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HomeMy WebLinkAbout16262 (32) CITY OF DIAMOND BAR � ------1�--.....__ ��� ; DEPARTMENT OF COMMUNITY 8c DEVELOPMENT SEF:VICE5 ` : r � w 21660 E,Copley Drive 5uite 190 (909)860-3195 Fax(9Q9)861-3117 —tl'"�PRESS �'�^'�+� BUILDING PERMIT APPLICATION FIRMLY _ � � JOBSlTE ` o ADDRESS I � S� � _ �!F�l�(d�V11` �h"�- ��-��� DATE'CAT�Q � PERMIT ���j —.,2 NUMBER P � V � � SSUE TYPE OCC APN LOT TRACT DATE � �� _CONST. GROUP p OWNER nlE' "t MI�� /�IA'41(.�l2.t�c�Fa `` ADDRESS_1 �S'ei .S�_ Dra'Jy�tCs/(�+�'✓�e� ��iAc� Lcq,rrT,� ZONING SEfBACKS Z CITY �r i� ZIP�,�5 TEL. FRONT RW C g APPUCANT �'P.�.a7 i�/7�S es�i t.'.�� TEL.7lsc� •-.'L�.+Fs� REAR _ ❑ � SIDElSIDE STREET RW p CONTRACTOR D19 � �'[�/+S�I��=Yi�� SIDE � a ADDRESS /Z�!ca L�`[7 ,/.?�- PROPOSED USE G���;iFU`"' �TiL'► s 7`f1taL:�"�t IL�r. O cirv �,/•i.� ziP�;�TEL.�'[�d"1 S _ �`Z-P o �ti�,-�r�_ r�r�ra-�� wo ARCH/ENG/ �' Z DESIGNER w NO.DWEL. VO. NO. n. ADDRESS � CITY ZIP TEL. UNITS 3TORIES BEDROOMS � — cn DESCRIPTION SQ.F1' FACTOR PSF ADJ.AREANALUATION ¢ �WNER-BUIIDER DECU4RATION SFR/ADD/REM Q I NEREBV AFFlRM UNDER PENAL7Y OF PE0.IURV THAT I AM EXEMPT FROM THE CONTRACTORS 41- G8�8Jg/CBfnOh W CENSEWWWHTHEFOLLOWINGREASON(SE47031.SBUSINESSAN�PflOFE5510NSCO�E:ANYCITYOR (f� C.� COUNfYNMICHREWIRESAPEAMRTOCONSTRUCT,ALTERIMPROVE,DEMOLISH,Opi7EPAIRANVSTRUC- (JJ Pat�aoeck � W TUpE,DRIOR TO ITS ISSUANCE,ALSO REOUIRES THE APPLICANT FOR SUCH PERMIi TO FILE A SIGNE� W r�• .�•�• � STATEMENT THAT HE OH SHE IS LICENSED PURSUANT 70 THE PpOVISIONS OF THE CON7RACTOflS LI- LL �� � CENSE UIW(CHAPTEfl B(COMMENCINO WIiH SECTION 7000)OF OIVISION 3 OF THE BUSINESSAN�PPO- P001/SP8 .. ,o' FESSIONSCODE�ORTHA7HEORSHEISIXEMP7THEREFIiOMANOTHEBASISFORTHEALLEGEDEXEMP- (� TIDN.ANYVIOIATIONOFSECTION703i5BVANYAPPLICANTFORAPERMITSU6JECT5THEAPPLICANTTO Z Re-Raof � A CIVI!PENALTY OF NOTMORE 7HAN FIYE HUNDRED DOLLAFS(35DD),): � �I,ASOWNEROFTHEPROPERIV,ORMVE0.1PL0�'EESWI7HWAGESAS7HEIRSOLECOMPENSA710N, ❑ Commercial _ - NfILL DO THE WORK,ANO THE STRUCTUqE IS NOT INTENOED OR OFFEH'e0 FOR SALE fSECJo4a,BU51• J � NESS AND PROFESSIONS COOE:THE CONTRACTORS LICENSE LAW DOES NOTAPPLY TO AN OWNER OF ? PROPERTYNTiO BUILDS OR IMPflOYES THERECN,AN0 WHO DOES SUGH WORKHIMSEI.FOR HERSELF OR � TH110UG:IHISORHEROMMEWPLOYEES.PROVIDED7HAT&UCHIMPROVEMENTSAflENOTWTENDEDOfl m QOFFEREDFORSALE�FHOWEVERiHEBUIL�INGORIMPROVEMENTISSOLDWRHINONEYFAROFCOMPLE- Z TIDN,TFIE OWNER-BUILDEfl WILL HAVE 7HE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD Ofl � M1PF�VEFOHTHEPURPOSEOFSALEx W ❑1.AS ONMEFOFhIE PROPERTY,M1 EXCLUSIYEIYCONTRl.CTING WITH LICENSED CONTRACTOP.S Q TO CANSTRUCT TME PRQIECL(SEC.7D�4.BUSINE55 AN�PROFESSIONS COOE:THE CONTRACTORS i I- \jalu2(10� � ' ADJ.AREA Ll1 CENSEUWDOESNOTAPPLYTOANOWNEROFAPROPERNWNOBUIiD50RINPROVESTHEqEON,qND ' � 'MiOCOMRACT5FOR5UCNPR0.1ECT5WIhIACONTRAC70q�5)LICFNSEDPUPSUANTTOTHECONTRAG QUANTITY DESCRIPTIOM FEE Y TOpS UCENSe LAW.j. � ❑I AA�EXEMPT UNDER S�C. 8.&P,C.FOR THIS RF,ASON Q _ 3 U � � DATE _OWNER, U 0 W __. � LlCENSEG CON7RACTORS DECLARATION W � I NEPEBYAFFIRM UNOER PENALTY OF PEa.IURYTHAT i AM LICENSED UN�EH PflOVI510N50F CHAP7ER �� p� 9(COMMENCINO WITM SECTION 7000�OF�NISION 3 OF THE BUSMESS AND PRO'rES510NS CODE,AND Z �X IAYLI�NSE IS IN FL1LL FOflCEAND EFFECT m � fJ "� �7{ LIC.NO.�,���J L.L� j . � LICENSE C[L�ASS G U DATE (�y, `�_� I��Z�%C7� CONTRAC70R�'.'�.1 _L(?IU.%T/Pi.'C% a W � WORKERS'COMPEIJSATION pECLARATION Q � � I HEPEBV AFFIRM UNOER PEMALTY OF PE0.1L1R�ONE OF THE FOLLAWING DECLARATIONS: Z ' � ,IliAVEANOWILLMAiNTAINA�£NTIFIC�ITEOFCANSEN7TOSELF�INSUREFORWOFlKEFS' x � CAIAPENSA710N,AS PR�^,VIDED BV SECTION 370o OF THE LASOR CODE,FOR THE PER�ORMANCE w O OF THE WORK fOR WMICH TNIS PERMIT IS ISSUE�. � W �IHAVEANOWILLMAIMAINWOAKEAS'COMPENSATICkiN5UR0.NCE,ASREOUIRE08VSECTION ppp` '~�. 37000F iHE LAH�Fi CIX)E.FOR THE PERFORMANCE OF THE WOfli(FOfI WHfCN THIa PERMIT IS � � � 4 ISSUED.MY.SY�AKERS'EONPE�NiS,qTIONINSU9ANCECAPP,IEflANDPOLiC�Y1�UMBERA E�. CONSTRUCTION ��_ j �� A � d����'Ai���;�i +„J ,! -' �� ��,� Co rsi�a i�� . 9 > � �� � /� PLANAEVIELN + �I � "�y���.��NU�I9EFV��.'i�'n:� d '.�l S1 ��' . � �= '� ELECTRIC QA i� n�c„9 ° :--� �.a v-•—��z...;,:-�.� -- Q ff sEctICK�FDruo'ieE�AMLEIEoocir+EaEwxrtSrasor<[M.rapED latoo?oRtEss; PLUMBING _ __ Z I CERTIFV THA?14 THE PERFORMANCE OF THE WORK FOA WHICH THIS P'eRAAIT IS ISSUED,I MECHAN�CAL _ (,'3 SHFLL NOT EMPtOV ANY PER,`AN IN q,4Y MqNNER 50AS TO BECOML SIIOJEf.T TO TNE � WORKERS'COMVENSATqNLAWSOFCtiIFORNIA,AN�AGREETHATIFISNOL'LDBc'CAM[ INSPECTIONFEE ____ � SUFIJECTTO TME WORKERS'COMPENSA7:ON PROVISIONS OF SEC?ION 37M OF TME LABOR � CADE, SHALLFORhIWtTHCOMPLYWITH?HOSEPROVISIONS. �SSUANCE _ � � /�� ���;.�,o�.�Z,t,�. SMIP e`�i�2— p DATE: APPLICANT. __� J WARNING�FAIWRETOSECUREWORKERS'COMPENSATIONCOVERAGEISUNL4WFUL,ANDSHALL9E ENERGYP/C _ , � SU&IECTANEMPIOVERTOCWMINAI.PENALTIESANDCIVILFIhESUPTOONEHUNDRELTHCUSAND ENERGYPERMIT OOlURS(f 10D.0oa),I�ADDITION TO THE COST OF CpMPENSATION,DAMAGES AS PROVIDED FOR IN � ¢ SECTiON3"/oeOF7HELA80H�DE,IN7EHE5T,ANDATTORNEV'SFEES. RETENTIONFEE: OCONSTRUC710N LENDING AGENCY PRE-ALT FEE: � IHEREBVAFFIRMUNDERPENAI.7VOFPERJURVTHATTHEREISACANSTRUCTIONLENGINGAGENCV _ FO��HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMI i IS ISSIIED�SEC.3D87,CIV.C.�. . Z W — — � LEN�ER'SNAME_ ' 1— LENOER'SADDRE55 � A � ICER7IFYTHA11HqVEREA�THiSAPPLICATIONANDSTATE7HA7THER90VEWFORMATIONISCORRECT. TOTf1L FEES �. . � IAGRc'ETOCOMPLVWITH/y�CINIWOCOUNTVORDINANCESANDSTATEUWSRELATINGTOgUILOING ` \ CONSTRU�ION,Ml�MEFE9VAUTNORREREPHESENTATNESOFTHISCOUNTYTOENTEFUPONTHE � �� �A; C XA1 � ABOVE-MENTIONED PFiOPERiY FOR INSPECTION PURPOSES. 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