HomeMy WebLinkAbout16260 (22) �
I
� �.,,� CITY OF DIAMOND BAR i"�
. -- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES ��y
: � . 21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117 PRESS
�'A�' BUQ,DING PERMIT APPLICATION FIRMLY
Q� JOBSITE i� �� ��,+ "'� •�� APPLICATION � ,". � PERMIT „I,+ '� P1C
ADDRESS � � DATE � �G' NUMBER.,;���Y�%'�" #
� ISSUE �, �/A . TYpE OCC
APN LOT TRA T ,: ,r
°C OWNER F� DATE CONST. GROUP
O
o ADD SS f3 `� 1 ' ZONING SETBACKS
W CITY . ZIP_ TEL. FRONT RW ;�
� APPLI ANT v TEL, REAR ❑_
� SIDE/SIQE STREEf RW__ fl _
CONTR OR E� �r G4r�' SIDE _ ❑
� CIIY E ZIP � TEL. PROPOSED USE e�Li 4%'w�. ,�/,d � ��j eJ�y
Oa.,.:._.:,_.....�w«..�.,u4 —
w ARCH/ENG/
� DESIGNEH ��
uZi NO.DWEL. NO. O.
a ADDRESS
� CITY ZIP TEL. - UNITS _ STORIES _ BEDROOMS
rn —
�n DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION
p� UWNER-BUILDER DECLARATION SFR/ADD/REM
O
p I HERE9Y AFF119A UNDEH PENi1LTY OF PERIURV THAT I AM EXEMP7 FROM iHE CONTRAC70RS Lb (�`Hf8gelCafport
W CENSEIAWFORTHEFOLLOWINOREASON(SEC.7o31.5911SINESSANDDROFESSIONSCODf'ANYCITYOR (n
�.� COUNTYWHICHREWIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANVSTRUP
Z TI1RE.PPIOfl TO ITS ISSUM7CE,K50 REWIHE5 THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNEO W Patio/Deck
LL� STATEMENT THAi HE OR SHE IS LICENSEO PUR3UANT TO THE PROVISIONS OF THE CONTRACTORS LI- W
�� CQJSEIAW(CHAPTERB(COMMENCINOHITHSECTION7000)OFDIVISION30FTHEBUSINESSANDPRO� V' POOUSpB
FESSpNSCOOE�Ofl7HATMEORSHEISEXEMPTTHEREFFOMANDTHEBA515FORTHEAILEGEOF%EMP� (J
V TION.ANVVIOLATIQVOFSECTION70.A1.SBVANYA7PLICANTFORAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Roof � �7
� A CML PENALT'OF NOi MORE THAN FIVE HUNDRED DOIIARS(ESCO)J: —.-
� ❑I,ASOWNEROF7HEPROPERTl,OFMYEMPLOYEESWITHWAGESASTl1EIq50LECOMP[NSATION, � CO(I1ff18IC18I -
WILL DO THE WORK,AN�7HE S7RI1CTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7oa,8US6 J
� NE55 AND PqOFES510N5 CODE:7HE CONTMCTORS LICENSE LAW�OES NOTAPPLV TO AN OWNER OF �
PROPERTY WFiO BUND90R IMPROVES TNEREQ4,AND YMO OOES SUCH WORK HIMSELF OP HEF5ELF OR
Q hIROUGHHISORHEFOWNEMPLOYEES.PNOVIDEDiHA75UCNIMPHOVEMENTSARENOTINTENDE00(i m
Q ,OFFEREDFORSALEISHOWEVER'�NEBUIL�MOORIMPfiOVEMENTI6SOLDWITHINONEVEAROFCOMPIE ,
'710N,iHE OYYNER-BUILDER WILL HAVE TNE BURDEN OF PqOYING TM�T HE OR SME DID NOT eUILD OR
� IMPROVE FOR THE PURPOSE OF SALE). �1
❑I.AS OWNEHOF THE PROPEHfY,AA1 EXq.USIVELY COMRACTING WITH LICENSED CONTRACTURS `
� TO CONSTRUCT THE PRQIECT(9EC.7oN,B1191NE33 AND PROFESSIONS COUE:THE fANTMGTOR5 LI� V8II1�Qf1 ADJ.AREA___
W GENSELAWDOESNOTAPPLYTOMIOWNEROFAPROPERTYWHOBUILDSORIMPHOVESh1ER[ON,ANO --- - -'------
� WNOCONTRACTSFORSUCHPR0.IECTSWIiHACONTR4CTOR(S)LICENSEDPURSUANTTOiHECONTqAC (g��q TITY DESCRIPTION FEE�
Y TOflS LICENSE IAW.J.
O ❑IAM EXEMPT UNDER SEC. __�, B.8 P.C.FOR THIS REASON Q
3 �
� — --- ¢
DATE OWNEA U
Q W
�a� LICEiVSED CONTRAC70RS DEGLAFA'I'ION W
��L IHEREBYAFFIRMUNDERPENALTYOFPEflJURYTHATIAMLICE43EDUNDERPROVISIONSOFCHAPTER �
� 9(COMMENCINOWIlH5EC71IXV70W)OFDIVISION30FTHEBUSINESSANDPROFESSIONSCO�E,AND z ,
MY UCENSE IS IN FULL FORCE AND EFFECT, s'-
0 UCENSE CLASS �y��� LIC.NO. ��� `S � �
�V UATE__�� (/ � COIVTRACTOfl_ � a �
W
� WORKERS'COMPENSA710N DECL4RATION Q
� 1 HEREBV AFFIpM UNDER PENALTY OF PERJURY ONE OF iHE FOLLOWiNG�ECLARATIONS: Z
. � __IHAVEANDWiLl1AAINTAINACERTIFlCATEOFCONSENTTOSELFANSUREFORWOqKERS' _
COMPENSATION.AS PflOVIDED BY 3ECTIIXJ 37000F THE LABOR CODE,FOR TME PEflFORMAhCE �U
Q OF 1HE WONK fOR WHICN THIS PERMIT IS ISSUED. �
W _I HIIVEMID WILL MAINTAIN WORKERS'COMPENSA7;DN INSURANCE,AS RE�UIqEO BY SECTION
Q 37000FTHELABORCODE,FOR7HE?ERFORMANCEOFTHEWORKf-0RWHICHTHISPEflMITIS �
�' � ISSUED.MY WORKERS'COMPENSRTION INSUflPNCE CANRIER AND POLICY NUMBER AflE: CONSTRUCTION _���_�
� c�aaiEn_____ ____, PLAN REVIEW ...._________ �.
---.....__.... ----- :
� POL�YNUMBER �
�Z ------ -------- ELECTRIC --------.._. ..---
a
� (IIiSSECI%7NN�NOTBEOJh1FLFTIDOFhEPERAttISFORONEFiIN�OREOWLLFAS(S1oo)OFiLESS} PLUMBING __. ___ _____
Z ICEfl11FYTHATINTHEPERFORMANCEOFTiEWORKFORWHICHTHISPERMiTISISSUED,I MECHANICAL ...,__.,.,___.___ ____ •
'.:
C`F SMW_NDTF.MPLOYANYPEH50NINPNYMANNERSOASTOBCGOMESUBJfGTTOTHF
�'� (n WORKENS'COMPENSATIONLAWSOFCALIFORNIA. OREETHATIF�SHOULDBECAME INSPECTIONFEE
_�_...
'; ' - SUBJECT TO THE WOFKEflS'COMPENSATION PftOV I Of SECT Of THE IABOR /�` � /�
i' j frOD[, SHALLF HWITMCOMPLYWITHT405 OVI ON3. �SSUANCE ,;,,,_,__��1� _ _y, ' ��
( —_ _ y' _
; p DATE:�� APPLiCANT: � +q`-{/-�,--�/r( `:. �'f�____._ '
�� � SMIP -----'--- ...... ....— �
#� J WARNINGFAIWRETOSECUREWORKEFS'COMPENSATIONCAYERAOEISUNUWFUL,ANOSHALLBE ENERGYP/C � .f ^�' C.I�O� __ __,_
LL SU&IECTANEMPLOYERTOCRIMINAIPLNALTIE5IWOCIVILFINESUPTOONEHUNUR'cDTHOUSANU ENERGYPERMIT
': DOLLARS(f100,0a0),IN ADDITION TO THE COSTOf COMPENSATION,DAMAGES AS PROVI�FD FOR IN ��-��--
':' � SECTION37080FTHELABORCODE,�NTEREST,ANOATTORNEY'SFEES. RETENTIONFEE: �� �
�. W ���-._...-.....n„�; .._.-.._._
O CONSTRUCTION LENDING AGENCY —--'"
� PRE-ALT FEE: ........_.--_,_--- �
�,� -- ------- ----------------
�� � 1 H[REBY AFFIRM UNDEfl PENALTV OF PERJURY TNAT TFIENE IS ACONSTRUCTION 1EN01N0 AGENCY
Q- FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITISISSUED(SEC.30B7,qV.C.j. --�--"------"---'�'-"��--�`""-----""""- "— �
Z
rw — "'."---_ . .
� LENDEH'SNAME__'"__"-"'_"_' _"_'__...__"_—_'.....'""'—' ' .
I. � �ENDEH'SAD�RESS _ __ -��-_�—_�---
W ICERTIFYTHATIHAVEHEADTHISAPPLICATIONAN�STATETHATTHEABOVEINFORMATIONISCARFECT. TOTAL FEES ��_ �� ��
p IAGIiEETOCOMPLYWITHALLCRYANDCOUNTYOR�INANCESANDSTATEIAWSRELATINGTOBUILDING
�. CANSTRUCTION,AI30HEflEBYAUTHORIZEFEPRESEtiTATIVE50FTHI5COUNTVTOENTERUPONTHE ,
Z A00VE-MENTIONEDPROPERTYFORINSPECTIONPUFiPOSLS.
COMMENTS_
_ -- ��`% �L�i'' i..�t -------------------------- ----
Q PERAIIT'fEENA1AE(PRINT) ��/y .� .1) __'
c.. iy
� � � � ,,,
� SIGNATURE OF PERAiITTEE DATE
= RECPT.NO.� � PAID BY ' VALI�ATION_._�- �
~ WHITE—{]epaAment Copy,YELLOW—Finance Copy.PINK—Assessor Copy,GDLDENRO�File Copy,GREEN—ApplicanPs Copy
s , _...... ._...r.. .._, ._._. :.... Y y 1 .�.
s I 1 I �
�� k ... � r { � � �^ i _ ._ � I i r � i€���� .
�-,*�'� i t� i , � I � t I '� �
� � b. � , � _ > � i ��. . .
� � ''x� � i � i ._ i � �� � � ' ` -
b Y '": �," ' i j � ': ' I i�. r ; t I �" �i � ° .
, ,
i
i
i x* a k � � i � . i � - i � � � �{ i a
t p �; f� : I � I . I �. ,- i,�,i I
� � � � �
� ,.. ��d ,,. ( f i, I I�.. 1 i-� f ' : .
E et 6 y` . : I � i � , { _
� 3 { _ � ' : i i 4 ' 2 3f
a_.
E � 1...._ E I ... � � ��i
1 Si�i § <. . ,... ' i f ' t __ �� .i - ...l._. _ '_�i ._i , {,�i�
4 . �
�
f ,..<.. .. .:d... � � ' � ; � , I ��'fi
� � ' � d � � � i ' j � ; ( I ' ,;, ,e
, ; �
; - � �
� , � � I__ _ _ _ ! ��;�`.
, � : r
� } � � , ': � ( �- � ' i � i, ' i i - tya� -
i i
� � i . � . 1 I �� ! i - i � 5 -
, � I . � j I , �z fi�
, � J'� � I , � '
' �. I I � � i x� £ .
( , 'I 1 i � i I I I i � � � ' � K� ,�i i
' , i I � � �
� i I ' ( ' ' i i i i � � I � � � ' � � � S .
� ; �
t
,
i j � � a � � � ` i i I � � �
� i � � 1 � � �� � �N
� €: � �. ' {.. I .� ' �, 1 ��� .
: %
i � I . .. �i �F - r�� I -I � .
ii I ' � . � 1 I t 1 ��.. '�I I C � � ,..�.
, ��.. �. .1 I . I_ I G � _ _ . _. ���� �r..,
� � i i k I ;� � I:y i p�zk�, � �.
d ' o � i . ' , ��, � i �� �
� � � "` ; � � �� � �
� � - � � i � � � ��r �-
� 3 � � i � E;
i. , i � L ' ' . I I i ry���'.,��
�
' � � { s � ����
; ° �� � � � ' _ _. , �
� •
, s �
, , ,
� -j ��
, :
, , • ,
. , , ; �
, , , ,-
,
, � ,
' ; � ; I , _ � j �;
� , E ' ; � , ; , i ��+
�` ' . I ; � ; — — — — �
' . . , �;
, . ; � �'.�� � i � �
;
, � � x
� �
, ' , , i i i � i � � ��:.
i � ' � � �� `
� i � j � � ' ��� � � � � i �� � _ ,
� I � ' ' ' '
e ; �
, ,
;
� ,