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Home My WebLink About12562 (13) r CITY OF DIAMOND BAR ;�•�t,, ! -----�� - DEPARTMENT OF COMMUNITY&DEVELOPMENT SERV[CES - ,� � I 21660 8.Copley Drive Suite 190 I � ; � (909)86(�3195 Fax(909)861-3117 ( ��. � PRESS � BUILDING PERMIT APPLICATION ``��"� FIRMLY ..WM�• y JOBSITE rt.- (� APPLICATION ( S � PERMIT ` P/ r � Q `DDRESS L� •� S.t�{�� 17� � � DATE `� ``"" ` N MBER I��o�# � � .- APN lOT T ACT DA EE v � �v CONST. GROUP � p OWNER — (iI �; " ADDRESS O ZONING SETBACKS � w D FRONT RW Cl__,__ F o CITY 21P TEL. APPLICAN TEL._ REAR tJ______ : Z SIDE/SIQE STREET RW L J._ � � CONTRACTOR SIDE C____ � � ADDRESS PROPOSED USE_T�I V►'rY � � CITY ZIP TEL._ w ARCH/ENG/ ` W �ESIGNER NO.DWEL, NO. NO. f = CDDRESS Z�P TEL. UNITS STORIES __BEDROOMS ; � F � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION �. � OWNER-BUILDER DECLARATION SFR/ADD/REM O {, I HEREBV AFFIq�I UNDER PENPLiY OF PERJURV tHAT I AM EXEMPT FROM THE CONTRACTORS LI- GaragB/C2fPOR ? W CENSEUWWHTFIEFOLIOWINGREASON(SEC.70.91.58USINESSPNDPFlOFESSIONSCA�E:ANYqTVOR U COUNTYWNICHREIXIIRESAPERMITTOCONS7'RUCT,PL7E(i,IMPROVE,DEMOLI5H.OPPEPAIRANYSTFlUC- pyti0/DBCk Z NflE,PRIOR TO ITS ISSUANCE,AlSO RE�UIRES THE APPLICPNT FOR SUtli PERMIT TO FILE A SIGNED W STATEMENT 1}iAT HE OR SHE IS LICENSED PURSUpNT TO THE PROVISIONS OF THE CONTRACTORS LI- W � CENSELAW(CHAPTEfl9(COMMENCINOWITHSECTIIXJ7000JOFDIVISION30FTHE6U51NESSANDPliO- LL" POOUSPd ' FESSpNSCO�E�ORTHATHEORSHEISEXEMPTTHEHEFROMANDTHE8A51SFORTHEALIECEDEXEMP- � TION.ANYVKKATIONOFSECTION7031.56YANYAPNLICANTfORAPERMITSUHJ[CTSTHEAPPLICANTTO z Re-Raof � AqVIL PEN�LiV OF NOT MORE iHAN FtVE HUNURED OOLURS(SSOD).): � ❑I,ASOWNEROFTHEPHOPERTY,ORMYEMPLOYEESWITHWA(iESASTHF.IR50lECOMPENSATION, 0 COrt1R10fC18I WILL 00 THE WORK,AND THE STRLICTUHE IS NOf IHYENOED OF OFFERED FOR SALE�SEC.70d4,BUSI- .,J � NE53 AND PROFESSIONS COD[:THE CANTFACTORS LICENSE LAY�DO[5 NOT ADPLY TO AN OWNER OF = PROPEHTY M1FI09UILD5OH IMPROVES T1EflEON,AND WHO DOES SUCH WORK HIMSELF OR HF.RSELF OR CL 7Hi10UGH HIS OR HER OWN EAIPLOVEES,PROVIDE�THAT SUCN IMPROVEMENTSARE NOT INTENOED OR m QOFFEflEDFORSALEIF,HOWEVERTMEBUILDINGORIMPROVEMENTI550tDWITFIINONEYEAROFCqMPLE� TION,THE OWNER�UILDER WILL tIpVE THE BUflfJEN OF PROVINO YHAT HE ON SHF.DID NOT PUILD OR = IMPROVEFOHTHEVURPOSEOFSALE). I ❑1,AS OWNER OF TiE PROPERTV,MA E%CLUSIVELY CONTMCTING WITH 1.ICi;NSED CONTRACTORS ( � TO CDNSTRl1CT TM[PflQIECT(SEC.70aG.BUSINESS AND PROFES510N5 COOE:THE GONTflAGTORS LI- VeIl18fi0P1 ,0 ADJ.AREA_, f, W CENSEIAWDOESNOTqPPLVTOANOWNEROFAPpOPERTYWHO&IILDSOPIMPftOVESTHEPEON,AND � h � N'YIOCONTRACTSFOHSUCHPRQIECTSWITMACANTftACTOR(5)LICENSEDPURSLIANTTOTHECO4TflAC- UANTITY DESCRIPTION FEE S Y TORSLIC EIAW). � AM ENEMPT UNDER 9EC. U.a P.C.FOt7 THIS REASOP! J G7 —`- --'- U � -- --- ¢ onre r�'` ____OWNER _ , � Z ; � W : Q UCENSED CONTl7ACTORS DECLARATION W r � I HEREBYAFFIpM UNDER PENXTY OF PERJURY TNAT I AM LIGENSF:D UNDER PROVISIONS OFCHqPTER � i p_ 9(COMMENCINCiWITHSECTION7000)OFDIVISION30FTHEBUSINESSANDPROFESSICNSC,ODE,AND Z � X MV LICENSE IS IN FULL FOHCE PND EFFECT. LL � F 0 LIGENSECLA55� LIc.hO. __,____ � V DATE CON7RACTOR_. .'_'._._____'_' �- W � � WORKERS'COMPENSATION DECLARATION -> ; � U � � IHEqEBVAFFIRiAUNDERPENALTYOF0E0.1UHVONEOFTHEFOLLOWING�ECLARAT10Y5: Z � 0 IHAVEPNDWILLMAINTAINACERTIFICA7EOFCONSENTTOSELF-INSUHEFORWORKFRS' _ � CAMPENSATION,ASPROVIDEDBYSECTION37000FTHFlABORCO�E,FORTHEPEfiFORMANCE �U � �' OFTHE WORK FOft WMICH THIS PERMIT IS ISSUEU. � O W _!HAVEAND WILLMNNTAiN WOPo(EHS'COMPENSATION INSl1fiA�CE,AS RE(]UIFlED BY SF.CI ION � O 37000FTHELABORC(�UE,FORTHEPERfOPMANCEOFTHEWOPKFORWHIGHTHISPEHMITIS _ _,��1�7� N. ISSUE�.MY WORKERS'COMPENSATION INSURANCE CARqIEfl AND POUCV NUMBER ARF.� CONS7RUCTION . . � J 1� '—_ �, j cAaaiea--' --- ------ ---...___ PLAN REVIEW N-- ' - t -.'- . �, �Z ---------'- ' � POLICYNUMBER__,__ -.—__ ELECTRIC ____ ___ _.,,.._,. __— �� '__' � � (IHI55[CIIONNEC�NOTBEOONpLETEDOFIHFPERNdT15FOq(NJEfiUNNiE�Od.lAAS(5100)ORLESS� PLUMBING ` _'_"—'_"'__' "' __—"'_— ': Z I CERTIFYTHAT INTHE PERFORMANCE Of THE WORK FOfl WIIICHTMIS PERMIT IS ISSU�D,I MECHANICAL '` --"---------��--- - '—'---- (.'} SHALLNOTEMPLOYANYPEfl30NINANYNANNEHSOASTORLCOMFSUeJECfTOTHE 7�f r '� � WORKERS'COMPENSATIONLAWSOFCPLIFORNI�.ANOAGFiEETHATIFISHOUL�dECOME INSPF_CTIDNFEE __.. _,___.____, itA■ �: SU&IECT TO TME WOflKERS'COMGENSAT;ON PROVISIONS OF SECTtON 370a OFTHE U60H az� _ '—_ _ _ r. � CODE,ISHALLFORTHWITHCOMPLYWITHTHOSEW��SIONS. ISSUANCE _.__—_— __...._ ._ �� ^ O __ - __�'"_ �I� p DATE: __ APPLICANT: ." "__.'_ SMIP �_r _1 _—__ —_ .__ — !i � ENERGY P/C _�_ _��__ — `�� J WARNINGFAIWR[TOSECUREWORKERS'COMPENSATIONCOVEftAGEISUNLAN�FII�,ANUSHAILBE LL SUBJECTANEMPIOYERTOCfiIMINALPENALTIESANDCIVILFINESUPTUONEHUNDREDTHOUSANU ENERGYPERMIT DOLLAHS(f1oo,000�,INADf)ITIONTOh1ECO5TOFCUMPENSATION.DAMAGESASPiiOVIDEDFORIN ('� '�r�, � J SECTION37aeOFTiELABORCO�E,INTEREST,ANDATfORNEY'SfEES. RETENTIONFEE: CITYOFDIAMVN (��/ " � - ---s--- , d CONSTRUCTION LENDING AGENCY p ALT FEEs�/�G �I��.DING AND S _ �� Q� IHEREBYAFFIFlMU4DERPENALTVOFPERJUFVTHATTHEREISACONSTRUCTIONLGNDINCAGENCY '('U ___,_._.__._ . . ____—"_—"' _ � FOR THE PEftFOFMANCE OF 7HL WORK FOR WIIICM THIS PERMIT IS ISSUED�SEC.3051,CIV.C.). � �a '—"' W ��_�_ .._ __ "'_ 'vf LENDEH'SNAME"_' __—__'_ —_—'_'_ "'_____-- f � "'""'__ "__ ...—._..__'—_ y� w F- LENDEH'S ADDRFSS_._.. __. —_.—.--.. ---. �J � ICERTIFYTXATIHAVEREADTHI5APPLICATIONhNDSTATEiHATTMEABOVEINFORMA710N15CORFlEC�. T TAL FEES� � -r j`� �(J •�~ ��,� / � W I AGRE::TO CAMPLY WITH PLL CIN AND COUNTV ORDINMCESAND STATE LAWS pELATING TO DUILDING 9 U� � � CONSTRUCTION,MDHEREBYAl1THORIZEREPHESENTATNESOFTHISCOUN7YTOF.NTERUPONTHE f�I�9V� w� I � ABOVEMENTIONED PflOPEfiN FOR INSP[CTIDN PUHPOS[5. �� ', <�� Z �V� '� �� l``V`v � _ C �AENTS a��•,—� � p _. d o }' � �' J ___ _ � � _ m PERMITTEENAM Rf __.._--.._ ._. _ �_ � `nl� /2- ��-�1� ;� __ � � SIGNP7 EOFPERMIiT V �TE RECPT.NO. —��_,23�_—_PAIDBY�___VALIDATION� � 2 � \ ~ WHITE—Dep ment Capy,YELLOW—Finance Copy,PINK—Assessar Copy,GOLDENROD--File Copy,GREEN—ApplicenYs Copy s ,,,\ � .. �_._. _. __ --- . � , _. _. . _ _ i _ e.__. _ ._ , . .._ _ - -• __. �ro , , �� ' ; � ; � � � � � I , � � \ `� i � ' i � j ' ' ; � , � _ �' � ; � � -"� . � � ` � � , '. � � � 5 � , � . � � ' , � + ; � � ti , � i : i ; � � �� ; ( � . E r i I i i � i � .S ; - � � . � , : j . - �� i �5 � ' , �_. 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