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HomeMy WebLinkAbout13881 i �� CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �¢ 21660 E.Copley Drive Suite 190 PRESS (909)860-3195 Fax(909)$61-3127 � "°�"� BUILDING PERMTI'APPLICATION FIRMLY o� JOBSI7E j/��D �lf � ` APPLICATION { ��9'` PERMIT ����;°" P/ e'��6' ` � ADDRESS 1� �3 V I^I-Jk u �� �C u'J DATE 7`�i�� ! _NUMBER� Kd E! � ��� � � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWIVER t i: �-�A�. �S%1'��/hl�tr✓,qt�;,r.��r�1 � ADDR � •' +��_y�� _ %--- .� ZONING SETBACKS oCITY. '_. `+ A� ZIP���° T L.I� " `�F�� FRONT RW l 1_ � APPLICAiVT S TEL. S DEISIDE STREET RW CJ_ _.__ � CONTRACTOR S.x S ��L .. _�___ SIDE ❑ p ADDRESS w �CI ZIP TEL. PROPOSED USE ��.� ��-�/L+n^rS ENG/� — � DESIGNER� �Cl�L- N�i_ .�.�'t� � d ADDRESS= rs�� i'asL�-L'-Z7 NO.DWEL. NO. NO. i u� UNITS _ STORIES _ BEDROOMS ! � CITV�:r''� (��iP�pTEL. L(( - cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREA/VALUATION � OWNER•BUtLDER DECLARA710N SFR/ADD/REM O [] I HEREBV AFFIqM UNDER PEN/LLT'OF PERJUFY 7HA�I AM EXF.MPT FROM TNE CANTflACTORS ll� � Garage!Carport �� W CENSEIAWFORTNFFOIIOWINGREq50N(SEC.'!L`31.50USINESSANOPROFESSIONSCO�E�ANVCITVOR U pOUPlfYWHICHRF.WIRESAPERMiT7000N57HUCT,AL7EH,IMPROVE,DEMOLISH,ORREPAIRANYS7RUC� W p8ti0/DBCk W NflE,PHfOfl TO ITS ISSUM/CE,ALSO REO(liRES THE APPLICANT fOq SUCH CF.pMIT TO FtLE A SIGNED W ^ � STA7EMENT iHAT HE OR SHE IS LICENSED PURSUANT 10 THE PROVISIONS OF THE CANTHACTORS LI� � `� '� CENSEUW(CNAPTERo(COMMENCINOWITHSECTION7000)QKDIVISION30FTHEBUSIIIESSANDPRO� POOUSpe FESSIONSCODE)ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEA!:LGCDE%EMP� (� E V TION.ANYVIOLATKKJOFSECTION7031SBVANYAPPLICANiF07APF,qM1TSU&1ECTSTHEAPPLICANTTO z Re-Fioof � AC117LPENALTYOFNO7'MORE7HANFIYENUNDRE�COLLAR5�;5pp))� � C11,ASOWNEROFTNEPROPERTY,ORMVEMPLOYEESWITHWAGESASTHEIqSOIECqMPENSATION, Q /'�' b Z WILL 00 THE WORK.AN�TNE STRUCTUFE IS iJOT INTEN�E�DR O�FERE��O�SA1 F(SEC.7064,BUSb J Commercial �C�� (,,,�(,� � NES3 AND PROFESSIONS CODE:THE CANTMCTOP$lICENSE LAW OOES NOT APPLY TO AN OWNEfl Of � � PRDPERlYWFi06111L0.SORIMPqOVCSTHEiiEON.AN�VMO00E35UCHWURKHIMSEIFORHEPSELFOR �� r � THHIX1pHHISORHEROWNEMPLOYEES,PflOVIOEDTHAT5UCt11MPHOV[MENTSANF.ND?INTENDEDOR P� � � OFFEREDFOii5ALE1F,HOWEVE0.'MEBUIIAINGORIIAPROVEMENi1550IDW17HINONEVfA(70FCOMGLE h Z TION,THE OWNER-BUILDER WILL HAVE THE OURDEN OF PROViNf TMAT ME OR SHE�ID NO7 B1JIlD OR -' ! � IMPROVEFOR7HFPUfIPaSEOFSALE�. '}�� �, Q-(„ . I]I.ASOWNEAOFTHEAFiOPERTY,AM&%CLUSIVELYCON?RACTINGWITNLICENSEDCANTFlACTONS 1 -'-+ � 1 YT7-7--- �' � � TO CANSTRUCT 7HE PROJECT(SEC,7044.BUSIN655 qND PRUFESSI04S(:ODE:THE CANTRACTORS LI � ValUBil0i1 _ __:.�,�. `�'� ti' ADJ.AREA IL CENSEUWOOESNOTAPPLYiOANOWNEIiOFRPROAEHTY1tt19EU1LD50RU7FROVlS7HEREON,AN� ---'------ --"- { ' W/qCONTRACTSFORSUCNPR0.1ECT5WITiiACONTPACTOR(S)LICENSEOPUPSUAftTTO7HECONTRqG QUANTITY D•SCRIPllON FEE t Y TONS LICENSE UW.). , ;; � � J [ � :]IAME%f.A1MUN�ERSEC._.,___._______ �.BP.CFOR7N�SHeASON Q �� 3 --- -- -- � �� ,� - -- -- � � !� � DATE ___-OWNER '_'______....'.____ � U 2 � 4 IICENSED CONTRACTORS DECLARATION � , n OC 1 HEflEBVAFFIRM UNDEq PENALTY OF PENURY THAT I AM LICENSED UNUEH PROVISIONS OF CHAPTER � � a, 9(COMMENCINGWITHSEC710N7000)OFDIVISION30F'THE6USINESSANDPROFESSIO�SCODF..AN� Z 3G MYUCENSEISIPIFUIIFORGEANDfFFECT. m �I3S � LICENSE ClASS � __LlC.NO. � �G`_`� _-_ j �! U �ATE �_ CONTHACTOR ,,,'`S•�^'� -L���- _ d � W � � WORKERS'CUMPENSATION DECLARATION —� V � � � � IHEREBYAFFIRNUNOENPFNAlTY�1FPERIURYONEnFTNEFDLI.OWINu`�ECLARATIONS� � 4 d !HAVE N1D WILI N.AIN7A�N A CERTIFlCATE OF CONSEM TO SELFINSURE FOR WORKEHS' _ � y � COAIPENSATION.ASPq�VIUE08YS[CTIQY97000f'T11ElABORCODE,FOR7HEPFRLO�iMANCE U __ _ � R OFTHE WONK FOR�NNICliTN15 P[RMIT IS ISSUED. W � . QW �1 HAVE AND WILI.TIAiH1AIN WORKERS'COMPENSATION INSURANCE.AS HE�UIHF.D BV Sf�TION � +'''� -•" ��' ,1 � 370oOFTiELAHOHWDE.FORMF.PEP,FORAfANCEOFTI�IF.WOFKFOR`NhIiGHTIIISFERMIf15 - - .K�.��, �/�. � � 139UED.MY WOHKERS'�MPENSATI04 INSURA4CE CRRHIER AND POLICY NUM9cfi ARE: CONSTRUCTIO _ _ . „ � '�� "—""" _ � 3E�)''7�r'�iTr�i�L- '��(.'j�_ PLANREVIEVJ� "'-�.���.. � ]. CARRIER..._�•.�',-".��",s����� ��_— "___- _ � Pa_ICYNUMBCR `-�-�- ��_�_3�T�1 ki���._____ "_ EL[CTRIC Q -—'--- �------- � ; e...; ., - •• �ressEcrzxuH�noreE�er[oa�rv�w�ar�sitwavrm�ront':o[�u�s(s�ro)cN�E�.$) PLUMBING • ...-.' n ---=-- �, -------------- w � Z SUBJEC�IOMHEOYIDRKEFlSCAM ENS TIO�PqOVISK)YSUr`�S�TION3H�OQL�SISSUEU.1 MECHANICAL � ICERTIFY7HATINTHEPERFOFlMANCEOfTHEWORKFORWNICHiHISPERMI __-_....-._ __._._. ___..__ (!j TOTHE Vy WOIiKERS'COMPENSATION�AWSOFCALIFOHNIA,ANDAGHEETHA71FiSFlOI�UEIFCOlAF INSPECTIONFEE _.__ `'..9 _,______,._______ � _ F THE IABOH �t'.`;y : t�\;'. +.�' :.. � CODE. SH LLFOR7tiWITHCOMPLYWITHTHO = O IS Ns. I�SUANCF_ � •�;�� ' ~ L`e. fs.�-_______ . -a•� _ o , . « � ...n . p i.... p DATE__ AP4'LICANT.+ "'�.., .• �� �' --"" "- F'.. SMIP ....�-.-- - J � _'_'_—__ ' 9 c i' ' . ' _" _ ' '_" ��.�. --- � - — —3.'.f''� '� �� � � �_'_ WAANING:FAILURE TO SECUAE WOAKERS'CAMPENSATION C.UVERAGE IS UNLAW'rUL,AND SHALL 0E ENERGY P/Cy;���� '' .-�� . `?.__�_?.1 '� J S�'} •.-�'-,Z...r_:_'., LL SU&IECTMIEMVLOYEti1OCRIM�NPIPENAL7�ESANDCIVILFINESUGTOONEHUNDflEOTHOUSA�D ENERGYPEFtAi1F�`�T1:+-�-y':' UOLLAflS(5100,000�,IN A�DIT�ON TO THE COST O�COMPENSATION.DAMAGES AS PROVIDED FOR IN ----- ' � _- _' _ J SECTbN37oBOFT1ELABORCODE.INTEREST,ANDATTORNFY'SFEES. � � RETENTION FEE: ----��--- ------...- -----— ... V_�-- OCONSTRUCTION LENDINGAGENCY PRE-ALT FEE:_ / }�. �1 , � 1 H[REBYAFFIflM UN�ER PCNAI.lY OF PERJURY THATTHERE IS ACO45TRUC7IUN LEIPJING AGENGY ��( -� ' /�-(�`��_ _ �� V � ' / � FOH7HEPERFORMANCEDFTHEWORKFORWHIC4ITHISPERMIT1515"UED�SEC.3C91,CIV.C.). ---"'�-���- --'--'--�— � J _.._..""-'_ __—_._.,._- ___"�'__"__ � LEN�ER'SNAME__.."—_ _""' "'_"' -'__'___ f- LENDER'SADDRE55 _ _-'_..- .._ --_ - "'-' - ""- " " s � � iCEHTIFVTHqTIMAVEREADTHI5APPI.ICATIONANDSTATETHATTHEA90VEMFORMAT10NI5CURRECT. IUTAL! CES ��/� ��'�{' � W IAGflEETOCOMCLYWfTHALLCINAkDCOUNTVORD:NANC[SANUSTA7ELAWSREWTIN3TOBWLDING R� � GONSTRUCTION,ANDHEFlEBYAUTY,ORIZEREVRESENTATIVESOFhIISCOUNTYTOENTERUPONTHE � ABOVEMENTIONC:D PROPEqTY FOR INSPECTION WURPOSCS. 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