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HomeMy WebLinkAbout12918 (14) � " �'., CITY OF DIAMOND BAR ( T / ^--1�--� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �� `� 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS ��.'�'.:., BUILDIIVG PERMIT APPLICATION FIRMLY � JOBSITE APPLICATION PERMIT P/C `�} o ADDRESS � OATE � ����� UMBER. # '`'" $ ISSUE TYPE i OCC APN LOT TRACT DATE CONST. GROUP � OWNER p ADDRESS Q ��L"t1�T ZONING SETBACKS gCITY �r� ZIP TEL. REART RW p APPUCANT TEL.____ SIDE/SIQE STREET RW LJ � CONTRACTOR SIDE ❑ Q ADDRESS �4 � ROPOSED USE__��/�� iA� o cm t,)�sTu,..�d�r.� zi P � ��� -T- f� u► ARCH/ENG/ � � z DESIGNER � NO.DWEL. NO. NO. a ADDRESS � CITY ZIP TEL. UNITS STORIES_ BEDROOMS � u> DESCRIPTION SQ.FL FACTOR PSF ADJ.AREANALUATION ` � OWNER-BUIIDER DECLARATION SFR/ADD/REM O - I NEFEBY AFFlflM UN�ER PENALTY OF PERJURY THAi I AM EXEMPT FFiINd THE CONTRACTORS LI- Ger8g8/C81pOR - �- W� CENSEUIWFORFHEfOLLOWINOREASON(SEC.�a31.50USMESSMDPROFE5510NSCODE:ANYCI7YOR U: COI1plJYNR{�REOUIflESAFEflMIT7000N5TRUCT,ALTEF,IMPAOyE.DEMOLISH.ORPEPAIRpNYSiRUC- d110/DBCK �,� - � TURE,PRIOR TO I7S I6Sl1ANCE.ALSO REQI1IqES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNEO � STATEMENT THAT HE Ofl SNE IS LICENSEO PUHSUANT TO THE PROYISIIXJS OF THE CANTflACTOftS LI- - CENSEUW(CIIAPTEflB(COMMENCINOWITH6EC710N7000�OFDIYISION30FTHEBUSINE55ANDPR0. - � PooUSpa - - FESSIONSCODE)ORTHATHEORSHEISEXEMPTTHEAEFROMPNOTHE9ASISFORTHEALLEGEDEXEMP- -(� TION.ANVVKKATIONOFSECTION70.'f1.59YANYAPPLICANTFORAPERMITSU&)ECTSTHEAPPLICANTTO - . Z Re-Roof - ACIVILPENALTYOFNDTMORETHANFNEHUNDREODOiLAR5(5500)J: �- ❑I,ASOWNEROFTHEPROPERiI;ONMYEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, : - O` � Gommercial - �__ .WILL DO THE WOHi(,AND YHE STRl1CTURE IS NOT IMEN�EO OR OFFEREO iOR SAIE(SEC.706A,BUSI- - ..J - �_ NE53 M1D P�FESSIONS CWE:THE CONTRACTOflS LICENSE UW DOES NOTAPPLY TO AN OWNER OF - :� P{pPEH7YWV100U0.D50RIMPROVESTHEREON,ANOWHODOFSSUCNWOiiKHIMSELFORHERSELFOR - �. TFiflOUGHHI30flHEflOHMEMPLOVEES,PFiOVIDE�THATSUCHIMPROVEMENTSAHENOTINTENDE00R . m - - W--OFFEREOWRSALEIF,F�WEVER,iHEBUiLDMGORIMPROVEMEM13SOlDWITHINONEI'EAROFCOMPLE - n- 'TION,THE OWNER-BUILDER WILL.HAYE THE BUFi�EN OF PPOVING THAT I1E OR SHE DIO NOT BUILO OR - '_,Aa ��� IAIPPOVEfORTHEPURPOSEOFSALE). l��f Ws ❑I,ASOWNEROFTHEPROPERfY,AMEXCLU5IYELYCONTRACTINGWITHUCENSEDCONTRACTORS -- � - - �; TO CONSTRUCT THE PROJECT(SEC.]Olb,BUSINESSAND pROFE5S10N5 CODE THE CWTqACTORS U- 2I118tiOft ADJ.AREA - : W` -CENSELAWDOESNOTAPPLYTOANONMEflOFAPROPERTYWHOBUiID50RIMPROVESTHEftEON,AND � � fI F- �W}iOCOMRACTSFORSUCHPRQIECTSWITNACONTRACTOR(S)LICENSEDPURSUAN7TOTHEWNTRAC- = QUANTITY DESCRIPTION FEE I: :-TOflS IJGENSE LAW.). . � Y Q�- ❑I AM EYEMPT UNDER SEC. 6.6 P.0.FOq THIS REASOu ' Q - - ��- . . .�' . U - . . . �'. � _'DATE OWNER F Z� W '�- �`- - LICENSED CONTRACTORS DECLARATION W - �-�- �'- IHEriEBYAr-FIflMUN�ERPENALTYOFPEflJUKYiNAT1AMLICENSEDUNDEflPROVI510N50FCIiAPTEfl � ;�- �-:: 9(CC)iAIAS\CiNGW1THSeCTiO�J70ao�OGDIVISION30FTHEBUSINESSAN�PROFESSIWSCADE,AND Z �_ MY UCENSE IS IN FULL FOHCE AND FFFECL m - �; LICENSECLAS3__�__UC.NO. -�� -j ~`= DATE- �' CONTRAC7 R �:. t-) �_- WOR E S'COMPENSRTION LARATION i = U - � 1 HEREBYAFFIflM UN�ER PENALTY OF PEflJURY ONE OFTNE FOLLOW�N6 DEGLARAt 5:��r - C!7_: ¢ O:-- IHAVERNDWiLIAUIYTAINACEHTIFiCA7EOFCONSENTTOSE�FiM5UREfOPWORKERS' Z �'-. COMPENSFTION,ASPROVIDEDBYSECTIOha7aoOfYNEI&90RCODE,FORTHEPEHFORMANCE w ' OF hiE WOFlK FOR WNI(,yl THIS PERMIT IS ISSUED. � 0= � -w` IHAVEANDN7LLMAINTAINWORKERS'COMPENSATIONMSURANCE:ASflEQUTAEDBYSECTION Qy - Q 37o00FiNEl.A80RCODE.FOF7HEPERFORMANCEOiTHEWORKFbRWHICHTHiSPERMITIS - // o�- ISSUE�.MY WORKEqS'COMPENSATION INSURANCE CARRIER AND POLICY Nl1M8ER AflE: CONSTRUCTION _ � ��i �`� � J. }' cnaaieq - - PIAN REVIEW - y� t - �� PatICY NUMBER ELECTRIC ��'Z✓� � Z Q �--: (lH55ECfro1JtJE�NoiBE0�.5tEimOFiFIEPEW�f1iISf�.ZatiEHUN[xiEDDa1nR5(37oo)aiLEss) PLUMBMG W... Z' ICERTIFYTHATINTHEPERFORMANCEOFiHEWORKFORWHICHTHISPERMITI51S5UED,l MECHANICAL (J SHALLNOTEMPLOVANVPEFSONINANY ANNERSOAST00ECAMESUBJECTTOTHE �- .�:: WORKERS'COMPENSATIONLAWSOFC IfOflNIA,ANDAGREETHA71FIS11WL00[COi.1E �NSPECTIONFEE . � ?:_ Sil&IECTTOTHEWORKERS'CObiPENS IO4RFOVISIONSOFSECilON37 FTHELABOR , E.ISHALLFORTHWI'MCOMPLVWI rTNO�'PROVISIONS. '�• ISSUANCE J � �W' DATE��� APPLIC T: �—� - SMIP q �h[1 j WAflNING:FAILURET05 CUREWORKER3'C M NSATIONCOVEfiA ISUNLAW , DSHALLBE ENERGYP/C � �PeAI '{ � I�A� � �, SU&IECTANEMPLOYERTOCRININALPENAL ANOCIVIIFINESUP700NEHUNDqEDTY.Ol1SAND ENERGYPERMIT - DOLLAFS(St00,oW),INAD�ITIONTOTHECOS OFCOMPENSATION,DAMAGESASPROVIDEDFORIN pg'[� J- SECTION 37080F THE LABOR CODE.INTEREST.ANDATTOflNEYS FEES. RETENTION FEE:���:�I���i Al`�'��.��/ - O.� CONSTRUCTION LENDING AGENCY pRE-ALT FEE: �j����'���a5�a�."��-S���- Q IMEREBYAFFIHMUNDERPENALTYOFPER,!URYTHATTHERE�SACONSTqUCTIONLEN�INCAGCNCY - - n- FORTHEPERWRMAkCEOFTHEWORKWftWHICH7HI5PEFMITI5155UE��5EC.3097,CIV.CJ. Z W - -�- LENDEFi'SNAME . __- _ - - � F- LENDEflSADDRESS � ICERTIFYTHATIHAVERFADTHISAPPLICATIONANDSTATETHATTHEAHOVEINFORMATIONI5CORPECT. TOTAL FEES , � IAGREETOCAMPLYWITHALLCITYANDC011NT'ORDINANCESANOSTATEUWSRELATNGTOBUILDING - � CONSTRUCTION,ANDHEREBVAUTHORIZEREPRESFNTATIVESOFTHISCOUNTVTOENTERUPONTHE (,� �/��1/ Z ABOVE•MENTIONED PROPERTY FOFi INSPECTION PURPOSES. COMMENTS�IY ��I� `� �/' 0 J- � ¢ ERMITTEE NAME(PRIM) . � � 1 - REOFPEfl E DATE (-�` RECPT.N0. PAID BY AUDATION_ ~ WHITE-0epartmen�Copy,YELLOW-Finance Copy,PINK-Assassor Copy,GOLDENRO�File Copy,GREEN-Applicant's Copy - } i=P"__ " T - �'---��-�`--"(" ,� - " �_ �` � ¢ � � ��� � i �3'� i E�' � � �' `�:-����� r � .m,�.,,e.. �,i � r�rr r � }t I _ � � � y ; . . � �f � -u"' '� �J��,"€�-�'�#,3 � � ( [ � ' �h 's, � :�!i � . 1 '.�'� I E ' _ .� . i � C" .t:Y . '--'�€& P�' Y tE cs %'' ; E I � i� S �� �-Y� � I i . ; t �#`�����i'��r .�,*'``-`^� �'��', : � 3 � � . � E � L 3 . �.E.� E � t I : "5 1 �a .. �'.' 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