HomeMy WebLinkAbout15592 �
u
�w CITY OF DIAMOND BAR �
--- -��- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES '�
� 21660 B.Copley Drive Suite 190 �
� � BU)ILDING PERMIT APPLICATION FIRMLY
� � JOBSITE\ ^�y�' e _ � '
¢ ADDRESS� �L.��I �l�{ APPLICATION •�� PERMIT j'�' �� P/C
p `- DATE S't' NUMBER �'°�'� #
� APN LOT TRACT �SSUE ,/1� %�.�� TYPE OCC
� , — DATE___ f� J �i� CONST. GROUP
p OWNER 1'_��K4� i{Y'��;'�l�G�i+
� ADDR SF� S ��'a� }'ad „��:� cS;::f,. ��� ZONING SEfF3ACKS
Z Cl'fY,`j��f ZIP ��� �TEL 4;`' :' .:(!�_�� FRONT _ RW- ❑-----
g APPI..ICANT f'i.�.t�dc���{!+:'�:r"-P��� TEL. `�� •�'n/-.11�' a S DE/SIDE STREET RW C7
� CONTRACTOR�I�3F 31�.�f j_ E_=a:i'rd.�.�;'�`�'.d- �i %C■= SIDE �]
� ADDRESS �i':` � .. 3 �
� CITY �"�1 Gn«#y.��;� ZIP ri` ELf`L' = �'�1 b 1 PROPOSED USE �� ��L��;t��
Q ARCWENG/ ---
�z,, DESIGNER _ NO.DWEL. NO. NO.
� ADDRESS - UNITS___ STORIES ____ BEDROOMS
� CITY ZIP TEL.
rn —
cn DESC�iiPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
p� OWNER-E3UILDER DECLARATION SFR/ADD/REM
O
p I MEHEBY AFFlPoN UNDER PENALTY OF PERRIRY TMAT I AM EXEMPT FFiOM THE CANTRACTORS LI- G3feJ0/C3�POrP
W CENSELAWFORTHEFOILOWINGREA50N(SEC.7031.50USINESSANUPFOFESSIONSCODE:ANYCITVOH (n
U COUNT'W�{�CHRE�UIRESAPERMITTOCON5TRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANVSTflUC-
W TURE,PRIOR TO ITS ISSUANCE,ALSO RE4��IRES TME APPUCANT FOfl SULN PEflM1T TO FILE A SIGNED w P2(10/DBCk
� 5TATEMENT TMAi HE OR SHE IS LICENSED PURSUAN i TO THE PHOVISIONS OF THE CONTHACTORS LI-
CEN5ELAW(CHAPTERD(O'JlAMENCINGWITHSfCTIONIWo)OFUIV!SION30FTHE-BUSINESSANDPHO- � POOUSPB
r FESSqNSODDE)ORTHATH'eOFlSHEISE%F.MPTTHEREFROMFNO7HEBASISFOR7HEALLEGEDEXEMP- �(!}
V TqN,MlYVIOLATIONOFSEC710N7031.SBYANYAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANTTD Z Re-Roof
ACML PENALTV OF NOT MOPE THAN FIVE 4iUNDRF.D WLIAHS(f+00).):
S ^ f.71,hSOWNEROFTHEPROPERI'Y,OAMYEMPLOVEESWITHWARESASTHEIHSCLcCOMPENSATION. C�R7(IlOfCiel �
� WILL W THE WORN,Ni�THE STRIJCTl1RE IS NOT INTENOE�OR OF(ERED FOH SALE(SEC.7044,BUSI� J
� NESS ANO PROFEESIONS COUE:THE CONTRACTORS LICFNSE UW DOES NOT APPLV TO A4 OWNER OF =
� PROPEHTYWIIOBUILDSORIMPRDVESTHEFEON,ANDWHODOES5UCHWORKHIMSELFORHERSEIFOR
CC TMROUGHHI90RF7EROWNEMPLOYEES,GROVIDEOTNATS�CHIMPHOYEAAENTSARENOTINTENOE�OF m —
OOFFEHFAFORSALEIF,HOWEVER7/iEBiJIL01NGORIr,IPROVEMENYIS50tDWI7HINONEYEAROFCOMPLE- _
Z TION,iHC UWNER-13UIlDER WILL HAVE 7HE BURDEN OF PftOVING THAT HE OR SHE DID NOT B41LD Cfl —
� IMPROYEFOfl?HEPURP(15EOFSALE).
W C]I.ASOWNEflOFTHEPROPERTV.AMEXCLUSIVELVCANTfiAC7iNCW17HLICENSEDCON7RACYORS
Q[ TO CANSTRUCT THE PRQIeCT(SEC.76a6,BUSINESS d.Np PqOFES510N5 WDF:THE CAIdTRACTORS ll- VdIUH11011 _ ADJ.AREA
W CENSEIAWDOESNOTAPPLYTOANOWNEROFAPROPERTYWI-bBUILD50RIlAPROYESTH�flCON,AND ---'-�'—--- '—'�------
�F WFIOCONTMCTSFORSUCHPRQIECTSN/ITIIACONYRACTOR(S)LICENSEOPURSUANTTOTHECONTRAC- QUANTITY i�ESCRIPTION FEE
Y TOHSLICENSEUW.).
0 ❑I M1 EXEMPT UNOER SEQ__ B.8 P.Q FOB i HIS REASON �
� U
...... �
u" DATE_'__'___'_"_OWNER.__...__.....__"'_—'—___.__._._.....'___ h .
. . .0 _ L�1 . .. .
�d LICENSED CONTRACTORS DECLARATIUN W
,LC� I HEHEBV AFFIRM UYDER PCNALTY UF PERIURY'iHAT IAMI LICENSEO UNUER PRDVISIONS O'.CIiAPTER �
,� e(COMMENqNCi YATM SECTION 7000j OF DIVI510N J OF 7N[�USlNESS M!U PROF[SSiONS C0�7E,luYD � _ _
M'!LICENSE IS Ih FULL f CE.LtiD EfFECT.
LLJ • 1 p �
o UCENSE CLASS___ ..'�=�,��� UC.NO.__'_ �_1_`�� �� . �
�U� DATE r'"T��`��.'•�'='' CONTRACTOR �+= / "---' d
— F--4.5.?:5.:..z`..._.._-
W
� 4VORKERS'COMPENSATION DEC.LARf1TION L' ,J��� ,�y � �
� � ��
�. ./�� Cs ¢ _� G_"� m,.1 �� C.�2.?I..i/ `�V.�T!: '
� IHEREBYAFfIRA1UIr�ERPENALTYOFPERJIJRYONEOFTHEFOLLOWIYGDECLARA'IONS: ' � Z �
�� I HAVE AND WiLL M9AINTp,IN A CER7:FICATE OF CONSENT TO SeLF�IN5UFE FOR WORKeRS' �
� CONPEh6ATroN,ASPRUYIDEDBYSeC1'IONS700CFTHELABORCODE,FURTHEPERFbRNR E `U __ _
Q yPfHF WORK fOR WMICH 7HI3 PERMIT IS ISSUED. � �
dw �/IMAVEAN'�WILLMAINfAINWURKER3'COMPENSATIOYINSURANCE,FSRE�UIREDBVSEGTION
. 37000F THE LAkIOq CO�E,FO;{7HE PFiiFORMMCE OF THE WORK fGR WHICH TI�IIS PE{iMIT IS
�n ISSUED.MY WOHKERS'C ENSATIOY INSURANCE CAflPoF_R ANO POLICY NUMB[R AIiF.: CONSTRUCTION
__'......—__.—...."'_"'"'—'— _'...______'
� CRHRIFA �r�. I__ _. ,- _ PLAN RE�VIEW ..................------._....
- ---I ---.......r_, .
Z POLICYNUMBF.R_ A C�.•��C.�"G:j .'S°` ]_"'"' ."—'_ —"'__'—___
/L�V�--'�._._._..—_—_� EL RIC
¢
�� (iFp55ECItONN'cWNOI"BEO�rREYE0.OFTNFPEE1Att.45FORIXJC4NX�DF7FDWlAAf1S(S� 1oq�E � UMBING ..___ _,_,.__
W MECHANICA�
z°' I CERTIFV iHAT IN THE PERFORMAGCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUFD,I ._,_.__.-- --._.....__
('a SHALLNOT[MPLOYANYPER90NINANYMAMNEFlSOASTOOECOMESUOJECI'iOTIiE
'(q WORY.ERS'CDMPENSATIONLAWSOFCALIFOFlNIA,AN�AGft`r.E7FiATIFISHOULDPECOM[ INSPECTIONFEE „__.,,_,,. (',��,3+.5 ���'�r:`try_ .______
- SUBJECTTOTHEWORKERS'COMFENSAilO �HOVISIONSO(�SECTION]]DaOfTHELA80R t � t
� ,' i
� COj�,I SHALL FORTHWITH COMPIY WITH T� E f+HOV1510NS. •'�• �SSUANCE .._.._ � '-" _ _ ��. e
O ,� `+.� ��� ..
p� DATE: �'� RPPLICANL �Id'c2 a_.__.�-._ %"'-'"_"�... SMIP _ . _..__-..__. __'__
-� WAHNINO:FAILURETOSECUNEWOPKERS'COM�ENSATIONCOVLRAGCISUNiAW�l1L,ANUSHALI.BE ENERGYP/C `.��.`� � _ ,_ t�'�`l�,�.________,.__ _
J .%""'�'`,v",".�.
� SU[7JELTANEMPLOVERTOCPIMINALPENALTIES�NDCIVILFINFSUPTOONEHUNDREDTHOU511Ii� ENERGYPERMIT,,� -���
ODLLARS(5100.000),INAOD1710NTOTHECOSTOFCAMPENSATION,DAMAGESASPflOVI�EDFOFIN , -- '
�J�' SECTION 37oB UF THE LA60F1 CADE,INTEREST,AND ATTORNEV'S FEES. RETENTION FEE:a"� s' ��"'" " ' ''� '""�"J�� �
�' ..,
•- ;. .. .. ..�. ;'_'__'
d CONSTRUCTIONLENDINGAGENCY PRF-ALTFEE: � i�J^-•---�=.-�.��,.,- .,�-..`,-. *r.. '���`.'-k. '"
p - -------..._ ---...---
�� IH"eREevAFFIRMl1NUEHPENALTYOFP[l1JURVTHA7THEREISACONSTFiUCTIONLENDINGAGENCY
FOR THE PERFONMANCE OF THL WORK�OF WHICH THIS PERMIT IS ISSUED(SEC.3097.CIV.C.). ---'��'�""-"""'-- ""'-' --
Z
[iJ. -__.__-___—.._._._-_-__.. _'_.'_—__-_
.�'. IEN�ER'S NAMF ._._._.__.._.._..."""..
F-. LEq�ER'SADDHE55.'_""_-__' -.-_._...'_""'_"_
�. I CERTIfY THAT I HAVE READTHIS APPLIGA110N AND STA7 E THPT iHE A�OVE INFOHMATqN IS COFiRLCT. TlATf1L FE ES r S
W 1 AGAEE?O COM?lV WITH AL CITY PND CAUNTV ORDINPNCES PND STATE LAWS RELATMG TO 9UII_DING
� CONSTRUCTION,AND HEREUV/U1H0111"L[RLPRESENTATIVES OF THIS COUNTV TO[NTF.R UPO THE
ZAOOVE�MENTKNIED PROPEflN FOF INSPECTION PURPOSES.
— � �'�'��i°� ]COMMENTS--��---------��-
�. i,— f.i tf r.�Rrr � 1-�---------- -------....----- -- -
� f �b=!�-� c 1�', r. .
--"----
r---..._--�-- -�------
are—'i�aHe�aRiNn � � --._...----... .--------------- —
4 � ,o'i.d}._�,.� J .-,;ti'i E�Lti ------
N ATU�E OF PEf1AlITTEE [>A7L � /
� RECPT.N0. PAID BY .._ ___._• i __VALIDATION
WHITE—Dopartment Copy,YELLOW—Finance Copy,PINK—Assessor Copy, OLDENROD—File Copy,GRE N—Applicant's Copy
r`
_ .. ..
. ; _. �. t
...
� . � ,, , :
� , a , i � ���,
�� � x� ' � .>�� � ; — � �
.F � � � i.. � .'
� .i _ 1 .� ; i • �,�,, � - T _
,,',k � k ', - _ '
� ,. �� , j . ! .� -
.
F
1 ', . Y i I � i � � _ , y
� A'
i
i
R . I , , � � i �
. .
, _
_M; Y _... ..�.- � � , � , , ';-- ——, -- . —
' r
. . .. ,
._ ..�, . _ _ � i , i , � �� i � � � i
,
G; , ; ; , , ' ' ,
, i , . , , . ' ; i_ � '
, � � i Y � � i � �
,
� • - � � � � ��.,, , ., i
t ; �
�,
� — — — "
, , ;
, � � r '
. `
,
� i . � . � •�. I . � - . tr
� �
I I
� I.....
�7 . �� � �. , - 'i � ; . � � t -
� I � ; I ' l � � � y
� !
- �� i I : I i, � � � � � �I � i
1 - I - i i - 1 ' ( t
� � 1 .,. . ,. I � ' i � �. i .
� � � � ,..�.._. � ` . .
i ,. � � � .;:1 * F :
7
i � ;
� � ,
� ' I f i I I � � 1 � , I � �r�� " �
,
�
. i ; , — �
' _ i _ i �_..... � Lrv
�� � - _, � I.� '� _
' ' . � i I � - ' .: � 'S 1 �l .
- ;. -i � . 1 � . �,,;. �-s ' m
, ( !' ' . ! i I I _ i �
f_ t � I }f t:i � v ;I ` . s
. i i , 'I t� � � - - � � � �
� �S ' P ..
� e n I �� : . � ; r
. � , , � � i ,�,�. . j ( . i i � � I � z.
k
_ � ..,', . I ,',. i �� ,��,.� I � 7 �� � �,� i � ���1
i � �
� �
� '. �� � . . .�, . ; �� , .
,
.
`
'. i . ' � !. 3 I � � ' " _ — I , i - 4 n� .
�
. � :' � � � � ( � �4SN
�
. �
4 '.
1 � � !�� ' , �� I L - ' - "�#�
� 3 .
F
I
f
,� I. , �� ' � ',, ( ,, I �
�. ', ' ( I I I � k
, i
� , ..
i , � � - i � - I . r
i�. i
.,, , 3 . ' . , . � � _ ' ' _' '
, . .'.. ..,. ; i � ; .' . ..M1 .._ ,. . , ,I.. ��,�.,I,�. .
I
i
� �. � , '� ; . . �
�� �. < ,. . � � a i - , i 4 �ry ..
,. ... k �� � �,�, � .� i j � ',, L d 4+';
. - � f � ' � �� '. .i f:
' ' ' , �.. ' _ ' ' :' i ! 'I, ' i � 6 A",�,
I... ''�. �. i � I� i �' � •� I '�, I ��:
� � I
... i ' ..� � � . � �i � 1 � f � §;''',
1- i �
�.
i . 1 ._.; �.. . ._ L� ._ ;__.� � i.�_. �._;.._ . ' � _.'
� ; f
• ___ ,. . ._, . __ . . ... ., i _ . .._ '