HomeMy WebLinkAbout12-1090 _ _
CTTY OF DIAMOND BAR � �l� � r����" ���_
"---�� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �����>-
. ��; . 21810 Copley Drtve,Diamond Bar,CA 91765
(909)839-7020 Fax(909)861-3117 Building Inspection Hotline( 8 -7 � PRESS
`�'�^'� BUILDING PERMIT APPLICATION 4 Y
o DDRI SSX�I�� �I/t'MOI�D ��IL �I.V!) O DA�CATION� 7�/II2 NUMB RI Z• fo�D�lC
v p
� APN L07� TRACT �'�VE TMPE
. DATE �ONST.��� ��
� OWNER 1J
o ADDRES�S �40 A1 . Dl RfrM,��� (�lA� P�WD I� ZONING SETBACKS
Z CITY g�� +.flD ZIP� TEL"�IKF ZZ7�Z� FRONT RW ❑
� APPLICANT 11_(i_Q TEI. S DAFJSIDE STREEf RW p
� CONTRACTOR SIDE p
ADDRESS
� CITY �Q�"�/'�g��'e ZIP TEL PROPOSED USE O i� �
w ARCWENG/. ;�1 ' •
z DESIGNER G'�'T+ � � �
a ADDRESS � NO.DWEL . ` NO.
v� � UNITS STORIES BEDROOMS
� CISY`���a�— ZIF TEL �
v� DESCRIPTfON SQ.Ff. FACTOR PSF AW.AREANALUATION
� OWNER-BUILDER DECLARATION SFWADOJREM
O
I HEREBV AFFlRM UHDEf1�PENALTY OF PETiIURV TUt I AM EXEMPT Ffp11 THE CONfMCfORg LL 6�8�.8�„
W CENSEUWFORT{Eid1UNBXiREASON(9EC.703t.6BU5PlE&3ANDPROFESSqN900DE:MlyCIT`/OR � , (n -�
U COUHryWHic]1fiEpUIRESl1PERMRTOWN9Tfri1CT,ALTE0.�VROVE.DFMOLISH,OHREPM1ANv37iNG W PatldDeek �
� 7UFlE PRqH TU�RS L59UANCE ALSO REOVIqE3 THE APMICAHf FOR SUCII PERMR TO RE A StCiME� W
� STATEMENT THAT HE OR SHE IS L10ENSED.PURSUANi TO T1E PRO�OF THE CONTMCiORy LF � ,
CENSE UW(CHAPTER G(OOM�IENCINO WI7H SECTx7N�000)OF OMSION�OF T1E BUSP1E59 AND PRO . � POOI/$PB . . . .
FE83101t5 COO�OR THAT HE Ofl SHE 19IXEAIPT TiEREFHOM M10 iNE el513 FOR THE At1E0ED E%EHP- .
8 TqN.ANYVqLAT10NOFSECT10N7o7t.68YANYAYPLICAHTFORAPERMRSUBJECTSTHEAPPLICANTTO . Z� RB-R001
� A CIViI PENALTY OF NOT MONE TWI FNE/RINORED DOLlARS(t6oD).j: - . . �
� �.T ❑I,ASOWNEROF.7HfPROPERTY.ORAh'EUPLOVEESWf7H1NAOESA3TNE1R60lECOMPENSATqN, O (`,pmmBfC{81 . . .
Z VALL DO TTfE WORIC AND THE 8TRLICTURE IS NOT INTEN�ED.OR OFFEAED fOR SALE(SEC.70M.BU34 J '
� .�NE53 ANO PROFESSlONB COOE:T1/E CONTHIICTOR9 lICp1�E LAW DOES NOT MPLY TO AN OVV11Ep OF .
VROPfiffYVJHOBURD90RRAPROVESTHEREON,ANDNM1iD00E83UCNNbHKMM9ELFORHEA.'.ELFOR � .
� 7HROUGHWSOR�HEROWNEMPLOYEEB.PROVIDED7HA78UP/IMPROVEAIplT9ARENOTD/TENDEDOR m
0! OFFERmWR3ALE1F.FqWEYE{tT1E0UlDMOQR�APROVEIA@Jf1350LDV1fTHMOt1EYEAHQFCOMPIE �
Z TqN,7FIE�ONT�ER�BUILDER W0.L HAVE T11E BURDEN OF.PROVY�O THAT�HE OR BHE pD HOT BUILD Oq .
� qAPiiOVE FOR TNE PURPOSE OF SALE} � .
w ❑L�QNMER OF 2NE PROPEHTV:AN IXCLUSNELY COffTMCTN(I NTi)1� �+COHTpACfpp$
p� ro ca+s-�aucr niE M�o,rFcr�sEc.�a�.susMess a+o vrrocEssrorrs cooe nrt contrucToas u- Veluatlon ADJ.AREA
W CENSEUWDOE9NOTAPVIYTOANO�YNEROFAPROPERTVWHD0U0.D90RIMPiKTlE8T1fEREON,11M1 ' '
� WNOCONT1iACT6FOR8UqiPAOJECTSWfTHACAHTRACTOfyS�LICB�A4EDVIM6UAN�T07/1ECOHfMG QUANTITY DESCRIPTION �E .
� TOqSUCENSEUW.�.
� ❑1 AM EXEMPT UNDER SEG B.L P.C.FOR iHIS pEASON �
}� U¢
� DATE OWNER ~
O �� LICENSED CONTflACTORS DECLARATION
�
I HEREBYAFFlfUI UNDER PENALTY OF PERNRV iHAT IM/L�CENSED UNDEfi VROVIS�ON9 OF CFNPiEfi �
4 c(�w�C!��TM SECTION 7000)OF Om510N J OF THE BUSMES9 AND PROFEBSIDIf3 COOE.MA
X 1/Y LJCENHE iS p/NI.L FOACE AND EFFECT. r,, ? . - _
� ucer+se c�n s C',��C 1 G . !���c.rro. �0_f�^�_k,��..�.{��� �
U DATE ZS Z . COMfUCTOR OC (!.dl�+-��M1YLTIb a . . .
L L)
� WORKERS'COMPENSATION DECLARATION �
� 1 HEREBYAFFIRM UNDER 7ENALTV OF.PERNRY ONE OF THE Fo1.lAWWCi OEClAMTK7/14: � Z � � � � .
0 _I HAVE AND WILL MARJTARI A CERTIFlCATE OF CONSENf TO SEIF-WSURE FOH NOPo(ERB' � . . . ' .
;� COMPENSA710N,A9 VRDVIOEU Bv BECTION 57000F TNE L�BOR COD�iOq 7HE PERPoRMANCE U�
Q OF ilft?VlORK FOR WHICH iHIS PERMI719156UED. � . . . . .
_t MAVEAND WILL MAMTA!!YIOW(Ei1S'COMPE7i4AT10N R79URANCE:A9 REOUIRED 9'/SECTION
, O �70o OF�1'ME LABOR�GODE.fDR THE�PERFORMMICE OF TiE N'Of1K PoR WVEUf 7}flS PER�qT IS, . . � U,
. � issum.�tr wowc�u'caaao+s�rpr�irisuFwvice awwea u+o aaucr 6na+eEauiE CONSI'RllCTION ��� .. _
� cnruaeq SiYll� l'U/�+� PLANREVIEW
0 POLICY.MJMBER ��Zr9D .
Z ELECTRIC
¢
o trmssEcnor+r�r+oTeeca.aEr�oFt*Ev�rs�ana+EM�a�oal�(t+oo�or+t� PLUMBING
' Z 1 CERTIFV T1UT UI h1E PERFOPaIANCE OF TfE WOPo(FOR WHICN THI9 PER3AIT 1S i56UED.1 �MECHANICAL� . . .
(�S SNALLNOTENPLOYANYPERSONPIAM�MANNERSO T09ELOMEBUBJECTT07HE, �
� N4RKER5 CWAPENSATION UWS OF CKfFOFW1A, �naeE nuT�c i 5Hot0.n eeca,iE� �INSPECTION FEE� �
sua.�ccr nie womceras coravsrisAnoro aRo� s oF sEcnn+aroo oc n+E ueoa
co�oy�,i s FOR7HWITM COAIPLY WITN 7HOSE P ISSUANCE �� •��
O DATE: D �Lk APvi�cANE�. �SMIP - .. . . ` � E�S
0
� ENEROY P/C
WAAHMI4�FALUAETOSECUREWOAI(ERSC0IAPENSATqNCOVEMOEISVNUWFIA., .eW1LLBE
� SIR.IECf AN EMPIOYER TO CRIMINAL PENALTIE9 ANO CIVIL FlNES UP TO ONE HUIDRED i/10USlIND '
oa��asts�ao.000�;rc��anonTon�cosroaoorno�s�rrori.o�uu�estisarrovmencaatt! ENEROY.PERIAT
� SECi1ON J7os OF iHE LABOR CODE INTfRE3T.AND ATTORNEVS iEEA � RETENTION FEE: � � • � .
�� ,� � CONSTRUCTION LENDING AGENCV � , �PRE-ALT FEE: �
O t �
�. 1NEREBYAFFlRMUNOEA'VENALTYOFPERNRYTHATTHEREISIICOHBTRUCTKNILENDM6MIENCY �c�� . . . . ' .� � QQ ..
Z �FON TNE FERFORMANCE OF TNE WORK FOR WHlpi TIIS VERMff IS ISSUED(SEG']oY7.CIV.GG .
W
�� IENDER3NAME . . . .. .
F— LENDERSADDRE34
� icFrnicvnuriw,veA�n�rs�aa�x.ati«+u+osT�renurn+ereoves�oii��naiisc«wECT. TOTAL FEES �-1 0� .$'�
� 1 AOREE TO COMVLY N7TH ALL CrtY AND COlM1Y ORD WANCES ANO STATE UN5 RHATD/O TO BUIL0470 � � .
� COHSTRUCf10N,AI�IDHEREBV�UTIqR1ZEREPRESENTATII/E90FT/IISC'QWTYTOENffiTil10p77N6 . ,
Z ABOVE-MEMIONED 7AODER7Y FOH WSPECTIOTI DURVOSES. .
/ � COMAAENTS
� � . � w
�
m PERMI7TEE wVAE- NT� ' � �
Q �
N � C �
uj SIONATURE OF P EE DA7 �
� . aecar.No: Pao sr vnuoArwa
wr��—oe�ro,+er,i c�y,vEuow—Fme„�c�,,PiNx=ns�aa c�y.oanENaoa-Fxe copy;aR�—n��cam�s coPy