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HomeMy WebLinkAbout14336 (8) CITY OF DIAMOND BAR r � e; - DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES'� 21660 E.Copley Drive Suite 190 (909)86a3195 Fax(909)861-3117 PRESS "�"� BUILDING PERMIT APPLICATION FIRMLY o ADDRiESS �/_F� �� � �/�IYf O,v✓ �/77� � � DATECATION //��,�,_�J+� NUMBE� "' �/C �/y`��' � I5SUE TYPE OCC � APN LOT TRACT DATE CONST. GROUP p OWNER � �+ � ��e ��C"JZ p�-�e1C��'/�?/ p ADDRESS ' �. 1'! J��•td,l/`, ZONING SETBACKS k• � CITY J �aTEL.(� � P�-G� FRONT � RW Cl ; APPLICANT TEL. REAR u � � SIDE/SIDE STREET RW r7___ ; aa CONTRACTOR '�%'--�T= � (' 5��� u-- � ADDRESS ! /�� • �..."L ::iC•C'e:¢ . j � CII�' 21P TEL. PROPOSEDUSE S�, /�'!� �°�--j� F�r" o rARQJ�/ENG/ l�,1 f C�L ���i,'('/16f/f �/`t'I C ij j L j C. . -�".�/�.1= F ivC ��� ; z '�ESlGNER / ` a ADDRESS ./ .' , a NO.DWEL. NO. NO. E N CtTY�J�__ 21P TEL. UNITS STORIES BEDROOMS y R <n DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � O OWNER•BUILDER DECLARATION SFR/ADDlREM p 1 HEFEBY AFFIRAI UNDER PENpLTY OF PERIURY THAT 1 NM EI(EMPT FROM THE CANTRACTOqS L6 G8f8QB/C8fp0ll � W CENSEUWFOHTMEFOLLOWINGqEp50N(SEC.7031.5BUSINESSANUPROFESSIONSCODE:ANYCITVOR (/� U COUNfYVYHICHqEWIRESAPEHMITTOCONSTiUC7,AL7EF,IMPflOVE,DEMOLISH,ORfiEPFIRANYSTRUC- � W pyfi0/DBCIC F � 7URE,PPIOR TO ITS ISSUMICE,AL:A REQUIRES THE APPLICANT FOR SUCH PEflMIT TO FILE ASIONED W 6TATEMENT THAT HE OR SHE IS UCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTOqS LI- � � CEN5ELpW�G7UVTEH9(COMMENCINOWITHSECTION7000)OFOIVISION30FTNEBUSINESSANDPRO- � �" POOUSPB FESSIONSCODE�ORTMATHEORSHEI5EXEMPTTMEPEFROMAN�THEBASISFORTHEALLEGEDEXEMP- � 710N.�ryVV10LAT10NOFSECTION70.97.5BVANYPPPIICANTFORAPEPMI75U&IEC73THEAPPLIGAN7T0 Z R8-ROOf � dGVILpEN11L7VOFNOTMORETHqNFNEHUNDREDDOLURS(55ooj.j: � ^ ❑I,ASONMEROFTHEPHOPEHlV,OHMYEMPLOYEESWITHWAOFSASTHEIRSOLECOMPENSATION, 0 COInI11BICidI �� J�"' � WILL DO THE WORK,AND iNE STRUCTUFF.IS NOT INTENOEO OFi OFFERED FOR SALE(SEC.7044,BU51- J ItlE5uAN0 PROFESSIONS CODE:TiE CANTflACTORS LICENSE LAW DOES NOTAPPLY TO AN OWNER OF � � PROPEqTYY7HOBUND90RMIPROVE97HEFE0N,IWDYMO�0ES5UCHWORKHIMSELFORHERSELFON 4 Q THROUGHHI60RHEpOWNEMPLOYEES.PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTEN�EDON m � W OFFEREDFURSALE.IF,liDWEVEfi,7HEBUIL0INGORIMPHOVEMENTI550LDWITHINOUEVEAROFCOMPLE- Z� �TIDN,THE OWNER-BUIL�Eq WILL HAVE THE eURDEN OF PROVING THAT HE Ori SHE DID NOT OUII,p OR � = IMPROYE FOR7ME PURPOSE OF SALE� � ❑I,FSOWNEROFTHEPAOPERTY.MIEXCLUSIVELYCANTMC7INGWITHUCENSEDCOMflACiORS ' � TO CONSTflUCT TMF PROIECT(SEC.7oM,BUSINE55 ANU PROFESSIONS CODE:THE CONTRACTORS ll- V2N2f10l1 .__ ,� _____ADJ.AREA._„ _ __ � � CENSELAWDOESNDTAPP�YTOPNONTIEROFAPROPERTYWH09UILDSORIMPROVESTHEPEON.AND " � ' YYFiOCqNTMCTSFOASUCHPRQIECTSWITHACON7'RACTOR�S)LICENSEDPURSUPNTTOTHECONTRAP (,�UANTIN DESCRIPTION FEE '4', Y ronsuc�sEuw.�. e r � �IAMEXEMPTUNDERSEC. � B.&P.C.FORTHISREASON � a � �.'r L�' �L�C.� y'��Z� � � � � _ � �'y'�s;��'.-�� __ ¢ [ DATE OWNEfl ,•' /i�'L� _ U � �Z W ,3� LICENSED CONTRACTORS DECLARATION W � I HEREBV AFK�RM UNOEF PEN1ILTY OF PERIURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTEfl V. C � r �+ /�/�,t `�J.` L 4� F � B(COMAIENCIN6WITHSECipN1000)OF�IV�SKKJ30FTHEBUSINESSANDPPOFES310NSCODE,AND Z r e— MY LICENSE IS IN FULI W RCE AND EFFECL /^ � LLl � � f'�C G ` i 0 LICENSE CIASS_ LIC.NO.___ ___„_ � � J V �ATE_ CONTRACTOR _ .___ d � W � WORKERS'COMPENSATION DECLARATION J E � , V �. � I HEREBY AFFIRM UNDER PENALTV OF PERAURV ONEOFTHE FOLLOWING OECLAPATIONS: � � Q I � __IHAVEAN�WILLMAINTqIkACERT�FICATEOFCONSENTTOSELfdNSl1FEFOqWOPKERS' _ ' i 'Td- COMPENSATKKJ,AS PROVIDED BY SEC7ION 3]OOOFTME LA9OR CODE,FORTHE PERFORMANCE IU '� Q OF TME WORK FOR WHICH THIS PFRMIT IS ISSUE�. � W 4 _I HAVE ANO WILL MAINTAIN WORKERS'COMPENSA710N INSURANCE.AS REOUIflED BY SECTION � E� Q 37ao OF THE IABOH CWE,FORTiE PERFORMANGE OF THE WOHK FOR WHICHTMIS PERMIT IS ISSIIED.MV WOHKERS'COMPFNSATION INSUPANCE CAqRIERM'D POLICV NUMBERARE: CONSTRUCTION ____._ � � y � �'"n /,T;--�� '_'—_'_ r r �. ' � � � 7 CARqIER. _ ._. PLAN REVIEW __' � __ _'__' __._ a f Zro��cYNUMBEr+'_ _ '__ ' ELECTHIC . _____ ___ " 6 � � � (R',ISSCCf�ONNEIDN�TBECdJPLEfEDOFhIEPEFAYfISFORONEHJNDiI'eDDOLLMS(510010!iLESS� PLUMeING ,--- ----. --- -- I Z I CEqTIFY THAT IN THE PERFORMFNCE OF THE WORK FOR WHICH THIS PEFMIT IS IS6UEU,I MECHANICA� ___.,. ___,_.,,___ _,__ __ i (,'} SHALLNOTEMPLOYANYPERSONINANYMpNNERSOASTOB[CAMESUBJECTT07HE � WORNER5COMPENSATIONLAWSOFCALIFORNIA,AN�AGflEETHATIFISHDULO[i[COME INSPECTION FEE _ .__ _ ______ _. � Sl1BJECT TO THE WORKEHS'COMPENSATION PROVISIONS OF SECTION 37o00FTHE LABOH j�'�, � ISSUANCE �'���+��+i�' vv ' ' � COOE,ISHAILFORh1WITHCOMPL�WITHTHOSEPHOVISIONS. _. __ ._,—.,._ � SMIP � Ti�- 7 � p �ATE: APPLICANT: ___ ' _—'_ .-' '—". `=-� � ENERGY P!C __ __ ___ __ � WRRNING FAILURL TO SECUPE WORKERS'COMPENSpTION fAVERAGE IS UNL4WFUL,ANU SHALL BE --���—� LL SU&IECTANEMPIOYERTOCRIMINAIPENAITIESANDCIVILFINF.SUPTOONEHUN�fl[�THWSAND i ENEFGYPERMIT �'"�° t'' N�-?�" DOLIARS(S1a0,000),INAODITIONTOTHECOSTOFCOMPENSATIOY,�AMAGESPSPROVIOEUFORIN --�—r-�'- ,�, .� -�--�� — ��� � � SECTION 3'/060F THE LABOR CO�E,INTEREST,AN�AiTORNEY'S FFE3. RETENTION FEE: �,^�, � _, � w �' 9 _". . .,.,�S�r;,�y'..(�., � p_ CONSTRUCTIONLENDINGAGENCY PRE-ALTFEE; ��J_�i3}�"- - _'�` `� '�� ., ___ I O ^�^a'ty-rr ..,v,„+:.�� ;•'—.�—+-r%;.''' --- � IHEREBYAFFIRMUNDERPENqLTYOFPERIURYTHATTHEREISACONSTRUCTIONLEN0INGAGENCY f"��_13�_��,?:,�:�..'� '� _ `.::L.L ZFaR THE PLfiFOftMANCE OF THE WORK FOFl WHICH THI3 PERMIT IS ISSUEO(SEC.3097,CIV.C.7. — �— � " — ` � � _ _—'_' '_ '_" _ '" —__ '_' '—_ 1 LENOER'S NAME__ F- LENOEH'SADDRE35___.__—. _— .__ . � � ICEPTIFYTXl.TIHAVEREP➢THISAPPLICATIONANDSTATETHATTMEABOVEINFORMATIONISCORRF.CT. TOTPtL FECJ f d ' a IAGREETOCOMPLYWITMALLCITYAN�COUNTYORDINANCESANDSTATEUWSRELATINGT09UILOINP �� CONSTRUCTION,AND HEflEBY AUTHORIZE REPRESF.MATIVES OF THIS CWNTV TO ENTEH UPON THE � Z A80VF.-MEMIpNEBro1rop Efl7Y FORJaeP�c.TION PURPOSES. r.% o ,.�• COMMENTS_. ____ .. �l-••"' '-,/ ,;��• � --- o -� � !'���.,. � ��'� _ ---- — �„' PERMITTEENAME(Pfll ,)^+•. �� — ___ k .. .;..� � ��/'- _,�,r� � N SIOtUf�REpFPERMITf,E2 �' -,�� „r�',,,-�.... DAT ' - ` RECPT.NO._, PAID BY �_ VALIOATION_ � G � �-` WHITE—Depertmant Copy,Y OW�inen py,PINK—Assessor Copy,GOLDENROD—File Copy,GFEEN—AppinanPs Copy �i 4 � � .., . ........ .. ..... . _.._. _ �q • ' _'-' r_.... ,., .. . wt� ' � : : ' ". "_". I,.... .... . .... .. \+, ... ...... . . . . ___... ... .._ . . .. - �Fs'�`W, � � I � ' i - . a\ ' j I ' i . I � . - � 1 � �- , _ �r�¢ � ' � - � I . . . . � n � . � � i , ` ���_ � ; � ` ` I I � ' i I �~ ' , ; . n �f�� � i � � . i ( � , � . 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