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HomeMy WebLinkAbout17103 CITY OF DIAMOND BAR -- _ �-___ � DEPARTMENT OF COMMt�TITY&DEVELOP&�NT SERVICES � . 21825 E.Copley Drive '�w (909)860-3195 Faac(909)861-3117 ( � PRESS ��•�r� BUILDING PERMIT APPLICATION T FIRMLY o� JOBSITE ,r�, APPLICATION a {_ D' PERMIT I� p/C(� ,,,, ADDRESS �I.JLjC� U%��ln+i+-�'.r %J,y�,Yt� DATE -! �> NUMBER f O� # l/ � W ISSUE TYPE OCC APN LOT TRACT DATE �'�� ID��CONST. p OWNER ���v �!>e� i<r��' GROUP p ADDRESS ZONING SETBACKS Z CITY_ ZIP TEL„���?--4�ST.-G� FRONT RW ❑ � APPLICANT LF✓�5%���G. TEL� 7��i�"7 REAR � z -� SIDE/SICE STREET RW ❑ � CONTRACTOR('�GiGi'�f�r..'i(9 ,Ij/,a�'G�ya SIDE L7 ADDRES .:� .f,. '1 w,S � �,�- � CITY � ' �f�.4? ZIP�j1� TELj' M,..E/ , Y„ PROP�E�r✓..5�%/` Z ��S i?r �f7'" ir'�L:T'ti' oARCH/ENG/ �_ � �,,r ' �„p, R.� z DESIGNER ����z�� � ������G� �" �� ��+ a ADDRESS NO.DWEL. O. N0. � CITY ZIP TEL. UNITS STORIES BEDROOMS � � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION p SFRlADD/REM p I HERE6V AFFIPM UNDER PENALT'OF PERJURV THAT I AM EXElAPT FROM THE CONTRACTORS Li� Gdf3 JB/CBIpOfI W CENSELAWFORTHEFOLLOWINGREASON(SEC.7031.SBUSINESSANDPROFESSIONSCODE:ANYCITYOR (n V COUNTVWHICHFEDUIRESAPERMITTOCONSTFiUCT,AITEP,IMPROVE,DEMOLISH,ORREPAIRANY57RUC� w TURE,PRIOR TO ITS ISSUANCE,ALSO REDUIRES TNE APPLICANT FOR SUCH PEflM1T TO FILE A SIGNE� W Patio/Oeck � STATEMENT THAT HE OR SHE i5 LICENSED PURSUANT 70 THE PROVISIONS OF 7HE CONTRACTORS LI� � CENSE LAW(CHAPTER e(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AN�PP.O� � POOUSpO � FESSIONSCO�E)OFITHATHEORSHEISEXEMPTTHEREFROMAN�THEBASISFORTHEALLEGEDEXEMP� (� U TION.ANYVIOLATIONOPSECTION7031.SBYANYAPPLICANTFORAPERMITSUBJECTS7HEAPPLICAMTO Z RB-Roof ACIVIL PENALTY OF NOT MORE h1AN FIVE HUNDREO�OLLARS(SSaO).)� Z~ ❑I,ASONMEqpFTHEPROPERTY,ORMVEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, Q WILL DO THE WOqK,AN�THE S7RUCTUqE IS NOT INTENDE�OR OFFERED FOR SALE(SEC.7o4a,BUSb J COfItrtl0fCl81 � NE55 AN�PROFESSIONS CqDE:THE CONTRACTOFS LICENSE LAW OOES NOT APPLY TO qN OWNER OF = Pf10PERTY WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR WTHRWGHMISORHEROWNEMPLOVEES,PROVI�EDTHATSUCHIMPROVEMENTSARENOTINTENDE�OR m 0 OFFEREDFORSAIE.IF,HOWEVER,THEBUIl01NGORIMPROVEMENTI550L�WITHINONEYEAROFCOMPLE Z TION,THE OWNER-BUILDER WI�L HAVE?HE BURDEN OF PROVING THAT HE OR SHE�IO NOT BUILD OR = IMPROVEFORTHEPURPOSEOFSALE). W ❑I.ASOWNEROFTHEPROPERTV,AMEXCWSIVELVCONTRACTINGWITHLICENSEOCONTRACTORS � TO CANSTRUCT THE PROJECT(SEC.7o44,BUSINESS AND PRpFESSIONS CODE�.THE GONTRAC70RS LI- V8IU8IIOf1 ADJ.AREA W CENSELAWDOESNOTAPPLYTOANOWNEROFAPRO�ERTVWHOBUILDSORIMPROVESTHEREON,AND � WHOCqNTRACTSFORSUCHPROJECTSWITHACONTRACTOfl(S)LICENSEDPURSUANTTOTHECONTRAC� QUANTITY DESCRIPTION FEE Y TORS LICENSE LAW.). � u i AM EXEMPT UNOER SEC. B.6 P.Q FOR THIS REASON � � U �� . LL � DATE OWNEfl H Z U � LICENSED CONTRACTOFS DECLARATION Q � I HEREBYAFFIRM UNDER PENALTYOF PERJURY THAT IAM LICENSEO UNDER PROVISIONS OF CHAPTER � 9(COMMENqNOWITHSECTION7000�OFDIVISION3OFTHEBUSINESSANDPRO=ESSIONSCODE,AND z �X MY LICENSE IS IN FU�IL*FOFCE AND EFFECT. m 0 LICENSE C S/S `=' 7 Ji� LIC.NO. ���,g�� a�.�f � V DATE�E+"��L�I CONTPACTO�_++liFf(! Ir'F� d W � WORKERS'COMPENSATION DECLARATION ¢ � IHEREBVAFFIRMUNDERPENALTYOFPERJURYONEOFTHEFOLLOWING�ECLARATIONS: Z Z _I HAVE AND WILL MAINTAIN A CERTIFICAT'c OF CONSEN7 TO SELFINSURE FOR WOHKERS' ¢ Q CAMPENSATION,ASPflOVIDEDBY5EC710N37000FTHELABORCODE,FOR7HEPERFOflMANCE C.� Q OF THE WORK FOR WNICH THIS PERMIT IS ISSUED. � QW �L—I HAVE AN�WILL MAIMAIN WOPNERS'COMPENSATION INSURANCE,AS PEOUIRED BV SECTION r 3700 OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS �n ISSUEO.MY WO ERS'COMP�NSATION WSURANCE CARRIER AND POLICY NUMBER ARE: CONSTRUCTION ( �3I �`� O � CARRIER ' � � '�'r-� PLANREVIEW f 0 POLICYNUMBER "`�#� � ELECTRIC Z Q p (tHISSECTIONNEmNOTBEOJMPLEfEDOFTHEPERMfTISFORQVEHUN�RED00lLhHS(E100)ORLESS� PLUMBING Z I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL (3' SHALLNOTEMPLOYANYPERSONINANYMANNERSOASTOBECAMESl1BJECTTOTHE � WORKERS'COMPENSATIONLAWSOFCA_IFORNIA,ANDAGREETHATIFISHOULOBECOME INSPECTIONFEE = SUBJECTTOTHEWORKERS'COMPENSA710NPROVISIONSOFSECT�ON37o�OFTHELABOR CADE,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. ISSUANCE � p DATE: APPLICANT. SMIP J WRRNING:FMLUftETOSECUREWORKERS'WMPENSATIDNGOVERAGEISUNUIWFUL,ANOSHALLBE ENERGYP/C � SU9JEC7ANEMPLOVERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPEHMIT OOLLARS(S1oo,o001,IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN � SECTION 3708 OF THE LABOR CO�E,INTEftEST AND ATfORNEY'S FEES. RETENTION FEE: OCONSTRUCTION LENDING AGENCY PRE-AlT FEE: � IHEflEBYAFFiRMUNDEFPENALTYOFPERJURYTHATTHEREISACANSTRUCTIONLENDINGAGENCV � FOR THE PERfOtiMANCEOFTHE WORK FOR WHICH THIS PERMIT IS ISSUE�jSEC.3097,CIV.C.). Z W � lENOER'S NM.1E F— LENOER'SA�DRESS � TOTAL FEES � 4 �- � � � I CEflTIFY THAT I rIAVE 9EAD THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS COqPECT. w I AGREE TO COMPLV WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATMG TO BUIL�ING � � CONSTRUC7ION,ANDHEREBYAUTHORIZEREPFESEN�'ATIVESOFTHISCOUNTYTOEN7ERUPONTHE (/`�/ /� Z ABOVE���ONE�PR�PERTY FOR INSPECTI N PU QSES. �Y ti,I ~' .�_lt_V� �� � COMMENTS J � �� � w " �./' m PERMITT. (PRINTI � ?�(/( �� • c¢i� .�' l/� � S� R PE DATE = RECPT.NO. PAID BY VALIDATION ~ WHITE—De artment Co YELLOW—Finance Co PINK—Assessor Co GOLDENROD—FileCo GiiEEN—Applicant's Copy P PY, PY� PY� PY• �''.v��,•�Y#,�':�+p;.tii�rc��;'r��i¢Ybx�$p��t.;,tiw.5�:;���.�'�wi'�'"p�+w"`;`� "'�.��,�X"`«��,i::;p�'�sit�n r a ..�r;a,�:�r � . ,„�•�a�� ,.. . M n ;cvx-. •�..�.;tws.i:a„�cr . . .. 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