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HomeMy WebLinkAbout14544 (19) �:,��_ CITY OF DIAMOND BAR � - DEPARTI 4ENT OF COMMUNITY&DEVELOPMENT SERVICES �g . . 21660 E.Copley Drive Suite 190 �� � (909)860-3195 Fax(909)861-3117 PRESS �`'91" BUILDING PERMIT APPLICATION �� FIRMLY i � J�BSITE APPLICATION�` ) r- PERMIT �(/ P!(�/ `F', � Y DDRESS I y oil ���t2i�r�-t�aa.. L..t�N�' l ~L^� �� f / `� ul.�~�C� p DATE NUMBER # I � � ISSUE TYPE OCC ! APN LOT TRACT_ DATE CONST._ GROUP I o OWNER _�fPR'nir�ivr�f A+N i � ADDRESS_ ��Cl�f'�e:vZ/L/611(,a�+�'"GL L/4�vt'`"-� ZONING SETBACKS w � FRONT RW Cl CITY��/�:Mc�:/::A ��LZIP TEL.�1'6f1^JC/rt� REAR ❑_ PLICANT,T EkG L� y t^K k"T"l'f TEL. SIDE/SIDE STREET RW U � CONTRACTOR r:• ��dN e" p! SIDE r7 ADDRESS, ' /� . r ^ ' ..-� p PROPOSEDUSE J�'A-P (.��"/' �i �.h�`!'�� �CE 'S�G'�ddCT aTv Clp�:xt�+sp Ci�. ZIP �/"7Sf(`,TEL.���e'.��+��r •��} ----� �� DES GNER -l'L6�'Z�l.� j/�+�i��L� � `i� �7 �� F=_r Tt� ,��- ADDRESS NO.DWEL. NO. � NO. � CITY ZIP TEL. UNITS >fivlr�/=____ STORIES � BEDROOMS�_` � DESCRIPTION SQ.FT. FAC70R PSF ADJ.AREANALUATION Q OWNER•Bl11LDER DECLARATION SFR/ADDIREM O p 1 HEREBV AFflRM UNDER PENALTV OF PERJURY THAT I AM EXEMPT FqOM THE CAN7RAC70FS LI- GafagBlCefPort LLl CENSEIAWWNTHEFOILOWINpRFA50N(SEC.70.97.SBUSINESSANDPROFESSIONSCODE:ANVCITVOp . � U CpUMYWHlGlREOUIpESAPERMITTOCONSiRUCT,ALTEA,IMPAOVE,OEMOLISH,OflREPAIAANYSTRl1C- Pd110/DBCk W Tl1RE.�RIOR TO ITS ISSUANCE,PL50 RE�UIRES TME�VPIICAN7 FOR SUCH PERMIT 70 FILE A SIGNED STATEMENT TNAT HE OH SHE 19 LICENSED PURSUANT TO THE PROVISIONS OF THE COMR4CTORS tl- � CENSEUW(CHAMEA9(QDMMENCINGWITHSECTION70ao)OFOIVISIDN30F1HEBUSINESSANDPRO- V" PaOUSpd FESSpNS CODE�OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLE6E0 EXEMP- 710N.ANYVKKRTIOHOFSECTION7087.56YANVAPPLICANTFORAPERMITSl1&IECTSTHEAPPLICqNTTO Z Re•Roof �,�(� ��(1��J ! r A CML PENAL7Y OF NOT MORE THAN FfVE HUNOAEO 00LLAF5(5500)J: y~ � ❑1.1150WNEROFTHEPROPEH7Y.OHMYEMPLOYEESWiTHWAGESASTHEIRSOLECOMPENSATION, � Commerciai 0 Og R WILL DO TNE WORK,AND TNE STRUCTURE IS NOT INTENDED OP OFFEfiEP FOR SALE(SEC 7aa<,BU51- J � NE55 AND PiWF�5510N5 CODE:THE C9t7rPAC70flS LICENSE UW OOES NOr qpp�Y 70 AN OWNER OF � PROPERiY NM1IO BUILD50R plPROVES 75iENEON,AND WHO DOES SUCH WORK HIMSEIF OR HERSELF Oq (t T}IROUGHNISOqHEROWNEMPLOYEES,VNOVIOFDTHATSUCHIMPPOVEMENTSARENOTINTENUEDOR m . QOFFEREUFONSRLEIF,MOWEVERTIIEBUIIDINGORIMpROVEMENTI550lDWITHINONEYEpROFCONPLE� z TION,THE OWNER$111LDEH WILL HAVE THE BURDEN OF PROVING THAT HE OA 9HE DID NOT BUILO OR = IMPROVEFORTNEPUflPOSEOfSALE). � w ❑I,ASOWNEROFTHEPROPEFlfY,NAE%CLUSIVELYCONTfiAC71NOWI7HlICENSEDCONTRACTORS �y � TO CONSTPUCT THE PRDJECT(SEC.70/4,6USINE55 PN�PROFESSIIXJS CODE:TNE CONTHAGTORS LI- V811/BIlOf1___,� -_�V"� ADJ.AREA W CENSEUWOOESNOTAPPIYTOANOWNEHOFAPNOPERTVWNOOUiLD50RIMPROVESTNEREON.MlD � WHOCOMRACTSiOPSUCMPRQIECTSWITHACONiRACTOR(S�LICENSEDPUR9UANTTOTHECONTMP UANTITY DESCRIPTION FEE � TOp3L10EN3EUW.�. 0 ❑1 NA EXEldPT UNDER SEG B.&P.C.FOR THIS REASbN � � U - � LL DAYE ONRJER_""_'___---_"'...__.-, U W � LICENSED CONTRACTORS DECLARATION W � INEFEBYAfFIRMUNDERPENALTYOFPEflJURYTMATIAMLILEMSEDWJDERPAOVISIOM50FCN�P7ER � d g�WMMENCINOWITH3EC7qN7aaolOFDIVISION30fTHEBUSINESSANDPROFES510N5CODE,AND Z �j� MY LICENSE IS PI NLL FORCE AND EFFECT. m 2 / g �/� � � LICENSECLASS/71�' �±�7� LIG.NO.�Q_�_�_�iL_�_____-___.. � /� J V DATE E" ��^ L]Q'J CONTRACTOfi�P7a.�+,,.l��j -r�'r ! 2 p. W Iy � WORKERS'CpMPENSATION DECLARATION r�,, •"y�1' d � IHEAEBVAFFIqMUNDERPENPITVOFGERRIRYONEOFTHEWLIOWINGDECLARATION� ,J U � Z Q � _IHAVEANDWILLM0.INTAINACEHfIFICATEOFCONSENTTOSELFdNSUHEFOftWORi(ENS' 2 CUMPENSATION.dSGROUlOEDBYSECTION3]OOOFTHELPHORCODE,FOFiTNEPERFORMA�CE LL' OF 1HE WORK FOR WHICH TMIS PERPdR IS ISSUEU. g � � � _�HAVE ANU WILL MAINTAIN WORKEPS'COMPENSATION INSUHANCE AS FiE�U1RED DY SECTION � ;�1 .sy� � O 37000FTHELA6DFCA�E.fOflTHEPERFORAIANCEOFTHEWOPKFORWHIGHTHISPEflM1T15 //J --_ -- - � � ISSUEO.MY WORKERS'COMPENSATION IN3URANCE CARRIERANO POiICY NUM9ER ARE: CONSTRUCTION��✓� �_[' J __ _ _ _. _. { 6J �Q � cnaAieR 7 T l�'P�� ����✓_y�-- � PLAN REVIEW F ZPOLICYNUMBEP�����+�-�e'L°��`����.t ELECTRIC _ l��----- -. ------_._' � a � � � (IF65El.TIONNE�NDTBEWHPI..EfEDOFTEPEF�fISFOR�M1EMA�tED00l1AR4(310D) �Ess). PLUMBING _ W _'_Y'.RxY_.__,__..____'__'_�.- x I CERTIFYTHAT M THE PEflWRMANCE OF THE WORK FOR WHICH THIS PEflMIT IS ISSUED,I MECHANICAL _,...____"�.��✓'�.�,J+-, � (°J SHHLLNOTEMPLOYANYPEfl50NfNANYMANNEFSOA5708LC041ESUeJECTTOTNE - i� N WOpKEHS'COMPENSATIONUWSOFCALIFORNIA,ANDAOREETHATIFISHOULOOECOME WSPECTIONFEE _ i;,�;�y ��r�_ . � SUBJECTTOTHEWORKEFS'COMPENSATIDNPROVISIONSOFSECTION37a00FTXELA60R •.� � y, � CO�E.I SHALL FORTHW17N COMVLY W�TH THOSE PROVISIONS. ISSUANCE _„ . ,_______ � �� +r� � � . �...�r�.• . .5.. 9 (,� p DATE: APPLICANi: ___ SMIP .. .""_._."__�___'..`1.'_"._'�rt� 7�C� W �Y ENERGYPlC ����� ��` ��"t J WARNINO:FAILURETOSECUREW�RKERS'COMPENSATIONCOVERNGEISUNLAWFUL.ANDSHALLBE —-'� �-'-�"'----"'--' �— � LL SUBJECTPNEMPLOVERTOCRIMINALPENALTIESANDqVILFINF.SUPTOONEHUNDREDT1i0U3AND ENERGYPERMIT �"1' ��'�"^. __ DOLLARS(t�uU.000�.INADDITIONTOTHECOSTOFCOMPENSATION,UAMAGESASPflOVIDEDFORIN y ;; � / � SECTION 3�oa OF 7HE LABOR CODE,INTEREST,qND AT70FiNEV'S FEES. RETENTION FEE: � ��1��f�� Y?�e , d O CONSTRUC710N LENDINQ AGENCY pRE- LT FEE: L�_ ���'�� :� ..i: --- � IHEREBYAFFIfl61UN0Ei1PENALNOFPERJURYTHlTTHFREISACONSTRUCTIONLENDINGAGCNCV � . ,_ FOR THE PEfiFORMANCE OF THE WORK FOR WHICH TNIS PLflWIT IS ISSUEO(SEG 309"!,CIV.CJ. i � � �y � Z _ ___"._"'_"'__"_ � '._""' '_"_-_"_— '-'"' � � "-_".�__ LENDEH'S NAME F- LENDER'SADURESS.____ ----- WICEFlTIFYiHpiIHAVEHEADTHISAPPLICATIONANO57ATETHATTHEABOVEiNFOHMATqNfSCOFFEC7 TOTAL FEES • d IAGREETOCOMPLVWITHAI.LCINMIDCOUNTYOFlDINANCESANDSTATEIAWSRELATINGTOBUILDING ,.R CONSTflUCTION,ANOHERE6YAUTHORIZEREPRESENTATIVESOFTNI5Wl1NTYTOENTEflIIPONTHE —^'_ -- � ABOVE�MEMIONEDPROPERTVFORINSPECTIONPl1RPOSES. !�� N_�/y1/� COMMENTS --� .a� 5��n ��.-t....� J a !/ J _�, � . tl+����_ _- - _._..�- � ' m PEftMITTEENAME(PRINf7 ____ ¢ �'�� 1� /l��n�-1. �' �.�"6 ^' � � � NA PEOFPERMITT �' �ATE � � RECPT.N0. 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