HomeMy WebLinkAbout055 (4) '`� CITY OF DIAMOND BAR `���`�`�"��L�
. DEPARTMENT OF BUILDING AND SAFETY PRESS
r �� BUILDING PERMIT FIRMLY x -� '
JOBSITE ,r / ' j DATE CATION NUMBER �` �5+ CODE
ADDRESS ��j1 ������"�1�P_��`� ��� ISSUE � TYPE f OCC.
r APN LOT � TRACT DATE T_�� �`-� � � CONST. GAOUP _
� CROSS STREET �`.l./�ts� w�a��N,s
a° OWNER -�'6"�� ��`��'1s'c�%,�-i ZONING SETBACKS
FRONT RW CO
o ADDRESS N REAR �
W CITY ZIP TEL. SIDE/SIDE STREET � RW ❑
o APPLICANT���< �-��rg`.�'" TEL.��>�•°--� � SIDE �
a CONTRACTOR �'��'1 ���1�"��-x� ��`�� °�O'��'' �`� � SEWAGE
e �''�;.i'�;i�' .�=. �!/'''�.�[2 �,�,� ,• ❑ PUBLIC PMT#
o ADDRESS � �� � r D15POSAL E
F'.r CIT �-"�°'.��'�°`7�•�/��� ZIP��''3�` • . TEL.�`�'�— �� f/ ❑ PRIVATE SQ.FT.1100 GAL
s STATE ,�
y LIC.NUMBER �.��.Sa�f:',� GRADING ❑ CU.YDS.EXC. CU YDS FILL
� ARCH/ENG/ � TYPE SQ FT FACTOR PS AI7J. ARE�lVJ�LUATtORI
�' DESIGNER � 1 -
o ADDRESS {,Wj., 2 '
$ CITY ZIP TEL. �r 3 �
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� PROPOSED US���=� ''1�' a'`� *�• � 't rf 4 �
� � � GARAGE
�
o NO.DWEL. NO. NO.
y UNITS STORIES BEDROOMS �. PORCH �
� LOT DIMENSIONS VALUATION ADJ.AREA _
;
o NO.OF BLDGS HOW QUANTITY p� {��p"�'�p�J F�� r
= ON LOT USED i
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IICFNSE�f,UNTRACTOHS(7ECLAflATION I herehy af(iim�hat I am licensed under pravisions of Chapter 9([ommencing � �.„ i��
¢ wqh Sr.ctian 700U�of�iviswn�of the BnsmFlss and Professinns Cade,and my license is m full farce and eHec. .
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� OVJNER�9UILt]EH�ECI ARATIGN�I hr.ie6y atfirm thal I am ecemU�irom tlie Contracinr's License Law for ihe tollowiny / `
Z ieasnn ISec iCi3i.5,Business miJ P�olessiuns CoAe�Any city or r.ounty which requires a pennit to wnstruct O} ( �� � , s
o nite�,uu4�ove.Jxmolrsh,m repmr,ny stnicture,priur to its issuance,also re.quues the apphcant Mr such permit �� P
Qlo fila a si9nal statemr.m�hai he is IicenseJ pursuan�to the provfsions o(ihe Cunlrac�a�s License Lew 1Chapter {j,y �� �
� 9lrommeiuing with Seciion 701)0�nf Drvision 3 nl the 6usiness and Piutessmns CoAel nr that he is exr.mpi therefmm � r �
a anJ ihe hasis im ihe alleged exemptian.AnY viplalwu of SecM1nn 7p715 hy any applican�fo�8 DN�1111 S11b�CCIS �' � �
"'� thr.appLcant lu a ciud penally ol not morr than 6ve hnndreJ Jollars(55UOL)
W Q. ! � � 1.
� ❑I,as ownr.r nf ihe pmperty,or my employees wnh wages as thcu sule campensalion,will do the worX,and {
F the stmclure rs nat iWenJed ai otfered loi sale�Sec.7D44,Business anA Pr�assians Code�The Cantractor's Liceuse Q I
� Law Aoes nal apply to au uwner ol prnpetly whn huilds ur impmves theieon.antl who Aoes sueh wnrk Nmself, �:C,? _
W nr tlimuyh his own eiuUloVPes,pmvided thot s�uch improvemems arr,noi imended or oftereJ fer sale.II,however, �:.� �
m the huAdmg nr improacmenl rs soid within nne year nf complehon,Ihe ownerhuilder wAI have Ihe burden nf pmvmg „-Q �'i
� that he JiJ nul 6uiIJ ur nnyrove kr the purpnse of sale� �.S `-
y � §:
V� ❑I,as mvnar of the prnperty,am exclusrvely coNracuny wilh licensed canraclois to constmet the pra7ect ISe� � �
7044,Busu�ess end Pmfessmns Cade�The Contracto�'s License Law dnr.s not apply to an owne�o�pmperty who -� `�
¢ Lutlds or unprnve.s thereon,and wlm contiacis kr sur,h prn�e�ts with a contractor�s)laensetl pursuant to the Camractor's ��'
�icense�aw.1 - CONSTRUCTION `
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� ❑i am ammp�unner sec B e v.t IA«ar.h Cernficatel. PLA�) F�EVIEW _. ;}
0 oeie Owner EL.FCTRIC €r
� WORKEHS'COMPENSA710N OECLARATION I herehy aflirm Ihat I have a certrf¢ate M consent tn sen���s��e,�� ,... pLUMBING � "--
a cerldrea�e ol Wudeis'C�mpensatlon Insurance,or a ceniheA coDV�hemof ISec.3800,Lab C) — ;
� ;i
� U Certitied capy is heieoy hxnished. � MECHANICAL
C7 LJ Cer�iheJ capy is 61tlJ wilh ihe Bmldmg Inspec6on�epa�lment or U¢pa�unent � GRADING „�
W
= CEfiTIFlC�TE UF EXfY�VTION FHOM WORKERS"COMYENSAlIMI INSUHANCE.This secuon neeA not he completed ISSUANCE �+
� il the permit is lur une hundred(S10UI or Icss.I reiL(y Ihat�n the performance nf the wark far which this y,,_
VJ f— t'
pennit is issued,I shall not employ any perwn in any manner so as t fcarge su6' Uf'o�he Ub� �r�ampensatinn SMIP
= laws nf f,alrfnmia ,�.�� �' W l�
o �-�� ,�, � 1....o" ., ,�,' ,s,,.�,r„fw W PARK FEE
p �ate F.. /"/ a�AVP6c �''^'7 . .:..s,'_.,.>.., ./'� E
� NUTICE 70 ANVI.IC�aking this Cert6¢atr.nl Exemptiun,you shuuld 6ecame suh�ect to�he Worker's u- SCHOOL FEES
� Compensatwn prwrsions ol tle La6or Cade,you must Porthwith tomply wrth such pmvisions ar ihis permit shall
�+- he JeemeJ revokeJ. -- I
� DIVISION Of INDUSfPIAL SAFFTY PEHMIT CERTIFICATION • i
W �
� UI hnmby terufy Ihat na exta�alion hve(5)nr mare leet in depth nVo whfch a person is requi�ed lo descend, �
s will 6e made m comiecimn wilh wnrk authorued M1y this yermit.and that na huilding stmclure,sce�foWiny,falsewoik, � Ur ��A�f���� ��;�{ 4
�— m demuhtinn or dismantling Ihemot,will be more than thirty-six(36)leet hgh.�Chap 32,Grp 2,Ar�2,Sec e���
= Y31,Title S.C A f:� . r� 4 M �7 \ I:
_ ��u�ct,t� ��:.a� 5,���� �
3 ❑As ownerhwlder,I will not employ anyone to do wark whah woultl reqwre a permit fmm the avisinn af ��
1— InJustrial Sale�y,as noled a6ove,unless sudi ce�son has a permn ta dv such work imm Ihe dinsion,
�_ �:
W LI Dnixinn of InAusinal Safery Permii No f+ I
d TOTAL FEES �
f.tNJSTRUCTION LENOING AGENCY I herehy affirm ihat there is a wnstructlan�ending agmry for the perfmmexe
c� _
x ot tl�e work lor whv.h this permit is issued(Sec 3097,Crv.C.I�
� lenAer's Name COMMENTS �t
m �eniler's Address t
Q CERTIFlCATE UF COMPLIANCE AND AUTNOAIZATION OF ENTflY�I cerufy 1 have mad this appliea�ion and atate =
�i� ihnt the mfnrmanon gven mrect.i agree to campl�y,J"�all stak laws and city otdfnances relatlng ta huitling
y cnnsimcbon,and aul �l ematwe of thq.0� i(nent af BwWmg and SahtY a enter upan the D�oYerty �
z Im wlnch 1 hay yennn lor 1 �' e oi making inspections, i
1-- .`^'�'r�% .f�. �
G'�-�� c,..x"���"-.!�� ..�'"�'�'�"���� •
Signamre of Pyplicm�i ai Agent p�g RECPT NO. � BY `�-� VALIDATIO
WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Capy,GOLDENROD—File Copy.GREEN—Applicants Copy �
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