.DWEL. NO. NO. a ADDRESS cn UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCAIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFRlADD/REM O 1 HEREBY AFFIRAI UNDER PENALTY OF PERIURY THAT I AM EXEMPT FROM THE CANTMCTORS LI- Gef89B/CBIpOA W CENSEUWFORTHEFOLLOWINOREASON(SEC.7o31.58U51NESSAN�7ROFE5SION5CODEANYCITYOR (n C-� COUNTYNMICHREOUIqESAPERMITTOCONSTRUCT,ALTEH,IMPROVE.�EMOl15H2ORREP/UflM1YSTRUG W lURE,PRIOH TO RS ISSUANCE,ALSO REOUIRES THE AGPLICANT FOR SUCH PERMIT TO FILE A SIGNED W Palio/Deck � STATEMENT THAT HE OR SHE IS 110EN5E0 PURSUANT TO T1E PROYISIOHS OF THE CONiMCTORS lF � CENSE UW(CHAPTER Y�COMMENCINO WI7H SECTION 7000)OF DIVISION 3 OF THE BUSINE55 AND PR0. LL PooVSpa � FESSqNSCOOE�ORTHATHEORSHEISFXEMPTTHEREFROMANDTHEBASISFOHTHEALLEGEDE%EMP• C7 � � i V TION.ANY YpUTION OF SECTION 7031.5 BY ANY APVL�CANT FOR A PERMIT SUBIECTS THE APPLICANT T0 R6-R001 � A CML PENALTY OF NOT MORE THAN FIVE MUNORED DOLLARS(SSOo�J; Z 4 � �J I 0 ❑I,ASOWNEROFTHEPROPERTY,ORMYEMPLOYEESWIhU4AGESASTHEIqSOLECOMPENSATION, 0 CORIff18fC101 � Z NALL 00 THE WORK M10 THE STRUCTURE IS NOT INTENDED OR OFFERED FOR S�LE�SEC.7aa/,BU51- J � NE55 AND PROFESSIONS COOE:THE CONTMC70RS LICENSE UW DOES NOT APPLV 70 AN OWNER OF � — 7ROPEHiYW1iO8UILOSORIMPROVE5T11EREON,M1UNTiODOE55UCHNqRKHIMSELFOHHERSELFOR Q THROUGH HIS OR HERONM EMPLOYEES,PROVIOED THAT SUqf IMGROVEMEHTSARE NOT INTENDED OR m � OFFEREDFORSALEIF,HOWEVERTMEBUILDINGORIMPROVEMENTISSOLON7iHINONEYEAHOFCAMPLE- Z TION,THE OWNER-BUILDER VALL HAVE THE 9UHDEN Of VROVING THA7 HE OR SHE DID NOT BUILD OR � IMPROVE FOR THE PURP0.5E OF SALEJ. w ❑I,ti50NR1EROF7HEPROPER7Y,AMEXCLUSNELYCAN7MCTW(iW(RIUCENSEUCONTHACTOflS [[ 70 CANSTRUCT THE PRO.IECT(SEC.7W1,BUSINESS AND PROFESSIONS CODE:THE COMMC70RS LI- V01Uet10� C ADJ.AREA W CENSEUWDOESNOTAPVLYTOANOWNEROFAPROPERiYWHOBUILD50HIMVROVE57HEREON,AND � VhiOCANTRACT5FOR5UCHPRQIECTSWfTHACONTRACTOR(S)UCFNSEDPURSUAM70THECONTRAG pUANTITY DESCRIPTION FEE . Y TORS 110EN5E UW.�. � ❑I AM EXEMPT UNDER SEC. B.i P.C.FOR THIS REASON Q � U � DA7E OH?JER ¢ Z U �Q LICENSED CONTFiACTORS DECLARATION w LL I HEREBY AFFIRM UNDER PENALTY OF VERIURY THAT IAM LICENSED UNDER PFOVISIONS OF CFIAPTER � � Y(COMMENCWO WI7H SECfION 7000)OF DIVISION 70F THE BUSINESS ANO PROFESSIONS CODE,AND Z XL' 4Y LILENSE IS IN FULL FORGE AND EFFECT. m LLI � UCENSECIAS �� LIC.NO. - � V DATE CONTRACTOR d W � WOFiKERS'COMPENSATION DECLARATION Q � � I HEREBV AFFIqM UNDER PENALiV OF PERIURY ONE OF THE FOLLOWING OEClARA710N5: Z 0 _I HAVE AND WILL MAINTAIN A CER7IFICATE OF CONSENT TO SEIF-INSURE FOR WOW(ERS' _ � CAMPENSATIIXJ,AS PROVIDED BY SECTION 37000F THE LABOR CODE FOR 7HE PERFORMANCE `U� Q OF THE WORK FOR NM1iICH 7HIS VERMIT IS ISSUED. � � - � Qw �1 HAVEAND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE.AS REOUIRED BY SECTION /� 770o OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMR IS l 112 7 ISSUFD.MYWO NERS'COMPENSATfpNINSURANCECARRIERANDPOLiCYNUMBERARE: CONSTRUCTION � j CARRIER �T�JT(� l"(.MJ/J -7 PLAN REVIEW ZPOLICY NUMBER_T7��12��[� ELECTRIC Q � (iNLSSECf10NNEIDNOT0E00M1f�E7mOFhEPFAhTf15FpqONEF6A�pR�pply/3��510olOqLESS} PLUMBING W Z � I CEFTIFY THAT IN h1E PERFOHMANCE OF THE WORK FOq WHlOf iH15 PERMIT LS ISSUED,I �MECHANICAL U' SHALL NOT EMPLOY ANY 7ERSON IN NIY MPNNER 50 AS TO BECAME SUBJECT 70 7HE � WORKERS'COMVENSATqN UWS OF CAIIFOR AND AGREE THAT IF I SHOVID BECAME INSPECTION FEE = SUBJECT TO THE K'ORKERS'COM7ENSATION VISIONS OF SE �N 9700 OF THE LABOR _ COOE, HALL RTHVATH COAIPLY WI7N 5 VROVISIONS. �SSUANCE � ' p DATE: APPLICANT: I �SMIP �y � W J WARNINQFA0..URETOSECUREWORI(ERS'COMPENSATIONCOVERAGEISUNLAWFU4ANDSHALLBE ENERGYP/C � SUBJECT AN EMPIOYER TO CRIMINf1 PENALTIES ANO CNIL FINES UP TO ONE HUNDRED iHOUSAND ENERGY PERMIT DOLLMS(S10o.0001,W PDDITION 70 THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN J SECTION�7oe OF 7HE UBOR CODE,INTEREST,ANOATTORNEYS FEES. � ¢ RETENTION FEE: OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: � IHEREHYAFFlRMUNDERPENALTYOFPERIURYTHA7THEREISACANSTRUCTIONLENDWGAGENCY � FOR THE PERFORMANCE OF THE WORK FOR N?i1CH THIS PERMIT IS ISSUED(SEC.3087,CIV.GJ. / Z W � LENDEfTS NAME F- LEN�ER'S��DRE55 w 1 CERTIFV THAT I HAVE READ 7HIS APPLICATIONAND STATE TUTTiEABOVE INFORMATION IS CARRECT. TOTAL FEES /�� � � 1 AGREE TO COMPLY WITH ALL CITY M1D COUN7Y ORD WANCES AND STATE UWS REUTING TO BUILDING V �V � CONS7RU ANDHEREBYAUTHORIZEREPRESENTATNESOFTHISCWHI7TOEMERU70NTHE Z ABOVE- ED PROPER7Y F SPECTION VURPOSES. COMMENTS 0 J SC� u i � m FERMITT N E(PRllfn � � - Q � � SIG PERMITTEE ATE = RECPT.NO. PAID BY V/LLIDATION ~ WHITE—DepaAment Copy,YELLOW—Fnance Capy,PINK—Assessor Co GOLDENqO�Ia Co GREEN— PY. PY. APPlicanCs Copy �i G 1! �6� °.�C'� �!i Ot��3�,d�ttid i i ��;.d'h g��r����:��"���s3 ���:�����' �-' '.��"�.,��;:���-_�. 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DRY1r?�ALL NAILIRG � � �DEDICP.l�lONS ------------ -----r------------------- _ �.-.----------- -------- -------------- - SENIER i i FINAL EPJG. - '------------- SEPTICTANK ---- ---�-----------j ---- ----- !LANDSCAPEiIRRIG. ------------ --1------- _ L_----- - --- - SEEP PITiLL. j �------- ON SITE IMPS. - ---------- GAS AIR T[ST �- ' FINAL ZOPJING r— FINAL CONST. j � j FIRF DEFT.FINAL FINAL HEATING , i j HEALTN DEPT.FINAL FINf1L ELECTRIC -r—� ;DFV.FEES PAID FINAL PLUM9ING �- I ENERGY FINAL PLANING I i --r------� --------------- rINhL ENGII�EERING i I '�' � --------------�-------�----- -----.i '� � '����`�� .-------- ------------- C�MMENTS - -- ------------- ------------ -- ------ SEPTICTANK 51ZE ------ —-------- SEEP PIT/U SIZE ---- - --------- ---- --- ----- : �� _ " -., ---- -------- ------- --------------- . _ �;,� - .�" � n � �-��� �-�-.. �� �_' - ------ --- ---------------- ------ -- --- - _ - -;��:;_ � �� � '"''�� - ----------- ----------- — ----------------------- � .�,�.. _ � �' - . ���� - _------------------- — -- ------- ---------— ,.,. � _ ,;�- : J:� - �:-� --------------------- — -------- -- -- _ .� �t.- a-