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HomeMy WebLinkAbout13680 . 1� CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVE ti 21660 E.Copiey Drive Suite 190 ; (909)860-3195 F�(909)861-3117 PR E$$' � �����°��� BUILDING PERMIT APPLICATION FIRMLY� - � o`, ADDR'ESS ` fv � ` �R �N��� ��� APPUCATION • ` �7/ PERMIT P/C fJ I � DATE �/�/!�7� NUMBER ����� # �--T ISSUE � � TYPE OCC �.I APN LOT ACT DATE CONST. GROUP p;' OWNE�C�N�dU ADDRESS ���F� J�i� .� - ZONING SETBACKS �` FRONT RW ❑ w" CIN �dA+^3e�Nt� l,�'e� ZIP�� TE ��� `� " a � �' APPLICANT �'A4�'»�-- TEL.� � � REAR (1 2 �nnn ❑ SIDE/SIDE STREET RW ❑ � CONTRACTOR SIDE ❑ - ADDRESS PROPOSED USE �' 'dr �'�.>' f �' CITY ZIP TEL. w ARCWENG/ � DESIGNER NO.DWEL. NO. NO. ,� ADDRESS UNITS STORIES BEDROOMS _3 _` CITY ZIP TEL. �- DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANAlUAT10N cn ,., _ �;- OWNER-BUILDER�ECLARATION - SFRIADD/FiEM p,� : I HEREBYAFFlRM UN�ER PENALTY OF PEflJUflY THA71 AA7 EXEMPT FflOM THE CONTRACTORS LI- � � ' (�8ffl B/C8 fI W„�.CENSEUWFORTHEFOLLOWINGREASON(SEC.7031.58USMES5ANOPROFESSIONSCOOE:ANYCI7YOF �,(� g � - �COUNTYWHICHREIX71qESAPERMITTOCONSTRUC7,ALTER,iMPROVE,DEMOLISM,ORREPAIRANVSTFiUC� W P8I10/DBCk - �^-'�.TUflE,PHIOR TO ITS I99UPNCE,ALSD RE�UIRES THE APPLICANT FOR SUCH PEfiMIT TO FILE A&IGNED W : �_, STATEMENT iliNT ME OR SHE IS LICENSEO PURSUANT TO THE PROYISIONS OF THE CONTRFC70PS LI- - CENSE LAW(CHAPTER 9((.'OMMENCINO WITN SECTION 7aoo)OF DIVISION 30F THE BUSINESS AN�PR0- � POOUSpB � FESSfONSCODE)ORiHATHEORSHEISEXEMPTTNEFiEFROMANDTHE�ASISFORTHEALLEGEOEXEMP- ry�p( - TION.MIYVIOt.ATIONOFSECTION7031.56VANYAPPLICAfiTFORAPERMIT5l78.lECTSTHEAPPLICANTTO . � RB-ROOf g(,yv , � �AGYIL PENALTV OF NOT MORE THM!FNE H�NDRED�OiLARS�S5oa).): � ❑I,ASOWNEROFTHEPROPEfiN,OaMYEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSAT�ON; L� CORIRIBfC18I - N7LL 00 THE WORK 1�ND THE STRUCTURE IS NOT MTEN�EO OR OFFEREO FOR SALE(SEC.7044,9U51- _l NESSAND PROFESSIONS CODE:THE CINJTRRCTORS LICENSE LAW��ES NO7 APPLY TO AN OWNEfl OF �' � �. PflOPERiYNRiO8U4050RMAPROVESTHEREON,ANDWHODOESSUCHWORKHIMSELFORHERSEIfOR m - THqOU6HHiSORHERUWNEMPIOVEES,PROYIDEDiliATSUCMIMPAOYEMENT3AHENOTINTEN�EDOR �'FEREO FOR SN.E.If,FIOWEVER TME9UILf�NO DR 9.iPf10VEMENT IS SOLD WiTHIN ONE YEAROFCOMPLE- `TION,THE OWNER-BUIIAER WIU.HAVE THE BURDEN OF PROV�N6 THAT HE OR SNE OID NOT BUIID OR� �s� ��_ IMPHOYEWRTHEPUHPOSEOFSAIE�. - y�(C'�C> ��� rJ 1,AS OWNER OF THE PpOPERTY.RM EXCLUSIVEIY CONTF1AC71NG WITM IICENSE�WNTRACTORS ��.,q���,�,�y �� N CONSTRUCT THE PROJECT(SEG 1019,8U31NESSAND PROFESSIONS CODE:THE CONTRACTOHS ll- VdIt10t1011� "o � ADJ.AREA W. GF.NSELAWDOESNOTMPLYTOPNOWNEROFAPflOPERNWHO8UILOSORIMPROVESTHEREON,M'D � � WVqCONTRACTSFORSUCNPRQIECTSWIiHAG�ONiRAC70R(S)LICENSEOPUHSUPNTTOTHECANTFAG QUANTITY DESCRIPTION FEE � � TOR4 LICENSE LAW.j. ❑IAM E%EMPTUNDERSEC. e,8 P.C.foR THIS REASON U �.' _ _-___ __— � LL' OATE J OWNER V � LICENSED CONTRACTORS DECLAFATION W �' �1 HEREBYAFFIRM UN�ER PENALN OF PERlURY 7HAT I AM LICENSED UN�ER PROVISbNS OF CHAPTEfi � ' � :,�9(COMMENCINCI WITHSECTION 7000)OF DIVISION 30F7HE BU5INE5S AND PROFESSIONS CADE,AND Z, N � X �;1/Y UCENSE IS W FULL FORCE AND EFFECL m . LL1 Q �.LICENSE CLASS LIC.NO. � �� � ,�j ,DATE � CON7RACTOR d W ��� . � ; WORKERS'COMPENSATION DECLARATION Q --_ - �. . U � _1 HEFEBY AFFlRM UNbER PENALN OF PERJURY ONE OF THE FOLLOWIN6 DECLARATKKJS: Z , Q � O ��IHAVEAN�WILLMAINTAINACERiIFICATEOF�WN5ENT70SELF•INSUREFORWORKERS' _ — '� �' _ 9 � Q qp�qPEN5A1'ION,ABPROVI�EDBYSECTION3%ooOFTHELABORCCOE,FOftTHE�FRFORMANCE 'U �y [� OF TNE WORN FOq WHICH THIS PENM�71515SUED. � x,,. q � ^.'( .. - S-- � - . . ,'_. :.. . �_f MAVE AN�WILlMA1NTNN WORKEflS COMPENSATION INSURANCE,AS REQUIftED BY SECTION �`_"q '�- ` ' ' � '-�- 4' � 3 Q� 3700 OFiNE LABOR CODE,FOR 7NE PERFORMAkCE OFTHE WORlC FOR WHICM 7HI5 PEfiM1715 � ��� � � ��� Y � a� `� � �/ � _..,. � FSSUED.MY WORK�RS'COMPENSATION INSURANCF,CARRIER AND POLICY NUMBEF ARE: � ;CONSTRUCTIQN _ __!`._...__._ J•'��= j. , �qq�Ep ---- PLAN REVIEW . � � poucvwuMSEa � ELECTRIC ��, ¢ Q mnssEcriar+r�rmreE�a.FrmoFn�cEwVvrxuwavEFax.oraEoroi.inas�xim�oA�Ess} PLUMBING __— W� MECHANICAL ' � - ICERTlFYTHATIN7HEPERFOPMANCEOFTHEK�ORKFaRWMICHTHISPERMITISISSUED.1 �� SNAIL NOT EMPLOY ANY PERSOtd IN ANY MANNER 50 AS TO BECAME SUBJECT TO THE t/j WORKERS'COMPENSA710NLAWSOFCALIFORNIA,ANDAGREE7HATIFISMOULOBECAME W5PECTIONFEE ' � � SU&IECT TO THE WORNERS'O�MPENSATION PAOVISIONSOF SECTION 37000F THE LA60F �SSUANGE � �� CODE,I SHALL iOHiHWITN COMPLY WITN THOSE PHOVISIONS. O. .SMIP � —�� p-.; DATE: APPLICANT. .� � W` ENERGY P/C _ J'. WMNING:FA�URETOSECUREVlORKERS'CAAIVENSA7IDNCOVEPAGEISUNU1WFUl.ANUSHALLBE LL, SU&IECT AN EMPLOYERTO CRIMINAL PENALTIES AND CIVIL�INES UP TO ONE NUNDRED THOUSAN� ENERGY PERMIT �&� DOLLARS(f700.000).IN ADOI710N TO THE COST OF COMPENSATION,DAMAGES AS PflOVmEO FOfl IN [� _��� SECTION37080FTHELABORCODE,MTEflEST,ANDATTORNEI"SFEES. ' RETENTIONFEE: k W� CONS7RUCTION LENDING AGENCY PpE-ALT FEE: �._ O --- pp?? �� IHEREBYAFFIRMt1N0ERPENALTVOFPERJUPVTHATTHEREISACONSTHUCTIONLENDWGAGENCY � FOR THE PERW(iMANCE OF THE WORK FOR WHICH THIS PERAIIT IS ISSUED(SEC.30W,CIV.C). LJ.! 2 LEN�ER'S NAME + y ______.— ,. f– LENDER'SAD�RE55 � ICERTIFVTHATIHAVEREADTMISAPPLICATIONANOSTATETHATIHEABOVEINFORMA710NISCOFRECT. TOTAL FEES , � IAGFEETOC6MPLVWITHALLCITYANDCAUNiYORDINANCE5AN�5TATElAWSRELATINGTOBUILDING CON9TRUCTION.AND N[REBY AUTHOFIZE REPPESENTATIVES OF THIS COUNTV TO ENTEP 11PON THE zABOVE-MENTIONED PROPERTY FOR INSPECTION PUflPO5E5. COMMENTS Q �,,;(`o f�j i+� `i� �� 1`�' ���V1� —— m PE TTE (PRIPlT) /`� L� N - � ri/ / �e � SIGNATURE EE m-�¢ �ATE RECPT.NO. � PAID BY � �V� VALIDATION � F=— � WHITE--0epartment Copy,YELLOW—Finance Copy,PINK—Assessor Copy, OLD ROD—File Capy,GFEEN—ApplicanYs Copy _-.-��1 '�r — � � .��. ��.. {a..s.. ' I �... ..j ..,_�..�, t..... .. -,�...» ..,...- I .�:....P.�.....�,.� , I� - _••3 I .� ! � .�� F F Y. . �. 1 I I � .. _ [ � � � I � � � � � � ��.. � ( � � � � I � i � �� �� � f ��� , �� � f � [ � � � '� s � t �� ��"-�. ' �.� � �_�:: ( i i �� I ? ' , ! � j � i�-�{ � i� € , i �f ' � �._� , e i�r - �e�� ` ' i , I ) t � i ! � i I ( �, i' f i � � +. � f � � I i � � � '' ! , � �, , aJ 4 � t.,..k � ��, � � � i �. I i 3 � � . I'.,.,,� ( -i � � � ' i - i � . ! � � I. E � ' ��- t I � � `� � _ � � ��i �. - i � i � ( - 1 �.. I � � � �` � ` � 3 �. � � i � � �, � i � ; I � i � �_ I � '_.� __-`—;_ � ` � --�---� ' _� j � � ( € � 1 � � � I t I �_._..I.....-L-'l.. ��...__.._ � � 3 � f �. E i. ._�_ F � � .! ! 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