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HomeMy WebLinkAbout10017 - CTTY OF DIAMOND BAR COMMUNIT'Y DEVELOPMENT DEPARTMENT -.,�w 21660 E.Copley Drive Sui[e 190 PRESS (909)860-3195 Fax(909)861-3I17 .'""' BUILDING PERMITAPPLICATION FIRMLY y JOBSITE •� r • (] APPLICATION PERMIT P/C o ADDRESS ��-�Ls� _] • I�11L:�+��Y1�L� �C��ilDr DATE � � NUMBER M $ ISSUE TYPE OCC APN LOT TRACT DA7E CONST. GROUP p OWNER _ ��a^�`tc;,n. V��.�l��"- p ADDHESS ZONING SETBACKS z CITY Zlp TEL. FRONT RW ❑ � APPLICANT ,�(�.+�C_ia FI..�.��:�c-- TEL REAR q SIDElSIDE STREET RW ❑ CONTRACTOR- ' ,a ' < • SIDE [� ¢ A�DRESS�e�m. �n v�C`.'a '�` �I•P ��' �. p a '�� �f�y ���� PROPOSED USE i o CITY C,�u r��.r,_ Tka.re�ZIP� c. T�tt�`� ?�:_, � w ARCWENG/ WDESIGNER NO.�WEL. NO. NO. I N ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. m u� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BI:ILDER OECLARA710N SFR/ADD/REM O 1 HEREBV AFFIHM UNDER PENALTV OF PERJURY THAT I AM EXEMPT FROM THE CONTqACTORS LI- G9IflQ8/CBIPOR W CENSEL4WFORTHEFOLLOWINGqEA50N(SEC.l071SBUSINF55ANOVROFE5510N5CADE:ANYCITYOR (n U COUNTYWNiCMREOUIqESAPEflM1TTOCONSTHUCT,ALTER.IMPROVE,DEMOUSH,ORNEPAIqANVSTRUC- z TUfiE,VRIOR TO ITS ISSUANCE,AL50 REOUIRES THF APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w P���a�eck w STqTEMENT THATHE OR SHE IS LICENSED PUHSUMJT TO THE PROVISION&OF THE CONTRAC70RS LI� W � CENfiE LAW(CH/MEfl B(COMMENCING WITH SECTION�000)OF�IVISION 30F iHE BUSINESS ANU PRO� LL POOUSp3 0 FESSIONSCO�E)ORTHA7HEORSHEISEXEMPTTHEREFROMPND7HEBA$I5FORTHEAILEGEDEXEMP� (� V TION.ANYVIDLATIONOFSECTION7o31,5BVANYAPPLICANTFOPAPEftMIT9UBJECTBTHEAPPLICANTTO Z RB-R00( r ACIVILPENALiYOFNOTMOAETF4WFIVEHUNDREODOLLARS(f5a0�.�: � ❑I.ASOWNEROFTHEPROPERTY,OHMYEAIPLOYEESWITHWAGESASTHEIfl50LECAMPENSATION, � COrt11178lCIel WILL 00 THE WORK,ANO THE STqUCTURE IS NOT INTEN�ED Dq OFFEFED FOA SAIE(SEC.]a4,BU51� �J � NESS ANO PROFESSIONS CqDE:TNE CONTflACTORS UCENSE IAW�OES NOT APGLY TO AN OWNER OF ? VROPERTY WHO BUILDS OR IMPFiOVES THEflEON,AND WHO�OES SUCNYIORK HIMSELF Op HERSELF OR � THRWGMXISORNEROWNEMFIOYEES.Pi70VIDE0THATSUCHIMVROVEMEN75ARENOTINTENOEDOR C� QOFFEREDFORSALEIF,NOWEVERTNEBUILDINGORIMPF�VF.MENTI6SOIDWITHINONEYEAFOKLOMPLE Z TION,iHE OWNER�BUIL�ER WILL HAVE THE BUPDEN OF PqO41NG THAT NE OR SHE�ID NOT BI/ILD OF ' IMPROVE FOp 7HE VURPOSE OF 6AL�. �y,� ❑I,ASOVMEROF7NEPROPER7Y,AMEXCLUSIVELYCONTMCTINGSYITHLICENSEDCANTMC70R5 � TO CONSTqUCi THE PROJEGT�SEC.70Ia,BUSINESS AND PROFESSIONS CODE:iHE CON)RpCTORS LI� V81113�10(1 ADJ.0.REA W CENSELAWDDESNOTAPPLYTOANOYMEROFAPFOPERTVWHOBUILDSORIMPROVESTHEflEON.ANO --' � WMOCONTMCTSFORSUp1PqOJEGTSWITHACONTRACTOR(5)LICENSEDPURSUM'TTOTHECONTPAF QUANTITY DESGRIPTION FEE Y TORSLICENSELAWJ. � IJ I NM EXEMPT UNDEli SEG__ B.S P.C.FON THIS REASON Q � U ti -- - Q DATE _______OWNER ,__ ` U z W �¢ LICENSED CONTRACTORS DECLARATION W � CC IHEREBYAFFIRMUNDERPENALTYOFPEflJUflYTHA71AMlICEN3EDUNDERPROVISIOiJSOFCHAPiER � � 9(COMMENqNGW1THSECTION70ao)OFOIVISION30FTHEBUSINE55ANDPROFESSbNSCODE,AND Z `X MY LICENSE IS IN FULI FORCE MIO EFFECT. m "'9 ,A� � UCENSE CL4SS �y yI'� [���J�UC.NO.�S�� • V j V �ATE ";�'eY�IS.�•y`17 _ GONTRACTOR _� � W � WORKERS'COMPENSATION�ECLARATION Q ' (� t' '. :• ,r-• � f � IHEREBYAFFIRMUNDERPENALTYOFPEHJURI'ONEOFTHEFOLLOWIN6�ECUHATIONS: � '1 D � Q r' ��3 tZ�.h � I HAVE AN�WILL MAINTAINA GERTIFICATE OF CONSENT TO SELF�INSl1flE FOR WORKENS' S "�1 : A r• 6 QCOMPENSATION,ASPROVIOfU9YSECTION37000fTHElPBORC�UE,FORTHEPEflFORMANCE U �t'- 1 %� � OF iHE WOHK FOR WHICH THIS PEHMIT IS ISSUED. W �°i � ' o � a � c. t�c.�.• � �5#�vh.` �a 5� v� �'l� W I HAVE ANO WILL MAINTAIN WORKEflS'GOMPENSATION INSURANGE,AS FEOl11flE0 BY SECTbN v '�yi � Q ^97000FTHELABOPCOOE,FOf77HEPERFORMANCEOFTHEWORKFORWHICNTHISPFRMITIS `L'� �t� "�°�G�'�r ���'G�l�?{•���+,�,-F-L,<r}� l:�.ti����r t• ISSUE�.MVWORKEflS'COMPENSATIONIjN1SURANCECARRIEflANDPOLICYNUMBERME: CONSTflUCTION jCAHRIER '�C.✓6�35� �l<::R .,�.La Y � �•t= a1 e PL4NREVIEW � -�`'"� � QPOI.!CVNUMBER (,s�r�:. P .� � �� �- ' ELECTRIC '��'"�/]Yn � (�HISSEG�NNE�N�TBEWMft.EfEDOFTHEPE(J.nISWHONEM.NORFDOCU.ARS(51a0�IXiLE55} PLUMBING _ -_..`�--. �!)` Z I CERTIFY THAT IN THE PEFFORMAryCE OF THE WORK FOR WHICH THIS PEHMIT IS ISSUED,I MECH� ANIC_ A_L, �.�i n �S (7 SHALL N0T EMPLOY ANY PERSON IN ANY MANNER SOAS TO BECOME SU&IECT TO THE . (q WORKEflS'GOMPENSATIONLAWSOFCALIFORNIA,ANOAC.REETHATIFISHOULOBECOME INSPECTIONFEE _ SIIBJECT TO TNE WOFKERS'COMPENSATION PpOVIS10N5OF SECTION 9700OF THE LABOP � COOE,1 SHALL FORTHWITN COAIP�V WITH THOSE PflOVI510N5. ISSUANCE _ a g � � � � �-- p �ATE: APPLICANT._. SMIP '_ __� � � J WARNING:fAILUflE 705ECURE WOPKERS'COMPENSATION COVERAGE IS UNLAWFUI,AND SHALL 9E ��RGY P/C LL SU&IECT AN EMPLOYER TO CRIMINAL PENALTIESAND CIVIL FINES UP TOONE HUNDRED iHOUSAND ENERGY PERMIT DOLLAflS(if 00.a00�.IN AODITION TO THE COST OF COMPENSATION,DAMAGES AS PpOV10ED FOR IN � SECTION 97o90FTHE LABOR CODE,INTEREST,ANDATTORNEYS FEES. RETENTION FEE: "'���:y_,ti` � �'"5 OCONSTRUCTION LENDING AGENCY pRE•AL7 FEE: � _. � IHEREBYAFFlRMUNDERPENALTYOFPER1URYiHATTHEREISACONSTRULT1IXJlEN�INQAGENCY _ ! FOR THE PERFORMANCE OF7ME WORK FOR WHIGN THIS PEflMIT Ib ISSUED(SEC.5087,CIV.CJ. Z W - � LENDER'SNAME_ _ _ 1- LENDER'SAOORESS,__ _ _ ¢ ICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETHRTTHEA60VEINFORMATIONISCORflECT. TOTAL FEES W IAGREETOCOMPLVWITN/LLLCITYAN�COUNTYORDINANCESMIDSTATELAWSflELATING70�UILDING � CONSTRUCTION,ANDMEREBYAUTHOflIZEREPRESEN7ATIVE50FTHISCOUNTYTOENTERUPONTHE Z ABOVHdENTIpNE0PF07EflT'FORINSPECiIONPUqPOSES. COMMENTS O -�� j�� � i I'�1��..ls T-1 L�,��e.!'"' m PEPMI'TyTEENAMEIPRIM) Cn 3� /9 � � ..J...��„�(.�'S �, � SIGNRNREOFPEFMITTE DATE �/ i = RECPT.N PAID BY ! UALIDATl01�! ` ~ WHITE—Department Copy.YELLOW—Finance Copy,PINK—Assassor Copy,GOLDENROD—File Copy,GREEN—ApplicanPs Copy ____ �- - - r ._._�. ___..�.__ __.--,_ � r__ _,. � I _._ �; �_�,. ��,_;_��,_ i ._. I.T..�_{ T.� _v.___ --�-- I - :I I - i ! I _ �. �.. l � � ! ' � � i � � � �. � ..� __' i _� � ._ .� I , , 1. I. ��,. ,. � I _ I' � � � _ �:: . � I I i . ' � . � � � ; . �,. _:_� I : `. 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