HomeMy WebLinkAbout10064 CITY OF DIAMOND BAR
COMMUNITY DEVELOpIo9ENT DEPARTMENT
�,.,� 2]660 E.Copley Drive Suite 190 PRESS
(909)860-3195 F:ix(909)861�3117
"'"°� BUILDING PERMITAPPLICATION FIRMLY
;g. 0 D RIESS.V I / ,v` �� L L�"�r DATEICATION � -�''q NU 0 R #/C
c� ' ISSUF TYPE OCC
APN LOT TRACT � DATE_ CONST. GROUP
o ApDRE -y- , LU� � D L)1: �Q� ZONING SETBACK5
z CITY ' / ZIP TEL.� FRONT RW Cl_
o APPLICANT _ 7 � REAR ❑__!
Z SIDE/SIDE STREET RW f7
� CONTRACTOR� .o nS'- �C7� SIDE _ L]_
� ADDR SS 5:5`S W • ��l P_n- . � `7 - �_-
� CITY�ff'N /'L tdG-7�.�- ZIP � 7EL.� - �� PROPOSED USE_ �.GL
w ARCWENG/ —
z DESIGNER - - ND.DWEL. NO. NO.
� ADDRESS UNITS STORIE5 BE�ROOMS
� CITY ZIP.---- 7FL.-----,— — —
� D�SCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
cn
� OWNER-BI:ILDER DECLARATION SFPJADD/FEM
I HEREBY AFFIHM UN�F.F PENALTY OF PERJUqY THAT I AM EXEMPT FHOM THE CONTiiAGTOR3 LI• ' G3fd90/C3fpOR
W CENSELAWFORTHEFOLLOWINGREASON(SEC.703158USMESSAN�PROfE5510Y5CODEANYCITYOR (f' .�_
U WUNTYWHICHqEWIRESAPEAMITTOCON3TRUG7,AL:Efi.IMPqOVE,OEMOLISH.OPflEPAIRANVSTqUC- W pailolDeck
L TUqE,VflIOR TO ITS ISSUANCE,ALSO HE(]UIflE5 THE APPLICANT FOR SLIGM VENMIT TO FIIE A 51GNEfJ
� STATEAIENT THAT HE OR SHE IS LICENSEO PURSUANT TO 7HE PNOV151(]NS OG THE COVTRPCTORS ll. 'w
� CENSE LAW�CHAVTER 9�COMMENCIN(i WITH SECTION 7000)O(�IVISION 3 OF TNE BUSINESS ANO PRD� u" p00�.(la
FESSIONSCODE�OflTHATHEORSHEISEI(EMPTTNEREFROMANOTHF.BASISFORTHEALIEOE�EXEMP- �
� TION.ANVVIOLATION�FSECTION7031.56VANYAPPLICANTFORAP[RMITSUBJECT5THFqppLICANTTO Z Re-Raaf
F A CIVIL PENALTV OF NOT MOHE THAN FIVE HUNOfiED OOLVIRS(5500].�:
Q ❑I,ASOWNEROFTHEPROPERTV,ORA/VEMPLOYEESWITNWAGESASTHEIRSOLC:GOMPENSATIOY, ❑ COmfYle[Cldl
z WILL DO THE WORK,AND THE STqUCTURE IS NOi INfENDED OR OFFERED FOR SPLE(SEC.7046,BUSI- ,J
•�' NE55 ANO PROFESSIONS fAOG:THE CONTFACTORS LICENSE LAW DOGS NOT APPLV TO AN OWNER OF �
PROPERTY Vh10 BUILDS Oq IMPROVES THFREOk,AN�WHO OOES SUCH N'ORK HIMSEIFOR HEFSELF OR
�' THROUGHHISORHEqOWNEMPIOYEE6,PROVIDEDTHATSUCHIMVROVEMENTSARENOTINTENDEDOH m
Q� OFFERED�Oq5P1E.IF,HOWEVER7HEBUR�INGORIMPROVEMENTIS50Li7WITHINONEVFJflOFC0AIVLE- __
� TION,THE OWNER�BUILDER WILL HAYE 7HE BUIi�EN OF PROVING 7HAT HE OR SHE DID NOT BUII.D OR
� IMPqOYEFOqTHEPURPOSEOFSALE�.
i.l l,AS OWNER OF THE PflOPERfY,AM EXCLUSNEL.Y CONiRACTING WITH LICENSF:D CONTRACTOHS
� � TO CONSTpUCT THE PROJECT(SEC.70a1,BUSIME55 AND PROFESSIONS CODE�.THE CONTRACTOpS LI- V8Il18IlOfi _,_.. _______.,_AOJ.AflEA_ :
W GENSELAWDDESNOTAPPLYTOANO'MIFROFAPflOPERTVWHOBUItDSORIMPROVESTHEflFON,AND
� WHOCONiRRCTSFORSlJCY1PROJECTSWITHACONTRACTOH(5)LICENS[DPURSIIANTT07HECONTRAC- QUANTITY DESCRIPTION J�;x, FEE
Y TOI15 LICENSF UW.).
� ❑I AM E%EMPT UNOER SEC._._ _B.4 V,C.FOR THIS REASON , Q � ' �
� '_.___—"_—_"_" '—' "_' '�'— :�. � ��D
� u" DATE___. �
_. OWNER___' '__"�__'__.... V �
W
� LICENSED CONTRACTORS DECLARATION � �� �
� IHEREBYpFFIflMUNDERPENALriOFPEfiJUfiY7NA71AMLICENSEDUNDER?ROVI31045C.FCHAPTEFl � ey �/h ` ✓J�
(i 9(WMMENCINGWITHSECTION]OOO�OFDIVISION30PTHEBUSINESSANDPROFES510@SCODE.AND Z �•/
�X AIYLIGENSEISINFULLFOHCEANDEFFEGT / `�'
(�"j] m
�. � IiCENS� SS "— LIC.NO._T 03(��/�___ ��. �
:�-�.=��------- �.��-- , _
r U �
DATF CONTflACTOH a
W ./l./j�� •.
�i� WORNERS COMPENSA710N DECI_ARATION �'t��
= U +f
� 1 NEREBYAFFIIM LINDER PENALTY OF PERJURV ONE OF THF FOLIAWMG DECLARATIONS: /�'
CA Q '��VCJ1C. .- `�' Y '' .
� _.___.!HAVE ANU WILI A7A;NT•A1N A CERTIFICATE OF CONSENiTO SELFINSURE FOR WOqKERS' S ;'� �U L� � —
CAMPENSATION,AS PROVIDED BY SECTION 3�00 OF THE LABOH CODE,FON THE PEAFORUP,NCE W
OF TH[WOflK FOfl WMICH THIS PERMIT IS ISSUED. �
�
W ,I NAVE ANO WILL MAIY�AIN WORKERS'COMPFYSAT:ON INSUPhNCE,AS NEQUIREO BY SLGTIIXJ
Q9]OOOFTHELABORCODE.FORTHEGERi'ORMPNCEOFTHEWOAKfOflWHICHTHISPEFMITIS
ISSUED.MY WO K 5'CO/MPF.�NSAT�IO,N INS.U-fRAN.,C,E C�ARRIEFAND PUUCY NUMBERARc: CONSTRUCTION .__ ._,._ __ � ('�
q �v C�''�,�'.l�/� ���--� FIAN PEVIEW _ �j_„[� :
] CARRIEfl _ �Ar�• ...�-7J �—" _ "_' < �C...f
� VOIICY NUMBER_.._���.��.L�-d�_—— E�ECi� _"'_ — �5�
¢
Q (iHiSSEf,ipNNE�NOTREC�Mf'LETFDOFTFEPERFRiASf�`FiONEMN�EDDOIfl�A$(S10�ORLESSA PLUMBING _ .- �...
ZICERTIfYTHATINTHE7EPFORlAANCEOFTNEWORKFOflWH�CHTHISPERMITI515S�E0.l MECHANICAL __ G� �
'�'��� (J � SHALLNOTEAIPLOVANYGERSONINANYMANNERSOASTOBECOIdLSUHJECTTOTHE
� ' (n WORKERS'CqMPENSATIONI.AW50FCALIFOqNIA,AN�AGREF7HATIGI5NOt1LDUECOME �NSPEGTION�FEE ._ __ � ��
r SUBJECTTOTHEWOFKERS'COMPLNSATIONPROVIS�ONSOFSECTION3]MVFTH ISSUANCE '`�yO � Y
� � CA�7�F('ISHA/�eL�R FlTMWITHCOMPLVWI 14N ....__ �' _ .. _
� OATE��.���[,�APPLICAtdT. ._ . . �� � ._— SMIP __" 3M L<. .... '
� � . . � ENERGV P/C — .-- — .—
J WAflNIN(�,FAILUPE TO SECUflE WORKERS'COMP[N6ATIOk CAVEAAOE IS 11NLAWFUL,AN�SN B
LL SU&IECTANEMPLOVERTOCPIMINALPENALTIESANOCIVILFINESLIPTOONEHU4DRED7HOUSANO ENERGVPERMIT ' ` :l +` �•.�
DOI.LtRS(5100,0001.IN AODITION TO THE COSTOF COMPENSATpN.DAMAGES AS PqOVIDED FOR IN -----�.==--.e-�'y- ���y�;�.�'
� Q SEGTION 3]oe OF TF7E LABOR CODE.INTEREST,ANDATTORNEI"S iEES. RETENTION FEE: ._,_ - 5
oCONSTRUCTIDN LEN�ING AGENCY PRE-ALT FEE: _ _
' qIHEREBYAFFIqMUNOERPENALTYOFPERIURYTHATTHER[ISACONSTFlUCTIONIENDINCAGENCY ______
FOflTHE PERFORMANCE OF THE WORN FOR WH�CN 7HIS PERMIT IS ISSUED(SEC.30W,CIV,C.�.
i`�'
W "' _
�' � lENOER'SNAME__' _" _ ___-'--'-_
I'.. _" ' '
F- IENDEq'SADDRESS__ _____ _. .-..-.-..-
� 70TAL FEES �
� ICERTIFYTHATIHAVEREADTHISRPPLICATIONANDSTATETHATTHEA60VEINFORMATIONISCORRGCT.
� �' IAGHEETOCOMPLVWITHALLCITYANDCOUNTYOqDINANCE5AND5TATEtAWSRf�TINGTOBUILDING
, � CONS TION.ANO HEREBV AUTHORIZE RLPRESENTATIVE IS COUNTY TO ENTEN UPON THE
ROPERTY OR INSPECT rv PUReos . COMMENTS
�
J
� "_ _ _
¢ P T7EE NAME(PRINT) f,, _,_ __
v� S-���IA' NL C'. L',,A U l.� �''� - Z - ' � _
(q SIGNATUHEOfVEHMITTEE aTE ' " G
, � RECPL N ._ PAID BY _ VALlDAT10N
. WHI7E—DepaAment Copy,YELLOW—Finance Copy,PINK—Asseseor Copy,GOLDENROD--File Copy,GREEN—Applicant'S Copy
-.. � � ��'rl 'r!'T -n f��i� (n � C� r � ^
_���._�.__.�.,.�.- .._._. ..._.._.._. � _-,_ _.__.�n
,w-- ;.. .�� � �.� — I D 'm`en � m`��� i O O�C O ��� D I m N a7 r ��m ?
mirl � .y� . � �z z'Z � r�''i �� �I���C c�OI�' O`-a ���ip m G5 �
m'D � ! r'ti- r r�' rm- y. '�,-+1m � �Irl� �S �i��� �,� -n � �°��f� �`�-s �lD P '°
'4� I � � I roic's �.n �a -� � xIx n z ui �"� i �
�Cs �.m � e� � — � z ..{i�� I I9p O'c7
f � � . rm :-a � �r � s1.� mxO �12v' Oy c� �In
��. �' -c ro s' o ,3m'��: z.:� ;z y I C��,�I� c rn�m�m � D x'.m C' � G'7 's�;..
,.C...y' _ I � I 1 � C> � y � . � G D� rn = <� rry ��� ��,:
z � ` -S. , I ���`�! �� �z' ^ �.g w � ��� � � �,�� � o cni
t�� � ,"; �. � z.��.G�l z � O � m z a���i �r�z m ' m�c,rnl . c�
L� i G�I I �i � �. ��. Z i Z
:N� I � � � , � �Iz � n��l_, ` ot '� � ( �
�,-I � � � I � � I o, � � �� �.�� �
, , ; ; i � - -� , � _ ��
I ; �- ��� .�, . . --+—a--E—�-�— - �—,
, ; I � .� � � � �,` , ,, , � � .
� � �
� �� i
� �; , � i ' �;�' i � II � � I , � �.
� , , - ,. �,�i - - � I -�-��- _-!� :,...
�� � � � � � �I ;��� �—� L � � �I ��
� ��:, � � ' I� ' � �� � ; ����j � � ;�� I �����I �I �, �� � � �
i , l
t� , � t� I I ; ! ; � �� � � ; ' _,_II '' ' ;
C ; , , i I I � E � �
i �; I '� I I � 'I ' I� � � I , , ' i �
�1': �i '� i � i � � ";�; ~� � ; I I I � ; • � �
1 ; I I I , _ �
�0 4��� ,� I ��i I c , ��' I �_� � , �� � ��� �I � � � � � �
� �� , , , , , ;_+� _1 _ _ -�-�-� _ - -� , �--- � �
, ` .�
I - ' ri^� oOlv �.� � am o';Tm � -n � c C ���
I .y?; .j � i � � I � Im o�iz��n�-il0i� � � Iml� i z� �
��<ID zlm m -nl0 OIOIZ Q � �I� D � � O CIAIO "� �
� .. l - __.. i. _.. �' . I. .� . e �z m mlmi�Icnl f Z���I7j0 OIO ��Cjh mlrD-�� 2 � v�rrtl�i�,G � �
� i � f 73i�.,�,r�.C�r � C�J r- ���Ir r r Zi��S�e� CG��ir�'-'37i�liR,�77
� � �I i. � ._` i i ,_- �.W . ,<I'��OI,���I�I�. ID -ii�iZr'iI'S7 ��I � �� D Ai O � � 5 � � ,
�iiAIO i I I
���� � ' � I I I I m � O 7.� miz;m�r�G7I4��nIQ'���o O�C?jt3 �;� �
Y� I � � I � I— �G7IG Dlf� C��D 17I i m�rn p �,�,
� ' � { � � � �I-o�� -nz � L �� -�c, �I ,7ia" z oap�m��i�OOcni-i � � ��
i �I I i D � Ii i.C� � �� i .
�' ' � � I, I { � z��'� 9� cn' G,���7'z� c� � �im�.�o�x �I � �
�I,,,,�i I � �, I � '; I ; y '�I�zI�I z I � �n �'..�ci� I ;�'�lnl�Io � � � � �
� i: , � � G> � i r�r tr�.i� � ,� �
I �� � � � �� C' �; E:, � � i �� . � ��� `n, I �� ' � � : _ . � i � �i�_jo�-?� I, �
� , ;
� ,
� � � � : _ � � i _� f_ �
� � �o � �
� � � ; � , �. i. j ; � � f � � ' � ;. i ; � � z �'
� ' ; . X �- �� ,� �� � �- � ,
, } �, � � , I i , � { i _ i j i
I � '' + �
� ��. �
� ,� I �: � � � ����� � ���' � � � � ,� �� �i� � � �� , � �' i ' ��
� �r—�; ` � ; � � ` ;` � � � a I �
i � I I i I i ( I � � .I , ' �
�� �°' � � I ' — ' ' —
�� = � I � � t ' I � -�- �-, -t-� `
' � , , ' - �, ! '_ ,� -� ' � i � ; :�' C �:
!� � ,� ,. I ,. . � � i I � i I - � - �
_ . ,
, �, .
�.i = �1 ' � `� �
.� � � � , � � I
,
�� I
�I ' ; �I � � , a
� �
� ���:�; � _ : �r � ; �- � . I t - 1 ; �
, I
- �
; _ , '� �
' �i�i I - ` ' — = I , � � � � � I .l � � i ' ;. � . � '
��� , . . � . �, I , : :.� � .E i i � � �
:. �� ; , . , , �, � __;_�_�- ---' �-- ` ' .�.�..i..�1..�. �._. _ � :
;...� ._.1_._. �.�...�.. __�._._.J_ _ .�