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HomeMy WebLinkAbout12911 �;� CITY OF DIAMOND BAR � , DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � ,, , x� 216 . 'veSuite190 �'=='" PRESS ( 860-3195 F (909)861-3117 �'v^'f BU ERMIT APPLICATION f %'� FIRMI.Y �..�a' ¢ DDRESS I��g �• ��et �Q{�Cf��\ �� APPLICATION �,�` ,- a � PERMIT 2 � P/C o —rT,— DATE � NUMBER # � ISSUE TYPE OCC APN LOT___�_�_ TRACT a!�C� `1[ I DATE CONST. GROUP p OWNER �(�(�� I�C b o ADDRESS f • �' � _ 1 ZONING SETBACKS gCITY ZIP�l� TEL. L nh/i 7�I-� FRONT _ RW f-1 APPLICANT TEL. REAR U � CONTRACTOR I�I''I _ SIDE SIDE STREET RW I 1 __ ADDRESS "� � � CITY �a� ZIP UcY�)_,+i TEL. � �+ PROPOSED USE � ARCH/ENG/ ���ZT --- z DESIGNER � ADDRE55__ NO.DWEL. NO. NO. � CITY ZIP TEL, UNITS STORIES __ BEDROOMS � � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER•BUILDEfl DECLARATION SFR/ADD/REM O p I HEREBV AFFIRM UNDER PENAITY OF PERJl1RY THAT I AIA EI(EMGT FROM THE CCNTRACTORS LI- Gdf8g6/Cafpof( W CENSEUWFORTHEFOLLOWINGREASON(SEC,7031.SBUSINESSANDPFOFESSIONSCODE:ANVCITYOF (f� C,7 COUl4TYWHICHflEWIRESAPEflMITTOCONSTflUCT,ALTER,IMPROVE,�EAAOLISH,ORREPAIRANYSTqUC• Z TUHE.PRIOR TO ITS ISSUANCE,ALSO RE�UIRES 7HE APPLICAN7 FOR SUCH PERMI7 70 FILE A SIGNED W PaliO/DBtk � STATEIAENT h'AT HE OR SHE IS LICENSED PURSUANI TO THE PROVISIONS OF THE CONTRACTORS LI� � C CENSE UW(CNAPTER 9(COMMENqNO WITH SECTION 7000)OF DIVISION 30F TME BUSINESS RND PRO� POOUSPe �E FESSKKJSCOOE)OATNATHEOHSHEISEXEMPiTHEREFHOMAN�THEBA515FGRTHEALLEGEDEXEMP- �j TION.ANVVIOLATIONOFSECTIOF17031.SBYANYAPPLICANTFORAPEfiMITSUE3JECTSTHEAPPLICANTTO Z Re-Roaf ACIVII PENAI.TY OF NOT MORE iHAN FiVE HUNORED DOLLARS(f5oo).): • � ❑I,h50WNEROF7HEPROPEHTY,OHMYEMPIOYEESWITHWAGESASTHEIR50LECAMPEN5A710N, ❑ Commertial WILL DO 7HE WORK,AN�THE STRUC7URE IS NOT I4TENDED OR OFI'F.RED FOFl SALE(SEC.7oa4,PU51- J � NE55 AND PFiOFE9SION3 COOE:iNE CONTRACTORS LICENSE lAW WES NOT APPLY TO PN OWNER OF � PROPERTY VYI10 BUI�OSOR IMPROVES TMEREON.AND WHO WES SUCH WORK HIMSEIF OR HERSELf OR � THqd1GHHI50RHEROWNEMPLOYEES.PROVIDEDhIATSUCHIA1PqOVEMENTSARF.l:(1TINTENDEOOR m Q OFFERE�FORSILE.IF,HOWEVER,THEBUILOINGOHIMPpOVEMENTI550LDWfTHINONEYEAROFCOMPLE- Z TION,7FIE OWNER�UILDEF WILL HAVE TME 6URDEN OF PROVING THAT HE OR SHE OIO NOT BUII.D OR � IMPROYEFORTHEPUHPOSEOFSALE). W LII,ASONMEHDFTHEPROPEHfV,l1ME%CLUSIVELYCANTRACTINGYfITHLICENSEDCONTRACTORS � [[ TO CONSTpUCT TME PROJECT(SEC.7016,BUSINE55 AND PROFESSIONS COOE:THE CONTRACTORS LI- V8 111 8 11 0 11 _________ ADJ.AREA___.,.______ � W CENSELAWDOESNOTAPPLYTOANOWNEROFAPFOPEflTYWHO6uI1D50RIA1PPOVESTHEREON,AND -�-�-'�- ""— � N5IDCONTMCTSFORSUCHPROJEC7SNflTY.ACONTRACTOR�S�LICENSE�PURSUANT70THECONTRAG pUANTITY DESCRIPTION FEE � Y TORSUCENSEUW.). QLIIAMEXEMPTUNDERSEC. B.BP.CFORTHISREASON Q , Y � U ------------_.— _._ v .' 1/�.f-1 y-),��,.�h '1 t LL DATE _.__�_E,r'�'. ,__ OWNER_"'—'_—_—___""_'_-- � J'_ � W � L.ICENSEO CONTRACTORS DECLARATION W � 1 HEREBY AFFIflM UNDER PENALTV Of PERIURY THAT I AM IICEN5F0 UNOEH PROVISIDNS OFCHAPTER � d 9(CCIMMENCINO W(TH SECTION 7000)OF DIVISION 30F THEBUSINESS MD PROFESSIONS COOE,AN� Z iL MV IICENSE IS IN FULI FOflCEANU EFFECT. m p LICENSE CIASS____.C� �. LIC.NO..___„��,�_y�_� � ,/� v V �ATE_;i t�� CONTRACTOR___j„�_�� =_ W �� �� �� ���� � � WORKERS'COMPENSATION DECLARATION C��aj��` Q t� �� U � 1 HEREBY AFFIflM UNDER PENAI.TY OF PEflJURV ONE OF THE FOLLOWING DLCLARATIONS: Z � �_IHAVEANDWILIMAINTAINACERTtfICA7EOFCONSENTTOSELF-INSUREFORWORKERS' Z — COMPENSPTION,AS PflOV1�E0 BY SECTION 310o OF THE LABOR CODE,FOR ThIE PERFOfiMANCF W OF THE WORK FOR WHICH THIS VEPMIT IS 15SUED. 5 G W 1 HAVE AND WILL MAIMAIN WORKERS'�MPENSATION INSl1RANCE,AS F2EO:11RE0�V SECTION Q3%ooOFTMEIABORCOOE,FOR7HEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS = ISSUEO.MY WORKERS'COMPFNSA710N:INSUHANCF.CAFRIERAND POl ICV Nl1MBEHARE: CONSTRUCTION _____ __ � CARRIER ' .F" �E q PLA IEW _""'__"' � POLICY NUMBER_ �L.a�� /'^�T` �6a 1� r �j ECTRIC .___,____,_ � Q 7 Q (rH�ssEcrior�n�wreE��rEooFTr�vEarnrr�5wnor+Erax�Eooa�s�5iao�ar;��ss). PLUMBING _____, _____ w Z 1 CEHTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHiGH THIS PEIiM1T 15 ISSUFU,I MECHANICAL .__ - � .. .,__ (} SHALLNOT EMPLOYANY PE4750N IN ANY MANNER SO AS TO BECOME SUBJECTTO THE ��;� (n WORKERS'COMPENSATIONLAWSOFCALI40RNIA,ANUAGHEETHA(IFISHOULUdfCOME INSPECTIONFEE , _ _____ ___ a SUBJECTTOTHEWORKEPS'COMPEN5ATIONPROVISIONSOFSECTION3]o OFTH[LA[iOR � COOE,ISHALLFDflTHWITHCOMPLYWITHTH SEVROVI IIXJS. ISSUANCE ___________ _ '�/ � � � € . � , � . __"'--"' '__"_"""—""_'__ p OATE:�t�� APPLICANT: ___. ,_�..((�:(�}Fi.�_:,..___--_-- SMIP ___}..� ... J WARNIN6:FAILUfiE TO SECURE WORNERS'GOMPENS�TION GOVERAGE IS UNLAWFUI,ANU SMPLL OE ENERGY P/C ��� _______,. ___ _._.__ __ �—y SU&IECTANEMPLOVEFiTOCRIMMALPENALTIESAN�CIVILFINESUPTOONEHUNDREDTHOUSAN� ENERGYPERAM1FT4g�j'+�2'1T TA h/ �%' �O�LARS(5100.000).IN ADDITION TO THE COST OF COMPENSATIIXJ,DAMAGES AS PROVIDED FOP IN ����F{�*+ Y- a�..A 8 f.J�" J SECTION37u90FTHElABORCA�E,INTEREST,ANDATTORNEV'SFEES. RETENTIONF A '+.:'_� � ,, LT�:?�_: ::?�''.'�'' -- d CONSTRUCTION LENDING AGENCY PRE•ALT FEE: � _..--------------'--...-- � I HEREBY AFFIRM UNDFF PENALTV OF PERJ4RV THAT THERE IS ACONSTRUCTION LENDING AGENCY _ _ ______ __ fOR TME PERFOHMANCE OF!HE WORK FOR WHICH TMIS PEflMITI5155UE0(SEC.3097,CIV.CJ. Z w _"_.._.'_"'__..____.—_.__ _''_—_"'.'._.— � LEN�ER'S NAMF"'_""'"__ ._._.._._ 1_ LENDER'SADDRESS w ICERTIFYTHATIHAVEREADTHISA7PLICATIONANDSTATETHATTHEABOVEINFORM�710NISfARRECT. TOTAL�E�S �, d IAGRFETOCOMPIYWITHALLpTVAN�COUNiYOflDINANCESANOSTATEtAWSRELATINGTOBUILDINO � CONSTRUCTION,AND HEREBYAUTHOHIZE HEPHESEN7ATIVES UF iHlS GOUNTY TO ENTLH UPON THE Z ABOVE-LIENTIONED GROPERTY FOR INSPECTION PURPOSES- Q COMMENTS _____,_,_.___.,____ =J 4 /?t(i� � / � " � ��_. .�[_____�- _-_ ._—___—�_ m PERMITTEE NAME(PRINT) � � —_'_' —_"—'_'_"_' ___ ' —_'_ ' `—" �-----�-�,� 'a o� �( � �1.�'�L � - � ontE --- ,. _ . � ._. .--------�- .-�--._.. ,� ._ ,.. � _ _ _.__._ .._ . . ._ -- y .. - _ . _ _ 'YFt 3; • � ; . � . � � ' � ' � ; i I ; � , , �,�� I � � � � � I i i . i � � I � 3� � I { � I � � i � i i ' . . . ' - . . _ � . s�A � ' i 1 � ' � � t � � � � ' . . � � I � ' � . � �°��o i � ' i � . ! � i ' � _ - . i � . . ; - _ • ' . - . ,.�;�A ' , :—- ' _ ,- .. . � __ , �. _.. . . _._.._ . - ,._ ._ ;._ . � .. , I _ . $�;:" i i . � � . �, � , i �;��y: , : , � I , � i I : ` - �� i � I I � i . I I _ , i I E i ' ; , � _ ��� ! ,-- � ;-- � _.. �--- - - ---- � I ' ��Y: i � � . . 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