HomeMy WebLinkAbout15348 (15) !� CITY OF DIAMOND BAR �
DEPARTMENT OF COMMiJHITY&DEVELOPMENT SERVICES
21660&Coplcy Drive Suitc 190
(909)860-3195 F�(909)861-3117 PRESS
�''^M'� BUII.DING PERMIT APPLICATION FIRMLY
o D flESS 2IO"i—� � 2���'2 diU(l[.J N • DATECATION �-�/� PERMR 1 3 � P/C
3��W NUMBER� x
c� ISSUE (1 1� ' TYPE OCC
APN LOT TRACT DATE ( [ CONST. GROUP
p OWNER 'i74L_E`/FJLY�D /'F_L`7.�4.
o ADDRESS ZONING SETBACKS
� CITY ZIP TEL REAR Rw O
APPUCANT TEL SIDE/SIDE STREET RW O
� CONTAACTOR F /� � SIDE ❑
� ADDRESS � PROPOSED USE �DO
CITY/Ui SS�n�_1 1/i.e i 0 ZIP TE �44)�lSB�1CJ4 � OL �' c
� ARCN/ENG/ • - •
DESIGNER NO.DWEL /� O. NO.
ADDRESS 11NITS Li — STOflIES �E3EDROOMS
� CITY ZIP TEI.
� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
�
p� OWNER-BUILDER OECLAHATION SFR/ADDlREM
O
Q 1 HEAEBY AFF6W UN�ER VENALTY OF PE0.RIRY T/IAi I MA E%EYPT FROM THE CONTIUCTORS L4 GaragelCarport
W CENSFIAWFORiHEiOLLOWNi7PEASON(SEGJ0.71.6BUSWESSMIDPHOFESSIONSCODE:IWYGTYOR (n
� GOIAYTYMnp/REOUNiESAPEAAIRTOCONSTRUCT,ALTEitMPROYE,DEA10Li5FiORREPAIRANYSTAUG W P1t101DeCk
1LME,YRIDR TO RS ISSUM/CE/LSO REW WES iHE APPLICANT FOR SUQf PE W.�IT TO fILE A SIGNED W
� STATFYFNT TNAT HE OR SNE IS UCENSFO PU0.SUANT TO TME DFOVISIONS OG THE CONTRACTORS LL
� cd+sE uw�uuvr¢n o IcaaM�cwo vnn�secran�000l oc on�san a oc n+¢eusv�ss u+o vaa � PooUSDa
fE55qN5 CO�k�OR 7}iAT NE OR SHE IS EXEMPTiNEHEFROM ANDTHE 8A515 FOR THE ALLEGE�EXEMP•
TqN.ANYV10lAT10NOFbECT1oN7o31.6BYANYADPtICANTGORAiER41T5U&lECTSTHEAPPLICFNTTO Z R�R001
� AUVtI PENALiY OF NDT MOHE i11/V1 FNE MR�DRED DOL1M5(Sso01.j: _
� OIASOMINEROFTMEVROVEN7Y.ORYYE4Pl0'IEFSwIiHY/�GE5A5TNEiRbOLFLOMPEN5�710N. � CpmTefC121
WILL pO tHE WON(AND THE STRUCTURE 15 1qT IH7ENDED Oil OGGENED iOF SFLE(SEG 7ou,BU54 J
� NE53 NO if10FESS10N3 OOOE THE�IfiRACTORS UCENSE Uw DOES NOT AVPIv TO AN oWNER Of ?
if10YFA(T 1Mq 9U1A50q MPROYES TNEREON./VO'Mi0 DOES bUGq WORI(M1115ELFOR HERSELG OR
- - (= T1NdKWwSO{iHEROVrt1EYPlOYEES.DpOY1DEDiNAiSUtlIWDROVFYFNTSARENOTMENOmOFI m . . .. ._ .
� ,OiFEREDfOH5AlE1F,11oVhVERiHEBlADw00RIMPROYEUIXiI550tDWIiwNONEYEAAOFCOMPIF
� TION.THE OMIMER�BUIL.DER WfLLlNYE TME BURDEN OF PHOYWG TMAT ME Oq SME D1D NOt BUILD Oq
YPFIOVE FOH TlIE GURDQSE OF SALE�
O 4 A+��ER Of THE PtiOVEHTV,MI Df0.U5NELY CONiRACTNO YniN I�CENSFD CON7MC10R5
� TO CONSTRUCT iT1E PHOJEGT(SEG 70N.BUSINE55 AND iROFE53qNS CODE iHE CONiHAGTORS LF V2IU2flOf1 AW.AREA
f�H4E UW DOE3 NOTA?PLY TO/JI OYMER OF A iR07ERTY Yrtq BUlD50R W 7ROVE3 TlfEREON.AND
� W/qCONTRACiSFOHbUCHPHDlECTSVl1THACONiRACTOFI(S)LICENSFDPU0.5UANTTOTMECONTRAG p�p� �ESCRIPTION FEE
� 70f1S ULEHSE LANL}
� O 1 AA1 EXEMPT UNDEN SEC. 6l P.G GOH THIS fiEA50N � _ . .
U
Q
"-- wte om,�a v
� J
� IICENSED CANTRACTORS DECLARATION W
� INERFBYAFFWMUNDERYENALttOFVE0.RIHYTMATIAM�ICEN5E0UNDER7ROVi5iON50FC11A7TER Ur
� •�C0IYIENCINa WrtN SECi�ON 7oo0)OF DIVISION]OF iME BUSINESS INJ PROFESSi0N5 CO�E Ni0 Z
W UCEriSE IS N1 fULL�OFiCE�ND EFFECL m
� LIGENSE C1A55 C,-3q LIC.NO.� � �
H ^ /�
� DATE f"I'1� OO CONTMCTOR - U d
� WORKERS'COMPENSATION DECLAFiAT�ON Q
� U
N IHEREBYAFiWMUNDERPENALTYUFVERJUfiYONEOFiHEfOLLOWWCDECLAfiAT10N5:
N ZQ
� ��IIiWE/JAWLLLMAW7AINACERiIF1CATEOFCONSEMTOSElGJNSUREFORMAORKERS' S
CpiAGQ1$ATpN.A5 PROVIDEO 8Y SEGTqN 777G OF TME UBOR CODE.FOfi TNE PEAFORMANCE W
pF TIIE y�q1K Fpq NM1YCH i7US VERuIT 45 LSSUED. �
�
�{uyEµpyAILW�WTAWWOAKERS'COMPENSATqNWSUiLWCE,ASREOUJiEDBYSEGTqN /�U.�
Q i7oo0F7TfELI80RCOOE.FORTHEPERFOFwANGEOFTMFWOWCFORWHiCHTHISPERMiT15
LSSUEp_W WOWCEAS'OOI,iPENSATIPV INSURANCECAHNEHAND POL�T NUMBERARE: CONSTRUCTION
� GNYYER 5T�1T�- �D,S __- PLAN REVIEW
� voucr rti..;_�� �� Z n - v - ELECTRIC
� (nusca�otir�raieEoa.�rIDovn�rEwaTsw�or���R+�)��? PLUMBING /�
Z ICERTFY7MAil/T/EiERFORM�NCEOFTNEWONCFORN'NICNTHISPERIAITISISSUE0.1 MECHANICAL �_ —
() SNALL/qTfuPIOYANYPEfl50NNANYMNWER50AST06ECOMESU&JECTTOTNE
N YlORICERSCOMPENSATqNUWSOFU1li0ANiAAN�►GREE7MATIfISFqUDBECOME INSPECTIONFEE ,_
S SUBJECtTOTMEWOpKERS'COAIDENSATqNPROV15qN50FSEGTqNa7o00FTNElkiOR ISSUANCE
COOE.I SMAIl iOFITTIW1iN GOMPLY WITH 71K1'c PROVISIONS.
0 �I, _ SMIP �
p OATE:�O APPIICANT: �
W ENERGY P/C
� WAHNINO:F/1LURE TO SECURE WOfiKERS'GOA/PENSATqN COVEMGE IS UNUWFUL.AND SFULL BE j
SUBJECiIWEYVLOYE0.70CkWYU1DENALTIESANDCMLFINESUPTOONEMUNDREDT1qU5AND �ERGYPEAMIT C+ �
ppUNy$(i100.0001.W/�DD�TbN 70iHE COST OG COA/DENSATION.OA4AGE5/S�R01lQ1ED FOR W
J SECiqN 77G OF iME L.FBOH GODE.NTEREST,AND ATTORNEYS FEES. RETENTION FEE: R�� —
� CONSTRUCTION LENDINGAGENCY PRE-AlT FEE
� IMEREBYAFFlMIl1N[IERPENALiYOFPE0.NRYTHATTXEREISACONSTRUCTqNLENOwGAGENCY
0- FOfiTHEPERWFMANGEOF7HEriORKFORWMIp1TMIS7ERAUTI5155UEDI5EG7oY7.qV.G}
Z
w
� IEHDER'S WME
F- IENDER'SMDRE55
w IGEpTIFYTMA7IMAVEREA0TMi5ADDL�CATIONAN�STATETNA1TMEl100VEWFORA/ATI0111SWRRECT. TOTALFEES
p_ IAfiREETOCOMFLYVf1THALl.GTYANDCOUNTYOFiOW�wCESANOSiA7EUW5RFLA7YiGTOBUlDING
CONS7FAICTIQN.MID HEFEBY AU�HOR�ZE REPiiESENTATiVES OF 7FIIS COUNTY TO EHiER UPON THE
� ABOVE-MENTIONFAPRO�ERTY FOfi W57ECTION PUHPOSES. COMMENTS
� �'�� 132c�[��l oo F/�VE,, .T_n�U_
a P��.�E�Pa� -�-r r�o
� o
� SIGNAIU OFPEwuT1EE WTE
� FECPT.N0. PA1D BY VALlOATION
WHITE-Department Copy.YELLOW-finance Copy.PINK-AssassorCopy.GOLDENROD--File Copy,GFEEN-Ayplicant's Copy �Y
,r I I I
... -- � _
t: ` I i � �
, _,_ _. ._.
, _ �
,., -
�; �
r ,;�
�
�`, -
� _
ry
; s,
� '� -
a �
t . ;
f F Z
Q � .
�
� � - �' . U � 4 m � � ,.
�., Q �-�, . _ � �Z p C � C7 �` � Z .!
m CL � o c� � zm ¢ w z � � cc ¢ � >r-
;, � '�'`;:H u� o o � m o w m C7 p z ¢ Z a � � � L Z F � t:}'_
� C� lT�'�n F- O O w w Z m o z ¢ � U v � g z t�i a � a a L;I; . ,
Z (i! :i.�.p � � � U V o � z o (7 ¢ [c w z ¢ o C7 d � Z � LL' cn e�.i .
� (7 � u- ¢ m Z p < z C7 �ry � w ? w F= z Q — O a � w �- �
O CL �'.� W ¢ ¢ `� J F O m CL = 2 W tL LL F- G 111 U W N W 2 Ll1 �
� '�1, O CL W W Q. Q. = m J C�S V C:S = J J J f!J U J � F- ...I � f- lL � .a`.-.�
� p ¢ o o W W � ¢ tiW Z � � O O O � o ¢ z � 4 w C > W "`-�
a o � xz z � � �izr� woz000LLwz — z � ww z �j!
� �,� � > > � LL � c� � am ¢ �. n. aao ❑ LL � o � u. = ❑ w
: F- � —
� o w
�; a ��< -�
� � I�,�, � _ _ -
� - �' L ,- - �'
��! -�
��• _
_+ 'l._
�P� �.
' �.:,� ,.
I��,' N
•.i; z — ` ,ii , �
. �� p� ' � � : .
. � J z � � Q � ,_ ' O , . . .
� �� / FW- � CD �' W Z J (7 q Z W z � � C7 N W . -. . �.
Z U � c�N
. .c�-'• tn p `- U — F- � Z m F- — _ 7 (!� . . . .
, � _ - S � c�
�
� � � � �� = z � S m O ~ � Y F- F= Z � Sl f- Y UJ y�
' W'�t 2 (r J p w Q Q"W u! Q W � � U] � uj -� tIJ � F , �t . I
• TtW�Y CC U Q" Q � W W � � W .J J � � Z ` ¢ J W F�- U � �u ¢� "'1 �. /d.
. 4:Y�U p � � Q O C/l 2 C7 O 2 W � ¢ S � '� F- h_ ~ D lU J J ' f-h � .. . . .
, ¢ u. � z � aQu� �. c� = x = w �' zt� a ¢ c� a � c� z wa 5 _ c�a. :
�� .
�:[Ll � U � m d W LL � tL C7 CJ Ci j � J LlJ � d 4 J J _I _ ' �S. F-O.. . , :�:
W � J CC J W 4 O � O O O O OS � ¢ W Q W W W �C Z Z � {� � W W '; =t ��
' � <.
�
� u� � w c7 �n r- 3 ¢ � � cr a � m w s c� n cn cn cn cs u`, u. �1�I U - - cnv� .`ti%_..,. ���;