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HomeMy WebLinkAbout13181 (14) _ �,�_ CITY OF DIAMOND BAR � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �, . 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-31I7 PRESS ��'�^'"' BUILDING PERMIT APPLICATION FIRMLY o DDRIESS 6U_ /�_�/I�.GyIl'1 / DATE CATION NUMB A 1�,� � #/C � � APN LOT TRACT �SSUE - TYPE OCC p OWNER It� DATE � I CONST. GROUP o ADDRE ZONING SETBACKS � ' `' � FRONT RW U__ CI i^ZIP TEL. �' `' APPLICANT TEL. REAA n_,___ � SIDElSIDE STREET RW CJ � CONTRACTOR ,� SIDE CI � ADDRESS p C� �, Z�P , � U. �) PROPOSED USE w ARCH/ENG/ - � z DESIGNER a ADDRESS NO.DWEL. NO. NO. � �'- CITY 21P TEL. UNITS STORIES BEOROOMS � u� - cn DESCRIPTION SQ.FT FACTOR PSF ADJ.AREANALUATION � o OWNER-BUILDER DECLARATION SP WADDhIEM E I HEREBY APFIRM UNDEH PENALTY OG PEfi.IUFY THAT 1 AM EXEMPT FROM THE COMRACTOAS LL Gef3gE/C81p011 � W CEN9EUWFORTHEPDLLOWINGREASON(SEC.7o31.5BU31NE55ANDPROFESSIONSCODE:ANYGTYOP (n F U COUtJTYW{{�q{pEWIPESAPEflMRTOCONSTRUCT,PLTEf1,IMPROVE,DEMOLISN,OHflEPAIRANYSTRUG W Patio/Dack � NP.E.PRIOR TO ITS ISBUPNCE,AlSO RE4UIRES iHE APPUCANT FOR SUCH PERMIT TO FlLE A SIGNED � � STATEMENT THRT H6 OR SHE IS UCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI� � CENSE LRW(CHAPTER D(COAIMENCING WITH SECTION 7oDa)OF OIVISION 90F THE BUSINESS AND PRO- POOUSp2 t '� FE5510NSCOD�OA71iATHEOR5HEISE%EMPTTHEREGROMAN�TNEBASISFORTHEALlE�EOEXEMP� � y V TqN.ANYVI0UT10NOF5ECTION70.91.58YANYPPPLIGANTFORAPERMITSU&IEc7STHEAPPLICANTTO Z qe•Roof 1 F, ACINLPENALNOfHOTMORE7HANfIVEMUNDqE�DOLlARS(S5v0)J: � ❑I,ASOWNEROFTHEPROPERTY,ORMYEMPLOYEESWITHWA6ESASTHEIqSOLECAMPEN9ATIDN, � Commerciai � � WILL W 71�E WORIC,M!D THE STRUC7l1RE IS t10T INTENDED OR OFFERED FOfl 5ALE(S6C.]044,3U51� J ! � kEBS PND PROFESSIONS CODE'TNE CONTRACTORS LICENSE LAW DOES NOT APALVTO AN OWNER OF � � PROPEfirl'Vh1D 8URp5 OR IAIVROVE5THEREON,PNO WNO DOES SUCH WOqN HIMSELF OR HERSEIF OR � TNROUOMMISORHEROWNEMPLOYEES,FROVN]EOTMA7SUCNIMPFlOVEMENTSARENOTINTFNOE�OA m QOFFEAmFORS/�LEIFNOYlE1lEFLTHEBUIIOINGORIMPROVEMENT1550lOWrtHINONEYEAROFCo�1PLE � TpN,TNE OWNEH$UILDER WILL HAYE THE 9URDEN OF 7qOVINR THRT HE OR SHE DI�NOT BUILA OR IMPNOYE FOR iNE PURPOSE OF S,LLE�. W ❑I,A60WNEflOFTHEPROPFHTI'.N�7EXCLUSIYELYWNTMCTINGWITHLICENSEDCOMfiACTORS y � TO CONSTRUCTIHE PRO.IECT(SEC.70H,BU51NE55 AND PROFESSIONS CODE:THE CONTRACTOqS LI� VeI1121�1Of1 A�J.AREA � W CENSEUWDDE3NOTAPPLYTOANOWNEqOFAPROPERTYWHOBUILOSORINPROVESTHEREON,AND -"'—'� —'—"� -- E � VIIIOCONTHACTSFOp5l1CMPRQIECTSWITHACONiRACTOR[5)LICENSE�PUflSUANTTOlHECONTpqC- Q���1,NTITY DESCRIPTION FEE Y roasuc�seuw.�. � � IJ I AM E%EMPT UNDEfl SEC. ` _B.8 P.C.FOR THIS REASON U j �! _ � -__ t � - � � OATE oWNER __ __.._ U W ( � LICENSED CON7AACTORS DECLARATION � '� � I HEREBV AFFIRM UNDER PENALTY OF PEHJURV THAT I AM UCENSF.D UNDER PROVISIONS OF CHAPTER � j p� B(COMMENCINOWfIHSECTION7a00)OFDIVISION30FTMEBUSINESSANDPROFESSIQ�SCO�E.AKU Z ' � ?C MV LICENSE�S IN FULL FOflCE ANO EFFECT. � o � r��e� fC� — � 4 LICENSE CLASS_g_.��UC.NO._, �.+- � ( U DATE CONTRACTO� P d � W B � tt� WORKEpS'COMPENSATION DECLARATION � � Q � U N 1HEREBVAFFIRMUNDERPEN/LLTYOFPEt3Jt1flVONEOFPHEFOLLOWINGOf:CIARATIONS: Z % 1 � _IHAVEpNDWILLMAINTRINACERiIFICATFOFCONSENTTOSELF-INSIIREFORWORKERS' _ � Q CAMPENSATION,ASPROVI�EDBVSEC710N870oOFTHELABORC00[,FORTNEPERFORMANCE �U � OF TNE WORK FOR WHICH THIS PFqM1T IS i55UE0. � ;, W ,IHAVEMIDWILLMAIMAINWORKER3'COMPENSA7�O41NSUPAA'(:E,ASRE�UIRc'CBVSECTIqV � Q 97000FTHELABORCODE,iOFTHEPEfl�ORMANCEOFTHEWORNFORWHICHhIISPERMITIS ,� ISSUED.MYWDflKEqS'COMPENSATIONINSURANCECARFIERANDPOLICYNUMBEpARE', CONSTRUCTION a ,.�p� � --------- ------ ;: � CARHIEN_,� f""-�}�-�� PLAN RE�/ItW . "'_"__" ___"_ — � POLICYNUMBEH �� .��`E"-L-/A� .. __-. ELECTRIC k Q -- - --------�r� (iHI5SEG7qNNEmt�TBE07�FLETEDOFTHEPEW.YfISFORONEF0.N.OFEDDDLIPAS(5��7�RL6RSF PLUMBING S O __-___ _______._ a Z ICERTFYTMATINTMEPERFORMANCEOFTHEWORKFORWHICHTHISPEfiMITISI3S�JED,I MECHANICAL ___ _ _,__ _ ` U' SNALLNOTEMPLOYANYPERSIXJINRNYMANNERSOASTOBECAMESUBJECTTOTHE -�M1?r'b. � � WORKERS'COMPENSATIONLAWSOFCAIIFOHNIA,ANDAGREE7HATIFISHOULDBECOME INSPECTIONFEE _,-'�'+.[1„��+t.' __.,,._____,____ SUBJECTTOTHEWORKERS'COMPENSATIONPROVISIONSOFSEC'ION37000f7HLL480R -1,.�•" �/^1/'1 f � CODE,ISHALLFORTHWITHCOMPLYWIiHTHOSEPROVISIONS. �SSUANCE _.,_____��___ l/6/ ` � SMIP ' �`��_ p DATE:__ ._. APPI.ICANT: --„ -- � --'--- -- '-' '—" ' - -. . , ¢� w ENERGY P/C . .Cj. z,j-- .-.-�r�6.> --...---' "_ I J WARNIMC:FAILURE TO SF.CURE WORKEHS'COMPENSATION COVEqAGE IS UNIAWFUL,AND SHAl1.DE �s�i —�-,,, LL SU&IECTANEMPLOVERTOCRIAIINALPENALTIESANDCIVILFMESUPTOONEHUN�RE�THOIISANO �,�::' . l� � UOILARS(Si00.000�.INAO�ITIONTOTHECOSTOFCOMPEN5AT10N.DAMAGESASPROVIOE�FORIN ENERGYPERMIT ._ _ �k _.___._„_____ ___ - J SECTION77080FTHELA90RCO�E,MTEREST.ANOATTOPNEYSFEES. + ' �'�P' FETENTION FEE: '�� `-' � p CONSTRUCTION LENDING AGENCY ` ��' �` � �� � ' __ E PRE-ALT FEE:'+...-'"..�;�'a':�- � IHEflEBYAFFIRMUNOERPENPLTYOFPERJUFYTHATTHEREISACONSTRUCTIONLEN�INGAGCNCY ___ J�'�'�'___ S ��� E FOR iXE PER W FMANCE OF THE WORK FOR WHIGH THIS PERMIT IS ISSUED�SEC.3087,CIV.GJ. � � __" _ ""'_" " "_— g � LENDER'SNAME __ _ ___- "_ . ._'__ '__ __"_' { F- IENDEi15A0OHE55 "_'""' __ � ICERTIFYTHATIHAVEREADiHISAPPLICA710NANDSTATETHATTHEABOVFIN(ORMATKKJISCARRECT. TOTAL FGES � w IAGREETOCOMPIYWiiHALICRYANDCOUNTYOADINANCESANDSTATEL4W5FiELATINGTOBUILDING � CONSTRUCTION.M1D HEREBV AUTFiORRE REPReSENTATIVES OFTMIS Col1N7V 70 ENTER UPON THE /� Z ABOVEMENTIONED PROPEHiV FOp INSPECTIDN PUFP0.5ES. �A�_/��� , jlA� 1��� _—_ � COMMENTS l. � d � /.C� ��.�.._�,y�_ � � ��.`�•,/�i'2'"/t21.�. ��'d .�.�.`2..raL�¢✓l�' — __ l/ � �.+� -- - m PERMITTEE� ,s � � Q ..�,'�""',�`��,�� ' -,� - -- - - -- �, � �, ��_(������ , � SIONATUREOFPEHMITfEE DA7E ��' �7 3 Z RECPT.NO. .__PAID 8Y ' �-'_�� VALIDATIOI t r WHITE-�epartment Copy.YELLCW�inance Copy,PINK-Assessor Copy,GOLDENROD--File Copy,GIiEEN-Applicanfs Capy � � ��� __ ' . ... _.. . _._.. _ .-. . _ _.._ ._ �. _ _ __ _ ... - . ; . .-..,.' . _ - .... . _ __.._._.__ ...-- --� .. r � i � � �w � i � � � i . I � . f ; , I � , ,�.� , � ' - , � : . � . 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