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HomeMy WebLinkAbout15861 � f. CITY OF DIAMOND BAR � - ---��— DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �� 21660 E.Copley Drive Suite 190 � (909)860-3195 Fax(909)861-3117 PRESS & 'ei" BUILDING PERMIT APPLICATION FIRMLY� o DDR�ESS /I� 4� .I��� '���� /��'�'�L- , DATE CATION G�� �- (� NUMBER ��'�t� I#/C �-�j� G d ' i � � ISSUE TYPE OCC APN LOT_ TRACT DATE CONST. GROUP p OWNER /��.11✓L a'..1 _ p ADDRESS i �`/� �` /_<��/Z [�Lc:.. C ,f�i�1� ZONING SETBACKS g CITY y�r��jjy'.�51a/� ZIP ��% ,; TEL. FRONT RW ❑ APPLICANT TEL. REAR ❑ SIDE/SIDE STREET RW ❑ � C9PI�F�r�F6R � C,NI E C> -_A I�/.�,S SIDE — ❑-- - � ADDRESS 0�- • n �'S ' ' ROPOSED USE��i � �•� � ' � CIN . 4� /1 ZIP ���TEI.� /�' ��a 1J C.L iJ • q/ .�. – w ARCH/ENG/ !, Z DESIGNER !� ���� �����6� NO.DWEL. NO. NO. � ADDRESS Ia�U Z . _�'J��yio_��'���'�_ - UNITS STORIES BEDROOMS � CITY i.��� �O vi�%� ZIP �i/7�r O TEL.�/ ��`'/�,"2�•S N � DESCRIPTION SQ.F7 FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADD/REM O Q I HEREBY AFFIRM UNOER PENALN OF PERttIRV THA7 t A1A EXEMGT FROM 7HE CANTRACTORS LI- Gafage/Ca1PoIS �i W CENSELAWFOR7HEFOLLOWINGREASON�SEC.70.97.SBUSINESSANOPROFESSIONSCODE:ANYCITYOp (n � U COUNTYWNICNREpJIPESAPEflMRTOCONSTFUCT,ALTEfl,IMPROYE,DEMOLISH,OFREPAIRAiiYSTRUG W PflIiO/DBCk ` W TURE,PRIOR TO RS ISSUANCE.AL50 REdUIHES THE APPIICANT FOFl SUCH PERMIT TO FILE A SIGNED W STATEMENT THAT HE OR SHE I5lICENSED PURSUANT TO 7HE PROVISIONS OF 7HE CON7RAC70R5 LI- � CENSE UW(CFi11PTER 9(COMMENCINp WITM SECTION 7000)OF DIVISION 3 OF THE BU3INESS AND PNO- u' POOUSPB � FESSIONS CODE)OR THAT HE OR SHE IS E%EMPT THEREFROM AND THE 8A515 FOP THE ALIEGED El(EMP- TION.ANVVIOLATIONOFSECTION7aA1.6BVANVAPPLICANTFORAPEflMITSU&IECTSTHEAPPLICANTTO Z Re-Roof S � A CIVIL PENALTY OF NOT MORE THAN FNE HUNDRF.D IIOLURS(55oa).): r � ❑I,ASOWNEROFTHEPROPERN.ORMYEMPLOYEESWITNWAGESASh+EIR50LECOMPENSATION. � COmmOrCial ,; WILL DO THE WORK,AND THE S7RUCTURE IS NOT INTENDED OR OFFEREO FOR SALE(SEC.70a4,BUSI- � NE33 AND PROfESSION3 CODE:THE CONTflACTORS LICEN9E LAN/�OES NOT APPLY TD AN OWNER QF � � PROPERTYWFIOBUILDSOHIMPfiOVESTHEREON,ANOWHODOE55UCHWOHKHIMSELFORHERSEIFOH = � � hIRODUHHI50RHEHOWNEMPIAYEES,PHOVIDEDTHATSUCHIMVROVEMENTSARENDTINTENDE�OR m �? OOFFEHEDFOR9ALEIF,HOYVEVER7NEBUILDINOOflIMPROVEMENTISSOLDWITHINON[VEARQfCOMPLE- ' z TION,T11E OWNER-BUILDEN W�LL NAVE TME BUR�EN OF PRDVING THAT HE OR SHE�ID NOT BUILD Ofl = IMPiiOVEFOR7HEPURPO5EOF5ALE). � ;; ❑I,AS OWNEfl OFTHE PROPERTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTOfiS 'P� � TO CONSTRUCT 7ME PqOJECT(SEG.]014,BUSINESS AND PHOFESSIONS CODE:THE CONTRACTOR5 LI� yIIJflIIOR � .7 1�l.� . ADJ.AREA W CENSELAWDOESNOTMPLYTOANOWNERO'rAVROPERNWNOBUILDSORIMPROVESTHEf1EON,AND � � Vh1000NTMCT6FOflSUCHPRQIECTSWII}iACONTRAC?OR�S)LICENSEDPURSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FEE � R1RS UCENSE LAWJ. �./� 1 6 o :7 I AM EXEMPT UNDER SEC,, 8.R P.C.FOH THIS{iEASON Q ,"`� `;Y V^� �) . ['�'t { � __—_' � � DATE `O.S• IJG�L}OYMER __—__ __""_'_"_' U�— � Z W p LICENSED CONTFiACTORS DECLARATION W � � I MEflEBYAFFIRM 11NUER PENALTY OF PERIUHY THTT IAM LICENSED UNDER PROVISIONS OF CHAPTER � � (L 0(O�MMENCIN(�WITHSECT10N7000�OF�IVISION30FTHE9USINE5SANDPROFES510N5CODF:.A4D z N X MYIICENSEISINFULLFORCEANDEFFECT. m L!J � ! � LICENSE CLASS . LIC.NO. ___._ ._-__. J � V DATE_ CO�TRACTOR___.,__ d W � WORKERS'COMPENSATION UECLARATION Q � � U � � IHEfiEBYFfFIHMUNOENPENALT'OFPEfiJURYDNEOFTHEFOLIOWINGDLCLARATIONS: z � Q ! Ll IHAVEANUWILLMAINTAINACERTIFICATEOFCONSENTTOSEIF-INSUREFORWORKEFS' = f � COMPENSATION,ASPROVI�E�6VSECTION3lo00FTHELA00RCODE,FORlMEPEFlFORMANCE `U � OF THE WORK FOR WHICH THIS PERMIT IS ISSUEO. � � � - W _IHAVEANOWILLMAIMAINWORKERS'CAMPENSATIONINSIJRANCE,ASREOUIREDBY5EC710N � /` I),✓ ��g� Q 3700 OF TME LABOR COOE,FOR THE PERFOBMANCE OF THE WOPoC FOR WHICHTHIS PERMIT IS f rY J� V Ca � ISSl1ED-MYWORKEHS'WMPENSATIONINSURANCECARq1ERANDPOLICYNUMBEftARE: CONSTAUCTION `+' _.. __ � jcnnRieR— .----------��----.. PLANREVIEW } •- -�------�------�--- j� � Z POLICY NUMBER__ - �� �v•�` D , --� ��------- ELECTRIG � 4 I 0 (IFilSSECTpNNEEDNOT6E00MRETmOFTHEPERMfrISFOROKEFRINMLDDOIUuiSl5loo)ORLE551 PLUMBING .._- _._.____-._._.-..'_._--._.__-_.__'_'__" Z ICERTIFYTHATINTHEPERf�flMANCEOFTHEWOFKFORWHICHTHISPERMITISISSl1E0,1 MECHANICAL ___......_._...___._.....-_.,:�_.::.;.______... i (,�} SFIAILNOTEMPLOYh4YPEASONINANYMANNER50A5TODECOM[SUt7JECTTO7HE ' . � WORKEFS'COMPENSATIONLAWSOFCAUFORNIA,ANDAGPEETHATIFISHOULDBECOME INSPECTIONFEE � � � � SU&IECTTOT1iEWOWCEflS'COMPENSATIO4PROVISIONSOFSECTION3]ooCFTHELABOR �SSUANCE - � CODE,ISHALLFOHTHWITHCOMPLVWITNTNOSEPROVISIONS. 1 -- � SMIP p OA7E: ._- APPLICANT: _'___'__ � , �. '-�-- � ENERGYP/C ---.------. ---- .-- ------. _ WARNIN�:FAILUflE TO SECUPE WORKEflS'COMPENSATION COVERA6E IS UNLAWFUL,AND SHALL BE " LLSLI&IECTANEMPLOVERTOCflIMINALPENALTIESANDCIVILFINESUPTOONEMUN�REOTHOl15AN0 ENERGYPERMIT _ _ ",. _.—_______.�__.__ WLlARS(S10o.a00),INADDITIONTOTHECOSTOFCOMPENSATION,DAMAGESASPROVIDEDFONIN �� ---�---- - . . ¢ SECTION370BOF7HELABORCODE,INTEAEST,ANDATTORNEY'SFEES. RETENTIONFEE: ___ �_ � CONSTRUCTION LENDINGAGENCY PRE-AL F[E: �� ___ � IHEFEBYAFFlRMUNDEflPENALTYOFPERJUflVTHATTHEREISACONSTRUCiIONLENDINGAGEhCV ���'� ___ _ W FOfl THE PEflFORMlWCE OF THE WOFK FOR WHICH THIS PERMIT IS ISSUED(SEC.309�,CIY.C.). �Y����j Q _ — — .�q- / � LENDER'SNAME___ - �� � LENDEH'SADORESS ___-_ - ----- r 1 I w ICERTIFYTHATIHAVEREA�THISAPPLICATI0.VANDSTATETHATTHEABOVEWFORMATIONISCORRECT. TOTALFCES ' iX ��� � I AGREE TO COMPLY WITH ALLCITY AN[1 COUNTY OR�INANCESAND STATE LAWS RELATINC TD BUILDING ��^'� � CONSTRUCTION.ANDHEREBVAUTHOR2EREPflESENTATIVF:50FTHISCOUNTYTOENTEFUPONTHE �^�C- / i j( ZA90VE-MENTKKJED PROOERTV FOR INSPECTION PURPOSE f„/\������~ ` �� �"� Q s ^ , CO ENTS_.__ • � _�O�sJ�-G? �.� �'� S _�uv LtL✓' G.�..�-- ---- ' � . — - ------ - — I. m PERMITT IVRIM) . ' -"_"_ _ — i c�_n �J " l�:a ' 2 Lj G7 G7 - --... , � �='----- !� � � S RMITfEE � DATE �"' \ I n:, ` � �� 6 PAID 8Y \.� VALIDATION_,_• = r.. . ..-.--_.. RECPT.NO._��---^--- � ��"`=--' I ~ WHITE-Department Copy,YELLOW�inance CoDY.P�NK-Assessor Copy,GOLDENROo--File Copy,GREEN-Applicanl's Copy � . . i i . - - ' � ' : , ` •:� i . j , , . ` i , ` . ; � � � � ' � , ' � s, 1 �; - � ' i ' i ' � ; � � .;i - � ' � i ' ' , : ' � , � � , . . ' . ' _._t< � : , _.•. �. _,. __ ..._ ' t - . �,.Yt, ' ' , ' i ._ ._ . _ ' ' -- . . _ i ' ' . . ' . - . ' . 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