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HomeMy WebLinkAbout13057 (16) • _ 1�_ CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DE 21660 E.Copley Drive Suite 190 � � �"�% (909)860-3195 Fax(909)861-3117 PRESS �' �'°w' BUILDING PERMIT APPLICATION FIRMLY � JOBSITE APPLICATIO (� PERMIT .,� e" P � ADDRESS I � .�b �S. r Gl�yy rs r1 �t� r+�r/ DATE �~�� l�• NUMBER��J����� # ��� � ISSUE TYPE��� OCC APN LOT �ACT DATE___ C��)� GROUP p OWNER �j l��i.t C'���' a_ Cy^�r"..1 IPPi P�'I�udL ADDRESS ZONING SETBACKS w FRONT n r T n " � ❑ Z CITY ZIP TEL� ' t ' �-. 5� REAR ' �� — O. p APPLICANT TEL. SIDE/SIDESTREET RW ❑. Z — a CONTRACTOR • CN l:.e_�` �� Y1 /✓,��j SIDE _ L7„ �� ADDRESS��l�s5i` M ' - j� �' CITY f P��CrCS �,'�.�r_ ZIP tj�;�c� TEL. .9` _:'7 9�4:?�a ROPOSED USE__�. .a w, ARCH/ENG/ �~ --' — z- DESIGNER — — W; NO.DWEL. NO. NO. a; ADDRESS UNITS STORIES _____ BEDROOMS � CITY 21P TEL. �n- y DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER-BUIIDER DECLARATION SFR/ADD/REM O 1 HEflEBY AFFlRM UNDER PENAL7Y OF PERJURY THAT I AM EXEMPT FROM THE COYTflAGTORS LI� Gfi(d90/CBfDOff W CENSEUWFOHTNEFOLLOWINGREASON(SEC7031.591/SM�SSANDaROFE55!ONSC/`�EM1YYCITYOit (/� [3' COUNTVWNICHRE�UIRESAPERMITTOCqNSTqUCT,ALTEF,IMVROVE,DEMOUSH,ORREPAIRANVSTRUC- W PgfiO/�BCK WTI1FE.GRION TD ITS ISSIIANCE,AL50 qEIXlIFES TNE APPLICANT FOR SUCH PEflMIT TO FlLE A SIGNE� W STATEMENT iHAT HE Oq SME IS LICENSED PURSUMlT TO iHE PROVISIONS OF THE CONTRACTOR9 LI� � CENSE LAW(CHAPTER e(COMMENCING WITH 9ECTION laoo)OF DIVISION 90F THE BUSINE95 AN�PflO� LL' POOVSPB FESSIONS CODE)OA THAT HE OR SHE IS EXEMPT THEREFROM AND THE BA515 FOR THE AI.LEGED EXEMP� V TpN,ANYVI0LAT10NOFSECTI0N7031.58VANYAPPLICANT�ORAPERAAITSU&IECTSTHEAPNLICANTTO Z Re-Roof � ACIVIL PENALTV OF NOT MORE THAN FNE HUNOflED DOLLARS(S50o).�: -- � ❑I,ASONTIEROFTHEPROPERT',ORMYEMPLOYEESWITXWAGESASTHEIRSOIECOMPENSAT10N, C, COR11110fC181 WILL 00 TNE WORN.M1D THE STRUCTURE IS NOT INTENDEU OR OFFERED FOR SME(SEC.70N,9USI- � � NESS AND PflOFE5510NS COUE:7HE CANTRACTORS UCEN3E lAW DOES N07 APPLV 70 AN OWNER OF ? PROPERTY WFIO BUILOS OR IMPROVES THEFEON,ANO WHO OOFS SUCH WOFK HIMSELF Oq HEflSELF Ofl Q THHOU(iNHISORNEROWNEMPLOYEES.PROVI0E0THAT5UCMIMPHOVEMtNiSARENOTINTENOEDOR m � OFFEREOFORSALE.IF,NOWEVERNEBUIL�INGOflIMPROVEMENfISSOIDWITtIINONEYEARQFCOMPLE� Z TION,THE OWNER-9UILDER WILL HAVE THE BUR7EN OF PPOVING THAT HE OF�SHE OID NUT BUIID Ofl � IMPqOVE FORTHE PUflPOSE OF SALE). ❑I,A40WNEPOFTHEPROPERTY,AMF.%CLUSIVELYWNTRACTINGWITliLiCFN5EDIX;N7RqCTORS � — � 'O CONSTRUCT TME PRQIECT(SEC.7044,BU91NE39 ANO PFOFESSIOMS(%:DE:7 HF COhTRACTOR3 LI� VaWetI0f1 •'�.[`�.�,� ADJ.AREA_ _ W� CENSEUWDOESNOTAPPI.VTOANOWNEROFAPFOPEflTYWHOBUIltl60HIMPROyESTHERFON,AND � - '- � N7qCONTMCTSFORSUCHPRQIECTSWITHACONTRACTOR(S)LICENSE�PUflSUANTTOTHECON7RAC QUANTITY DESCRIPTIUN F�E Y TOHSLICENSEUW.). _ _ � ❑I AM EXF.MP7 UNDER S�C. ____B.8 P.0 FOR 7HI5 FEASON J � U � �1_���.11-��_ ■/� ,,,_ a LL OATE�+^L.� »•�� OWHER_�43 1 U — lL � LICENSED CONTRACTORS DECLARATION W � I HEflEBY AFFIRM UNDER PENALYY OF PF.RIURY THAT IAM LICENSLD UNU[R PROVIS:ONS OF IAPTE � d 9(COMMENCMN3WITHSECTION7000)OFDIVISION30FTHEAUSINESSANDPROfESGIIXJSCCD,� Z ,. • X MY UCENSE IS IN FULL FCHCE AND EFfECt �( � � LICENSEaCryLASS_C--_�___LIG.NO._L(�`p�a',.�`�ie-u(� _._L_"_ j V DATE�_��,��,_._CONTRACTOR rv r'C�,�S7_1.��� a - --I 17J �+ � WORKEFl.i COMFEiJSATION DECLARATION ��i� -� ��j N IMEFEBYAFfIRMUIY.)ERPEhALNOFFERJURYOhEO�THEFOLLOWINGDF.CLARAT10fJ9�' U N � E � IHAVEANOWIILMAINTAINACERTIFICATEOFCONSENrTOSELF-!\Sl1RGFORWOqKEHS' _T_ � lCOMFENSATION,ASPflOVIDEDBVSCCri�3�OJOFTHELABORCOOE,f'ORThI'ePERFORMANC'c �U �____ OF THE WORK FOR WHICH THIS PFRMIT IS ISSUED. C] � _ _L F _IHAVEANDWI�LMAINTAINIVORKERS'COMPENSATI041;15URANCE,ASAEaIiIRE�6Y5cCTION __ . „R Q3]OOOF7HELABOfiCCAE,FOiiTHEPERFORMANCEOFTHEWOPKFORWHIC!iTHISPEflMITIS " _ ISS�ED.MV NK7RKERS'IXJN.PENSATION INSUFANCE CARRIEF M'D POLIGY NUFIBEH�FE CONSTRUCTIO ___.._. ___ __.___��,_f ___,.�- y cARRIER -'---- '-"----.._ '-- PLANREVIEW ����,__ -.. ---'. �l..l''...l1 ./ - - -- � PouCYNUMBEa __—..'_ __.'..._"__ ELECTRIC __ __ __.-_.. .__-.__ __ ¢ � ply]- fn�SEcnoraNE�rvo7eeo�.u�.[r�oFir��ram'��ouEtax�c�[owuntis(sioo!oa�Ess�. PLUMBING -•� �—.._--_�., -�-'-- --`--- � ICERTIFYTHATINTHEPERFORMANCEOFTHEWORKFOFIWHICHTHISPERMITISISSUEf1,1 MECHANICAL __ __ � � � __.__ (J SHAl4NOTEMPLOYANYPERSONINANYMANNER50A5TOBECA41E5UBJECTTOTHF -��p ^ � � WORKERS'COMPENSATIONLAWSOFCkLIFORNin.AN�AGREETHAiIFISHOULOBECOME INSF.'.ECTIONFEE _.__.,,__ ____,., � SU&IECTTOTMEWORKFRS'GOMPf.N5ATI0NPROVISIONSOFSC:CTION37000FTHELABOft ( �• ^�.., ( �� ��• � COOE.ISHALLFOHTHWIiHCOMPLYWI7HTHO5EPAOVISIONS. '{ISSUANCE� _,_„ t �J��;.1���_— �9 �p \ `r.��' :`__ r�__ Ip DATE:� cq APPIICANT: � \ t SMIP�y� __ .. �' -p ��--+�r'..F'--.•_-��• o -�-i--F-_ _1l�' s:'a_..��- -- \.` �_p. ,�.,,,2,, J — � Vaip'iJ" _'"_""_—' ENERGY P/C _..�-_ ��'� ' r'^''�" J WARNING FAILURE TO SECUF,E WOFlKElYS'C061PENSA71OY COVEAAGE IS UNLAWFUL,ANU SHALL BE ' ��:T-"' LL SUBJECTANEMPLOYERTOCRIMINALPEN�LTIESANDCIVILFMFSUPTOONE141NDREDTHOl15AND ENERGYPERMIT 1��� ^:����� OOLLAflS�f100.000),INADDITIONTOTHECOSTOFCOMPF.NSATION,DAMAGESA9PROYIDEDFOHIN - -- - ,�i,`�,� , �---'- - ------ � SECTION]]aBOFTHELABOHCOUE.INTEFEST.ANDATTOFN[Y'SFEES. RETENTIONFEF.: __��'�l"__._ ' "__ .. ...-""' QCONSTRUCTIONLENDINQAGENCY PRE-�LTFEE: ��'_J ` _______._____._. Q 1HERE�YAFFIFMUNDEFPENALTYOFPERJURVTHATTiiERFISACONSTflUCTIUNLENDINGAGGNCY ___ _' ___ _ ' � ��' _"_.r_'_'-_�.. FOR TFIF PERS"ORMANCE OF THE WORK FOR WHICH TMIS P!liM1T IS ISSUE��SEG.3a9],CIV.C). � � �� .r W ; -- -� ----.- -----��-��-,._ ���_J_. T IENDER'SNAME_'^"_'_""'_""_'_ '_ __ _'___ " S �.�... .."_ _"__-"_____'__' > F- LEN�ER'SA��HESS__ -_._.-_- .------ � ICERTIFYTHATIHAVI:REA�THISAPPI.ICATIONANDSiATETHATTHEAHOVEM�ORMATiONISCORREC7. Tl/TAl_��E� w IAGqEETOCOMPLYWITHqLLQTYANDCOUNTYOflDINANCESANOSTA7EL�1W3RELATINGTO0l/1LDING � CANSTRUCTION.ANOHEREBYAUhiORIZEREPfIL5EN1'ATIVESOFTHISCUUNTV70ENTEHUPONTHE � AOOVE-MENTh�NEDPROPERTVFOR�NSPEC710NPURPOSES. Z COMMENTS __.__. � �rc'�::,>� � �� --.....----- --—- , -- _ --- - --- - - �%- -��--�-��� ---�- ; Q PEFMITTEE NAME(PF�Nf1� _� _-- � ��.��y-------�----_ Uj SIGNATUAE OF PERMITTEE �ATE •'��� I .= RECPT.N0�_PAI�BY _ _ __VALIDA710N ___ ~ WHITE-Depahmant Copy,YELLOW-Finence Copy.PINK-Asssssar Copy,GOLDENRO�-File Copy.GREEN-Applicanfs Copy � - -.. _ ... . .. . .. .. ... . ... . .. ; . ._ . . . , � . ._ .. , , � - ' . ' � ' � � . . . ' . . _ - . , i i . .9 _ , . � ' ' . � ' - , . � ; .. ' � � . ' ' � � . - ` :` ' � • ' - i . ,.. ... , � � : � � � .. ' �- � � � - �� . . 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