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HomeMy WebLinkAbout12114 i CITY OF DIAMOND BAR .'--•� --��-- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES.:"�� �'�"�-j� � •. n 21660 E.Copley Drive Suite 190 ' _ , W (909)86(�3195 Fax(909)861-3117 (� ... - " PRESS ����^�"' BUII.DING PERMIT APPLICATION FIRMI.Y � JOBSITE ,• , P APPLICATION L.j Q�PERMIT P/C � ADDRESS `t�C�R� � s ��(,, '��li_L/��E DATE �r I I � ��J NUMBER ��-� � � # � APN LOT TRACT DATE ��/�— ��CONST. GROUP p OWNER MtL ,i� ►Y�fLk� /'s]Qu(,F- l.iwG�e u" AD�RESS S�L!� tV Y7 i5� y C k:.- L/�4Al� ZONING SEfBACKS w 4 o FRONT RW ❑__ � CITYQoAMUN� f3i�Pt ZIP il_7�� TEL. g APPLICANTi���G tilu5'�ill� TEL���rY °�`if`'I SIDFJSIQESTREET RW ❑----! � CONTRACTOR C� F AJtr SIDE C7 � ADDRESS�'�`L� �@ F' f.�u 5ii !S � CiN11�W dVJiiVIS ZIA Q1411� TEL���S )��i.�L� PROPOSEDUSE�F���� ��.1'�.! JW(r i,ilc3(7A iZG�f3� [� Z Nr i'T�t.%-- /Z ` � `-- `J(.uuo� / �1/S i/r- wo ARCWENG/ C.i:X�55 7 � �E�G�-l.ta- �y sc"cr'yi 'N71 � L ylJ- � aADDR SS � NO.DWEL. 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FACTOR PSF ADJ.AREA/VALUATION O OWNER•BUILDER D�CLARATION SFR/ADD/REM p I NEREBY AFFlRM UNDER PENPLTV OF PERJURV 7HA7I AM EXEMP7 FqoM THE CAMRACTORS L6 G8f2Qe/C2fpOh �J CENSELAWWRTHEFIXAOWINGPEASON�SEC.7IXit.5BUSMESSAN�PROFE5510N5CODE:ANYCITYOR (n U CDUN7yWHiCFiqEWIRESAPEflMITTOCONSTRIICT,/U.TER,IMPHOVE,DEMOUSH.ORREPAIRANYSiRUC- W P8I10/OBCk � NRE,PFIOH iD 1T5153UANCE.AL50 REQUIHES TME APPLICANT FOR SUCM PEflMIT TO FILE A SIGNED STATEMENT THAT HE Ofl SHE IS LJCENSED PURSUANT TO THE PflOVISIONS OF THE CONTRACTOR6 LI- CENSELANr(CHAPTER9(COMMENCW�WITHSECTION7000)OFOIVISION30FTHE9USINESSANOPRO• V' POOVSPd fE59pNSCODE)ORTHATHEOflSNEISEXEMPTTHEREFqOMANDTHF.9A515FORTHEALLEGEDEXEMP- � TION.ANYVIOLpT1ONOF9ECTION7091.59YANYAPPLICANTFORAPERMITSU&IECiSTHEAPPLICANTTO � �Z R8-ROOf � ACIVILGENALTYOFNOTMOilETHANFIVEHUNDREUUOLUIRS(SSoo).): ❑I,A30VMEROFTHEPROPEflTY.ORMYEMPLOYEESWITIiWAGESASTHEIRSOLECOMPF.NSATION. 0 COI11111BICI81 " �� Y/ILL DO THE WORN,AN�THE STRl1CTUHE IS NOT INTENUED OR OFFEREO FOR SAIE�5[C.7044,BUSI� J NESEMID PROFESSIONS COOE:THE CONiRACTOR3 LICENSE LAW OOES NOT APPLY TO AN OWNEfl OF � PROPERT'!'Mi08UILOSOqiAfPROYES7HEREON,ANDNMOWE55UCHWORKHIMSELFORNERSEI.FOR � � THROUGNNISORHERONMEAIPLOVEES,PROVIDE07HATSUCHIMPflOVEMENTSARENOTINTENOEDOR m QOfFEREDFORSALEiF,NOWEVERMEBUILDIN�ORIMPROYEMENTIS50L�WITHINONEYEAROFCAMPLE- z. TION,hIE OWNER-BUILDER WILL HAVE THE Bl1RDEN OF PqOVMG YHRT HE OR SHE�IO NOT BUILD OR IMPRpVE FOA YHE PURPOSE OF SALE}. W, ❑I,ASOWNEROFTHEPROVE{7TV.AIAEXCLUSIVELVCAMRACTINGWRHLICEN5EDCONTRACTORS � TO CANSTRUCT TF1E PROJECT(3EC.70a,BUSINESS ANO PROFESSIONS CODE:THE CONTRACTORS LI- V8I118�1Ofl - ADJ.AREA W CENSEUWDOESNOTAPPLYTOANOWNEROFAPROPERTYWNOBUiLDSOHIMPftOVESTHEREON,ANO �' WFpCONTMCTSFOR3UCHPROIECTSWITHACONTflACTOR(S)LICENSEDPURSUANTTOTHECONTRAG QUANTITY DESCRIPTION FEE �; TORSLICENSELAW.). o [71AMEXEAIPTUNDEHSEC. ___v_B-BP.QFOR7HISREASON � �. _� __._ V ti.. � DA7E ,OWNER __".."' � U .. W �. LICENSEO CON7RACTORS DECLARATION w � INeREBVA�iRMUrvDEi�PENAL'lYUFGEAJURV7HA71AMLICENSF�l1NDEHPROVI510NSOFCHAPTEP � �� 9(QOMM&NCING ri9TM SECTION 7000)OF OIVISION]OF TtIE DUS�NE55 AN�PROFESSION3 CODE,ANf1 Z xj� MY LICENSE I51N iULL FOHCEAND FFFECT. m 0� LICENSE CLASS_y.+��.��.LIG.NO.���y?�q�3��j7 i � V DATE `�� J�� ""1 �iS _ CON7MCTOR I.�'v'"'- � d W n��. WORKERS'COMPENSATION DECLARATION J � U � IHEPEBYAFFIRMUNDERPENpLiVOFPE0.1l/HYONEOF7HEG�LLOY7NGDECLARATIONS: Z 0 _IHAYEANOWILLMAIN'fAINACERTIFICATEOFCONSENTTOSELF-IYSUREKORWGqKEHS' ¢ CAlAPENSATIOY,ASPROVID[�AYSECTIO�Y37000FTHELhBORCODE,FORTHEPFFiFORMANCE . �U � OFTHE WORK FOR WHIqi THIS VERM�T I5155UED. � �. � W �_I HAVE AN�WILI_fAAINTAW WORKER5'COMPENSATION INSURqNGE.AS RE�UIRF.�dY SF.CTION Q 3YooOF THE LABOR COUE,FOR TME PER(ORMANCE OFTHE WOflI(FOFi WHICH7HI5 PEflM1715 - - — '',Z_ i �� � ISSl1ED,MYN/ORKERS'COMPENSATIONINSURANCECARfiIERANDPOLICVNUM6ERAq[� CONSTRUCTION __. _ _ _�J i r_+.�-� � CARRIER S I ��F � � ��� _..--- -- PLAN REVIEW .. ���.. ?� . ---- -�--- ---- ; •- z aa.icrrvuMBEn � �j"�� " �`���aV � �� _.._ ELECTRIC ----- ----..__ .._-- �-------- 4 0 (IHISSECf10�lNE�NOTBEWNFY.ETm�FT{�PEPAM�SFORONE:4NWFiED�011AR5(5100)ORLESS) PLUMBING ....,.____ W � MECHANICAL Z IGEflTIFYTMATINTHEPEflFOHMAiJCEOFTHEWOflKFOflWHICHTHISPERMITI5155UED,l ----.__.. .._____ __..____...___-__ ' (,�J SW�LLNOTEMPLOYANVPERSONINANYMANNERSOA5T06ECOMESl1BJECTTOTHE INSPECTIONFEE (/�.. 1YOflN.RS'COMIPENSATYJNLAWSOFCA(.IFOFNIA,qNDAOREETNATIFISNOULOOECOME ---.--- --�..----.. ----..-- �- ,- � SUBJEC7 70 THE WORKEFS'COMPENSATION PROVISI04S oF SECTIIXJ 370o OF 7HE tABOR y���C,I ' � COOE,ISHALLFORTHWRHCOMPLYWI7HTH SE Rowsiorus. ISSUANCE .__, _..___. O �' I Y" ��^APPLICANT.���4�-�� _. . -._....__-..—.__ p� DATE: ��"L SMIP .--- ---- "- — w ENERGY P!C "'� WARNING:FAILURE TO SECUflE WORKERS'CAMPENSATION COVF.RAGE IS UNLAWFUL,AND SHALL�E '"'----' """-"- _-_... LL SU&IECTANEMPLOVERTOCRIMINALPENALTIESANDf,IVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPFRMIT DOLLAfl3(Slco,000),�N ADDITION TO THE COST OF COMPENSATION,�qMAGES AS PROVIDED FOR IN " '----"" """'-- --� - � SECTION37o80FTHFIABORCODE,INTEflESLANDATfOf1NLY'SFF.ES. RETENTIONFEE: _.._..___..,_. ___.. _____,__— a CONSTRUCTION LENDING AGENCY PHE-AL7 FEE: __-___._... ,___. _ O � IHEFEBYAFPofiMUN�EFlPENALTYOFPEHJUPYTrIATTHEREISACONSTRUCTIONLENDINGAGENCY ______ _ FOR THE DERFOHMANCE OF fHE WORK FOR WHICH THIS PERMIT IS ISSUED(SEG.3097,CIV.C.�. Z — W -- � LENDEH'&NAME '__'_'___ -- _""'___'"""" ___'_ H LENDEFi'SADDRE55__�____ �-•�----- W ICERTIFYTHATIHAVEHEADTHISAPPLICATIONAN�STATEhIATTHEr1BO�EINFORMRTIONISCAflRECT. TOTAL FEES //� / d IAGREETOWMPIYWITHALLCIT'ANDCOUNTYORDINANCESANDSTATELAWSPELATINGTOBUILOING � � �L..,. ` L-� � � CONSTRUCTION,AN�HERE6YAUTHOflIZE REPflESENTATIVES OF TMIS WUNTY TO ENTEfl UPON THE . �' ���` � Z ABOVEMENTIONEDPROPEPTYFORINSP[CTIDNPUqPO5C5. COMMENTS � � flC /�usi 11�/_ Q' J -_ �__ ¢ PERMITT E E(Pfilfir) -" G J _"_' �`�tl�" _ ' � O � 1� _ �� — N $N1 TUqEOF R EE DATE �/y� + _ / _, RECPT.NO. 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