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HomeMy WebLinkAbout11238 � , , 4' r ' CI'['Y OF DIAMOND BAR � COMMUNITY DEVELOPMENT DEPARTMENT � , 21660 F.Copley�rive Suitc 190 �� (909)860-3195 Fax(909)861-3117 / PRE`SS .''%»"'���' BUILDING PERMIT APPLICAT[ON --'`� FIRMLY � DDR'ESS �� �/�J7�'V/V1+� K�(.��- -�'�✓ DATECATION ' � i CJ NUMBER �� N/C @ �� � �- �-__ � issuE rvPe occ APN LOT TRACT DATE CONST. GROUP p OWNER �-f..t' !� � �` ADDRE55 � ' � �-'� ZONING SETBACKS z CITY,� +� IP f C.+ TEL. • `CS FRONT RW C] p APPLICANT �� '/��• � S DE/SIDE STREET RW ❑ z - ¢ CONTRACTOR C , i SIDE ^ ❑____ � ADDRESS �Cv` " ` / , � CITY ��z • ZIP � ` � jfEL. t' -` PROPOSED USE_�_ � � � oARCH/ENG/ � — �i z DESIGNER NO.DWEL. NO. NO. � a, ADDRESS UNITS STORIES BEDROOMS �- CITY ZIP TEL. y DESCRIPTION SQ,FT. FACTOR PSF ADJ.AREANALUATION � p� OWNER-B�ILDER DECLARATION SFR/ADD/FiEM O � p I MEREBY AFFIRM UN�ER PENnLTY OF PERJURY THqT i AM ExEMPT FROM THE CONTRNCTOHS LI� G8f89B/C81P011 W CENSEIAWFORTHEFOLLOWINGREA50N(SEC70.975BUSMESSANDPROFESSIONSCODEANVqTYOR (n C.) COIIN7YWHICHRE�UIRESAPERMITTOCONSTRUCT.FLTER,IMPROVE.DEMOLISH,OHqEFAIRANYSTRUC� W PdtiO/DBCI( w TUqE.PRIOR TO I7S ISSUANCE,�LSO qE�UIRE3 THE APPLICANT FOfl SUCH PERMIT TO FILE A SIGNED W j STATEMENT THAT HE OR SHE IS LACENSED PURSUPNT TO 7HE PflOVI510NS OF THE CONTRFCTOHS lt• � � CENSE LAW(CHAPTEq 9(CAMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSMESS AND PRO� � POOUSP8 , FESSIONSCODE)ORTHATl1EORSMEISE%EMPTTHEREFROMANDTHEBASISFORTHEFLLEGEDE%EMP� (� � TION ANYYIOLATIONOFSECTION7037.5BYANVAPPUCANTFORAPERMIiSUBJECTSTHEAPPLICANTTO Z Re-Root A CNIL 7ENALT'OF NOT MOfiE THAN FIVE HUNORED�OLLARS(5500)) ' � ❑I,ASOWNEflOFTHEPROPERT',ORMYEMPLOYEESWITHWAGESASTNEIflSOLECOMPENSA710N, O CommBfGl31 �i Z WIIL 00 THE WORK,ANO THE STRUCTIIRE IS NOT INTENDED OR OFFERED FOR SALE(SEC 7066,91151� J __ I � NESS ANO PFIOFESSIONS CODE THE CIXJTRACTORS�ICENSE LAW DOES NOT APPLY TO AN OWNEFi OF ? , PflOPERTY WHO OUILOS OR IMPROVES THEREON,AN�WHO DOES SUCH WORK HIMSELF OR HEpSELF OFl . � THROUGHHISORHEqOWNEMPLOYEES,PROVIDEDTHA75UCHIMPFOVEMENTSARENOTINTENOEDOq � � WQ OFFEREDFORSRIE IF,HOWEVER,THEBUILDINGORIMPROVEMENTISSOLUWITHM�NEVEAROFCONPLE Z TION,THE OWNER�BUILDER WILL HAVE THE BUqDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR � IMPpOVEFORTHEPURPOSEOFSRLE) W C11,ASOWNEROFTHEPqOPERTY,/JAE%CLUSIVELYCANTflACTINGWITHLICENSEDCANTRACTORS W70 CONSTRUCT THE PHQIECT(SEC.70C4,BUSINE55 ANO PPOFE5SION5 CODE THE fANTRACTOPS LI� VfiIU2�i011 _ADJ.AREA____ �� CENSEUWDOESNOTAPPLVTOANOWNEROFAPROPERTYWHOBUILOSORIMPROVESTHEHEON,ANO -- '— — � � WNOC�NTRACTSFORSUCHPRQIECTSWITHACONTRACTOR(S�LICENSEDPURSUANTTOTHECONTHAC� QUANTITY DESCRIPTION FEE , Y TORS LICENSE LAW). Y �ofIIAME%EMPTUNDERSEC __B BP.0 FORTHISREASON Q ? _ '—_"' _ _' —'_ U � � � OATE _,_ OWNER__ ___ __ � �` W F. QLICENSED CONTRACTORS DECLARATION W F OC I HEREBY AFFIflM UNDER PENALTV OF PEFJURY THAT IAM LICENSED UNOLR PROVISIONS OF CHAP7ER � E 1' " _ �� ' � � i � � 9(COMMENCING WITH SECTION 700D)OF DIVISION 3 OF THE BUSINESS AN�PROFESSIONS fAOE,AND Z L � �_ X MY UCENSE IS IN FULL iORCEAND EfFECT r" , y �L�¢' ! � r � LICENSE CLA � _'�LIC NO ,_ � � � � �, ' V DATE_' �> f __' CONTRACTOR� � �G.��� � �, W �� ; � WORKERS'COMPENSATION DECLARATION � a ( = U � I F7EREBY RFFIflM UNDER PENAI.TV OF DERJURV ONE OFTHE FOLLOWINO DECLARA710NS � Z r � IHAVEANDWILLMAINTAINACERTIFICATEOFGONSENTTOSELF-0NSUREFORWOqNERS' _ � �COMPENSAiION,ASPROVIDEOBYSECTION3�000FTHElA60RCOpE.FORTHEPERFORMANCE U � Q OFTHEWORKFORWHICHTHISPERMITISISSUED � O � �I HAVEPND WILL MAINTAIN WOqKEHS'COMPENSATION INSURANCE.AS REOUIRED BY SECTION Q ]7aoOFTHELABORCODE,FOqTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS � ISSUED MY WO_�RKENyS�''CO,M,�P�ENSATIOAN IN5URANLE CAFfl1E M1D POLICY NUMBEflAqE� CONSTRUCTION � CARRIER /.�(.�✓��_ _ ` e�'��j PI.ANREVIEW ----'- ------+- — E Z POIICVNUMBER��-�+� ����'�� _{_yr.,�•�-; ELECTRIC _ __—__ e t � f � (iH65EC1qNNE�NJTBECOMRE7m�FTHC-PEWNr64FUH0�`1EMX�OFEDDOLLARS(510WORLESS} � PLUMBING _,_, __ _, 2 ` W . � �.. Z . .• .. . .•. � • . •• • . � , . . - ti_.._. _ _..__ _ . ' . —. �f ' : '. Y ' • ,,..� .:5: • �y .. ... i� . � I 1 � . �• , . •. • n, •r MECHANICAL y � • .. ., �•.•. ,. •. . � , INSPECTION PEE . _1�'.- -- ---.-. -��` �yy-^''-������ ///{{{yyy���l� � CODE,�ISH FOFiTfiWI7HCOMDLVWITHTH SEPROVISIONY � ISSUANCE ____ ____ �V' � � p DATE � ' ' APPLICANT. _ SMIP ___ £:_ � __ 'J n �i . .. � . +�� � . ENERGY P/C ``.s J � �' �i ^ ' ' ' '' ENERGY PERMIT . S , . . .� . � SECTION37080FTMELABOR�E.INTEREST,�NDATTORNEY'SFEES • RETENTIONFEE: _____ ,________ _ _ � O CONSTRUCTION LENDING AGENCY PRE-ALT FEE. �' ---- ----- -- l. Q I HEREBY AFFIRM UNDER PENALT/OF PEPJURY THATTHERE IS A CONSTHUCTION LEN�ING AG[NCV t� n- fOF THE PERFORMqNGE DFTHE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC 3087,CIV.C) --- --- —� — — ( Z 1� W —"' — f- � IENDER'SNAME__ _"" _'__' _ __ _ '_ __ ii F- IENDER'SADDRESS__ '� ( � I CERTIFY THAT I HAVE REl�D TMIS APPLICATIONPND STRTE THAT TNE ABOVE INFOFMATION IS CAFiRECT TOTAL FEES , C � � IAGREE TO WMPLV WITrI ALLCI7V ANO COUNTV OR�INANCES AN�STATE LAWS RELATING TO BUILDING �� t � CANSTRUCTION,ANDHEHEBVAUTHORREREPRESENTATNES FTHISCOUNTYTOENTC-RUPONTHE �• Z ABOVE�MENTIONEOPROPEfiTYFORINSPECTIONVUiiPOS[S COMMENTS � � �/ � U -- - - � m PERMITTEE �PRINT) _ a �._--��—.. � � i � ---�= � y 9IGNATURE PEiM11TTEE D E t s RECP7 N0. 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