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HomeMy WebLinkAbout16929 i �\ CITY OF DIAMOND BAR i DEPARTMENT OF COIvIIvIUNITY&DEVELOPMENT SERVICES EXP I RED 21825 E.Copley Drive '"" (909)860-3195Fax(909)861-3117 JUN 19 2[k71. PRESS '`'���� BUILDING PERMIT APPLICATION FI Y � JOBSITE aa--� � �, ����E.cn��� APPLICATION PERMIT P/C o ADDRESS v r DATE ' �G NUMBER���N � ISSUE TYPE OCC APN T TRACT DATE d CONST. GROUP p OWNER p ADDRESS ZONING SETBACKS Z CITY �� . ZIP TEL. �' ?I FRONT RW O g APPLICANT TEL. R�R � � SIDE/SIDE STREET RW O � CONTRACTOR L �Gl SIDE ❑ � ADDRE S � � � PROPOSED USE o CITY . iIYD ZIP�TEL � S � l wo ARCH/ENG/ � i � DESIGNER NO.DWEL NO. NO. . ADDRESS UNITS STORIES�_BEDROOMS_,� � CIN ZIP TEL � cn DESCRIPTION SQ.Ff: FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFWADD/FiEM O 1 HEREBY AFflFiM UNDER PEtULTY OF PERNRY THAT I AM EXEMPT FROM 7NE CONTMCTORS LF Garage/Carport W GENSELAWFORTMEFOILOWW6flEA50N(SEG7071.68USINESSANDVROFESSKKJSOODE:►NYGITYOR (n U COUNT'/WHICHREWIRES�PERMRTOCONSTRUCT,ALTEH.IIAPROVE,DEMOlJSH,ORREPAIRANYSiRUG W Z TUNE PRpR TO RS ISSUMlCE A150 REOUIRES THE A7PLICANT FOR SUCH PERMIT TO FILE A SIGNED Pal(O/OBCk W STATEMENT THAT HE OR SHE IS LICENSED FUiiSUANT TO iHE VROVISIONS OF TME CONTMCTORS L4 W � CFNSEUW(CMAPTERY(COMUENCRIOWITHSECTION70o0�OFDM510N�OFTHEBUSWESSANDVqO � PooUSpa FESSIONSCODE)ORTHATHEORSHEISE%E�IPTTHEREFROMAN�THEBASISFORTHEQlE0E0E%EMP� (� � TION.ANVVIOU1iqNOF6ECT10N7071.SBYANVAPPLICANTFORAPERMITSUBJECTSTHEAPPLICAMTO Z Re-Roa1 ACML VENAITY OF NOT MORE Tl/AN FNE NUNDHED DOLURS(f5oa).): � OI��WNEROFTIEVRDPERTY.OqMYEMGLOYEESWITMWAGE5A5THEIR50LELOMPENSRTKKJ, 0 Commerciai � Z Wlll DO THE WORIC.AND i11E S7RUCTURE IS NO7 INTENOEO OR OFFEREO FOR SALE(SEG 7M1,BUSI� J � NESS/NO PROFESSIONS CODE TNE CONTMCTORS LICENSE UW DOES NOT A➢PLY TO MJ OWNER OF ? PROPERTY Vh10 BU0.D5 OR IMPROVES THEREON,AND WHO DOES SUCH WORK NIAISELFOR HERSELF OR STHROUGHHISORHERONMEMOLOYEES,GROYIDEOTHATSUCHYdPROVEMENTSARENOTINTENDE00R m � OFFEfimFORSALEIF,110V/EVE0.IMEBULDINGORIIIFROVEMENTIS50lDWITMNONEYEMOFCOMPIE� Z TION,7HE OWt1ER�6UIL0ER WILL HAVE THE BU1iDEH OF VqOVWO THAT NE OR SHE�IO NOT BUItD Oq = tlACROVEFORTHEVURPOSEOFSALE} O 4 AS OWNER OF 1HE PROPEHTV,M1 EXCLUSfVELV COMMCTING WRH LICENSED CONTMCTORS Q TO CONSTRUCT 7HE PRQIECT(SEC.70N,BUSIHESS NID PROFESSIONS CODE:TME CONTNACTORS LI� V8IU0Ii � ADJ.AREA 111 CENSEUWDOESNOTAPVLYTOANOWNEROFAPflOPERTYWHOBUILD50R4.IPROVESTHEREON,NlO F� NTIOGONTMCTSiORSUCNPROJEGTS'MTMACONTMCTOR(5)LILENSEDPURSUANTTOTMELONTMG QUANTITY DESCRIPTION FEE Y TORSLICENSEUw.), � O I/�A1 EXEYVTIXdDERSEC. B.t V.C.FOR THIS REASON � � U U.. � DATE OWNER V Z W �Q LICENSED CONTRACTORS DECUIRATION W ¢ IMEREBYAFFIRMUNOENPENALTYOFPERNRVTNATIAMLICENSEOUNDERiROVIS�ONSOFCHAPTER � p„ i(COMMENCWOWITHSECTqN1000)OFOMSION�OFTHEBUSINESSAND OFESSIONSCODE,AND Z �X MYLICENSE IS N FULL ORCEANO EFFECT. m � /� � LICENSE CUSS LIC.NO. �+�" J V DarE � cor+rrucron a . w �O � WORKEFS'COMPENSATION D RATION a NIHEREBVAFFIiUAUNOERPENALTVOFPE0.)URVONEOiT1EFOLLOWINCiDECLAfUTI0N5: Z � �IYUVE/WOWILLMAWTNNACERTIFtCATEOFCONSENTTOSELF-INSUREFORXORKERS' 2 COMPENSATION,ASFROVIDEDBYSELTIONJ7000FTHEUBOqCODE.FORTHEFERFORMANCE W OF THE WOPX FOR NM1IIp1 TFIIS VERMI715155UED. � O _IHAVEANDWILLMAMTA�NWORKERSCOIA7ENSATqNINSURANCE,ASREOUIREDBVSECTqN I . �f, Q J7000F THE LABOR CODE,FOR THE PERFORMNJCE OFTHE WOfiN FOR WNIC11 THIS PERMIT IS YJ V 155UED.MYWONKERS'CAMPENSATIONINSURANCECARAIERANOGOLICVNVMBERARE: CONSTRUCTION � CARRIEH PLAN REVIEW � POLICYNUMBER ELECTRIC 0 (n+ssecrnnr�mwreEm.aFrEo �v a+e�+n��ocuu�sa�m�oa�rss�. PLUMBING Z ICER7IFYTHATNTHEPERFORMAN OFT RK ORWHiCHTNISPENMIT45155UED,1 MECHANICAL C7 SMALLNOTEMPIOYANYVER50Ni ANYM CR ASTOBECOMESU&1ECTTOTHE � WORKER5COMPENSATIONLAWS FCALI NIA,A 11GRE�j TIFISMOUIUBECOME INSPECT�ONFEE S SUBIECTTOTHEWORNERS'COM _NSATI PFO qNSO�SE ION77000FTHEUBOR WOE,1 NALIFORTM4ITHCOM VWI SEP ON 6Ns. ISSUANCE 0 p OATE: � �O APPLIC NT: SMIP D � ENERGY P!C J WARNINQFAILURETOSEWREYRNiK 5' MPENSA COVEMGEISUNLAWFUL,ANDSNALLBE �y SUBJECTANEMPIOYERTOLRIMINALV TIESM1DdVILFWESUPTOONEMUNDRE0iF1W5M70 ENERGYPERMIT OOLURS IS1o0.0oa1.IN ADDRION TO THE CAST OF COMPENSA7ION,DAIAAGES AS PRONIDEO FOR IN � SECfION77DeOFTHELA00RCO0E,IN7ERE5T,ANDATfORNEYSFEES. RETENTIONFEE: pw., CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � IHEREBVAFFIRIAUNOERPENILLTYOFVERNRYTHATTHEREISACONSTFUCTION�NDINGIIGENCY FOR ME PERFORMANCE OF THE WORK FOR WHid/TH45 PERMIT IS ISSUEO(SEC.]OY7,CIV.G). Z w � LENDER'SNAME F_— LENDEf7SIDDHE55 � ICERTIFYTHRTIHAYEREIIDTMISAPFUCATIONANOSTATETHATT7EhBOVEMFORMATqN15CARRECL TOTAL FEES O2��U W I AGREE TO CMdPLY WITM ALL CITY/J!�COUNTV OROINANCES MIO STATE UWS FEUTING TO BU0.DING � CONSTRUCTION.ANDHEREBYAUfHORIZEPEPRESENTATIVE50FTH15COUNTYTOENTERUPONTHE Z ABOVE�MENTIONED PERTYFORINSPECTIONPURPOSES. COMMENTS � ��t�L ��.ut' m oErv.un e ro �_ '¢ r � � N SIGNAUREOFPERMITTEE DATE � RECPT.NO. PAID BY VALIOATION WHITE—Department Copy,YELLOW--Finance Copy,PINK—Assessor Copy, LDENRO�File Copy,GREEN—Applicant's Copy . .• .•,�r.,, .... y.�.. .,...,,.� .. .. . . -.. ,- . .....'� .. .. .�,.n�a y�r✓4:,�i'�7�J�t�;'.:J.:d'�:"`•';'i��O�.ri"�(4. .a_,5 _„�oi� , .-.,7,c .� ,.... .. r e n.. . . . .. . ..,.-_ . . _ , . . v�t�� d� ❑�14������� ��-��i If'�'��=�C�9�P�! i;ECOrD .�.�_.^.______��___.._---_ _--_ __...-- ------- _-- -. _.��� __ � �1►k-`��I_:�4�'�`7►1 =}'F.��. .�l►�!-'���-?�' t'�1�� I1'�-'i'�_�c',t'Ccl►�E my��o'�: �►���;.1�c'��'o�;t 'FTGS/FORMS,STEEL_._.._ .. . . . I _.._ _1--.-.. y _ �.. '_I FHA REQPJITS . __..�_.�__---._ ____ ...__=. _.__....-.-w--�__.__...._._. 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