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HomeMy WebLinkAbout12057 (13) i—'-1� CITY OF DIAMOND BAR ' '� �!� -- DEPARTMENT OF COMMUNITY&DEVELOPMBNT SBRVICES � ) 21660 E.Copley Drive Suite 190 �. j PRESS � � (909)860-3195 Fax(909)861-3117 �_�.-• ��ro�°� � BUII.DING PERMIT APPLICATION FIRMI�Y }, JOBSITE ����/ ,�,., � `{ APPLICATION�,^�� [)� NUMBER 2�j/ #1C o ADDRESS �'✓ ' '�£. ��`' ' DATE � � ` ISSUE C7 IYPE OCC � APN LOT TR CT DATE � ������J� CONST. GROUP °� OWNER - � C' -., c. : OO ��i 1�.�_ _, ADDR�S 1 �.o .�� �a-'v.la4�' ! .�-. � ZONING SETBACKS �"' CITY�::,,�, ZIP,t. +..1,�R TE�T_ �. s L-Y c:!%s`� � REART RW �--- APPLICANT - ',t(•, 4'•��silcs TEL(�•=� z/'�•-''iab}! ' SIDEJSIQE STREET RW fJ � CONTRACTOR "„ti,�:�- �?o-v�"t'_�% y SIDE fl ADDRE�SS "�i'' ' �'��` "' � � PROPOSED USE � � CITY���(.,���•�.k;� ZIP�. �6_�a�S! TE .,�"�'��� �f�:�'_�i,i•;�' o ARCH/ENG/ i W �ESIGNER NO.DWEL. NO. NO. � a ADDRESS UNITS_ STORIES BEDROOMS i � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION - � \ Q UWNER-BUILDER DECLARATION SFR/ADD/FlEM EO ! p I HEREBY AFRF4d UNDER PENALiY OF PERNRY THAT I AM EXEMPT FROM 7HE CONTRACTORS LI- G8fe9B/CefpOR { W CENSFUWFOflTHEFOILOWINCREASON(SEC.7031.59USINESSANDPROFESSIONSCODE:ANYCITVOR (/� �1 � U COUNTPWHICHREWIRESAPEFMff7000N5TRUCT,ALTER,IMPROVE,DEMOLISH,ORHEPAIRANYSTRUP � 4 �' 7URE,PRIOR TO 1T313SUANCE,ALSO REWIFlES THE APPIICFNT FOR SUCH PEflMIT TO FILE A SIGNE� W P2110/DBCI( ! � STATEAIENT TH�T HE OR SHE IS LICENSED PURSUANi 70 THE PROVISIONS OF THE CONTRACTORS LI� l CEN9ELAW(CFIAPTERB(COMMENCINOWITHSECTION700a)OFOIVISION30FTHEBUSINESSANDPRO- � PooVSpa ( FESSqNS CODE)OR Tl1AT HE OR SHE IS EXEMPT lHEREFHOMAN0IME BA515 FOR TNE ALLEGED E%EMP- E V TION.ANYVIOLATIONOFSECTION7o31.58VANVAPPLICANTFORAPEHMITSU&IECTSTHEAPPLICANTTO Z qe•Roaf � I O ACML PENALT'OF NOT MORE IHAN FIVE HUNDRED UOLURS(5500)� CII.ASONMEflOFTMEPROPERTV,ORMVEMPLOYEESWITHWAGESASTHEIR50LECOMPENSFTION, 0 Commercial Z VALL 00 7HE WORI(AND THE STRUC7URE IS NOT INTENOE�aR OFFERE�FOH SALE�SEC.7aa4,BUSI� J p � NESSAND PROFESSIONS CODE:THE COMTRACTORS LICEM&E lAY!DOES NOT APPLY TO AN OWNER OF � � PflOPEflTY WFiO BUILUS Ofl IMPROVES THEREON,AND WHO DDES SUCH WORK HIMSELF OR MERSEIFOR � THHOUGHHISORNERDNMEMPLAYEES,PROVIOEDTHATSUCHIMPROVEMENTSARENOTIN7ENDF�OR m QOFFEREDFOfl3ALE.IF,HOWEVERTHEBUILDINGORIMPROVEMENTI550LDWITHINONEYF.AROFCAMPIE- Z TION,7HE OWfiER�BUILDER WILL MAYE TME BUPDEN OF PROYING THAT HE OR SHE DID NOT BUIID OR = IMPROVEFOHTHEPl1HPD5EOFSALE). ❑1,AS OWNER OF THE PROPERTV,M1 EXCLUSIVELY COMfiACTINQ WITH LICENSEO CONTRACTORS Q TO CONSTHUCT 7HE PRQIECT(SEC,70{G,BUSINE55 ANO PROFESSIONS CODE:THE CONTMCTORS LI- VaIU3I1011 ADJ.AREA___ W CENSEUWDOESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUIL�SORIMPROVES717EREON,AND � K}IOCONTRACTSFORSUCHDFQIECTS`MTHACOIJTRACTOR�S)LICENSEDPUFSUANT70THECONTRAC- QUANTITY DESCRIPTION FEE TORS L10EN5E UWJ. � --� a���� ��° y ).'�'� r' ,i :.E� I ^ ❑IAMEXEMPTUNDERSEC._ _ B.&P.CFORTHISREASON Q �.•l� t L�•� fi•' � Y U � i� � � ¢ i.✓�i��1 c'.'ki ..t"� . u' OATE_ —_ON?JEH _____'_...,..'.'_"—_ U '.a� { W t� � LICENSED CONTRACTORS DECLARATION W u � 1 HEREBYAFFIRM UNDER PENALTY OF PERIURY THAT I AM LICENSEO UNDLR AROVISIONS OF CHAPT[R � g d 9(COAIAIENLYN(I WI7H SECTION 7000)OF DIVISION 30F THE BUSINE35 AN�PROFESSIONS COOE.AND Z � X MY LICENSE�S IN FULL FORCEPND EFFEC7. m � IJJ ( � LICENSECLASS i"� j� LIC.NO. ��� ��.�y`� _. � � V DATE +� �"��'�:�} CONTRAGTOR ^ s--�- d'"� a y, 's � WORKERS'COMPENSATION DE LAR ION d � � I HEREBY AFFIFM UNDER PENALTY OF PERJUtSY O�E OF THE FOI.IOWINti`DEC�R4TION5: � � � ZQ O __IHAVEANDWILIMAINTA�NACERfIflCATEOFCONSENTTOSEIF�INSUREFORWORKERS' S Z COMPENSATION,ASPROVIDEDBYSEC710N370UOFTHELABORCODE,FORTHEPERFORMANCE U i Q �fAKTHEWORKFORWHICHTHISPF.RMITI5155UED. � � � � '�I HAVEANU WILL MAINTAIN WORKERS'COMPENSATIDN INSURANCE,AS RE�UIFED 8Y 5E�ION ' Q97000FTHELABORCOOE,FOR7HEPERWRMA�CFOFTt1EWOflK�ORWHICHhIISPERM1T15 yry /y � _ ISSUED.MYWq},�tKERS'ODMPENSATIONINSURANC(E+CARRIEHANDPOLICYNUMBERARE: CONSTRUCTION _______ ____.__,__._,__ __.__...,_._,__,,.,...�1E._.Y� � � CARRIEFl T i��4� �!��'l, l.s�'•`��.,t,, �u�_ PLANREVIEW ___ _ � —e.----._" s�,:K, ,. -------- --- - L� POLIGYNUMBER IfJ� <' `'3°•�da.T� � --------- ELECTRIC ¢ � 0 (�iISSE(;TIONNE��iOTBEOJMPLEfEDOF7HEPERMRISFOROFIEM1NNiEDDOLLPf4S(51oo10FiLESSx PLUMBING ___.,____ ( W MECHANICAL Z I CENTIFY THAT INTHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I - � ('3 SHALLNOTEMPLOYANYPERSONINANYMnNNERSOAS70BECAM[SUBJEGT7UTH[ y WORKERS'COMPENSATION LAWS OF CALIFOFNIA,AND AGflEE THAT IF 1 SHOUID BECOME INSPECTION FEE ._ ; .. SU&IECTTO7HEWORKERS'COMPENS�IONPROVISIONSOFSECTION37a0UFTHELABOR ./��ty � CAOE�ISHA�,IFOHTHWITMCOMPLYWI HOSEPROYISIONS� �SSUANCE __,_.__�_�5�. j- � .�(^�.. /�.l< 4i��r SMIP i; p �ATE:`1',•a L � APPLICANT. . .-_ --_—_.__-_._________----_--__ _.-- '. w � , �f ENERGY P/C —.---._..... , . 'S J WARNING FAILURE TO SECURE WOHKERS'CO EN TION COV[RAGE I6 UNL4WFUL,ANO SH�LL E3E LL Sll&IECTANEMPLOYERTOCRIMINALPENALTI��CIVIIFINE5UPTUONEHUNUR[DTHOUSAND ENERGYPERMIT ____._____ �� DOLURS(5700.oao),IN A�DITION TO THE COST O�COAIPENSATION,DAMAGES AS PROYI�ED FOFI IN - k � SECTION37aBOFTHELABORCODE.INTCREST,AND)�rroaNersFees. RETENTIONFEE: .. � OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: � � I HEREBYAFFIRM UNDF.R PENALN OF PEHJURY THAT THERE IS ACONSTRUCTION LENDING AGENCV _____ ____ ,__ _ __ FORTHE PEf1FORMANC[OF THE WORN FOR WHICH THIS PERMIT IS ISSUED(SEC.3087,CIV.G�. Z —_' _' —___ _" '"_"__ W � LENDEFYS NAME ___._. __- _ F- LENDER'SA��PE55_,. .-.-----�---- WI CERTIFYTHAT I HAVE READ THIS AGPLICATION ANU STATETHATTHE ABOYE INFORMATION IS CORRECT. TOTAL FEES � ��, � � a � IA6REETOCOMPI.YWITHALLCITVANUCOUNTYORDINANCESANDSTATELAWSREIATINGTO8l11LDING � CONSTRUCTION.AND MEREBV AUTHORIZE REPRESENTATIVES OF THIS COUNTV TO ENTEfl UPON THE � Zp80VE-MENTIONEO PROPEATV FOR INSPECTION PURP0.5E5. COMMENTS _._ —..__.____ � `' ,,r' y' � l � l��`'F,.t,_. _ _-'��� �{ _ \ :�.�. __�.��... ' '-.-�,=�-=r`' -- __ - - j ¢ ERMI�NAME IPRINT �t ry .�; -.fr �-)))�� =� — p (!J f'���.- 4,6�. �:.��.,.,,�....:� �i � ..}'�.' �it, TU FPEFlMITf E-�=•� ' DATE /� _ � � RECPT.N0. 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