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HomeMy WebLinkAbout17931 �` CTIY OF DIAMOND BAR DEPARTMENT OF COMMUNI'IY&DEVELOPMENT SERVICES �.�y 21825 E.Copley Drive - (909)860-3195 Fax(909)861-3 l 17 E$S `��� BUILDING PERMIT APPLICATION FIRMLY oJOBSITE � � .7 _> APPLICATION ' PERMIT � p/C ADDRESS �Z�S / /;L�O � /�/LIGE N • DATE � �� NUMBER # ISSUE � TYPE OCC p OWNER �� �.(� DATE CONST. GROUP o ADDRESS uT E. ZONING SETBACKS Z CITY • / ZIP TEL. �' � FRONT RW p g APPLICANT TE�, REAR � � CONTRACTOR L p! . SIDE/SIDESTREET Rw ❑ � SIDE � � ADDRESS a✓�ti r i . � CITY ��'s'� ZIP TEL PROPOSEDUSE o ARCH/ENG/ � DESIGNER NO.DWEL. NO. N0. = C'DTDRESS Z�P TEL. UNITS STORIES BEDROOMS � � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION p SFR/ADD/REM 1 HEREBY AFFIiUA UNDEq CENALTY OF PERJURY THAT I AA1 E%EMPT FR01.1 THE CONTRACTORS LI• G3l8ge/C8�0A W CENSEL4WFORTNEFDl10NlINOREASpJ(SEC.70.71.SBUSMESSANDPROFESSIONSCODE:ANYCITYOR (n U COUNTYWHIGNNEWIRESAGERMITTOCONSiRUCT,AL7ER.MPROVE,DEMOLISH,OHflEPAIRANYSTRUG W patio/Deck � b TUHE,PRIOR TO RS ISSUANCE,ALSO REOUIRES THE APVLICANT FOR SUCM PERMIi TO FILE A SICNED W .� STATEMEM THAT HE qi SME IS 11LEN5ED FURSUANT TO TME PROVISIONS OF THE CON7RACTOfiS l4 S GENSE Uw(CMAPiER G(COMMENCIN�W17H SECTpN 10D0)OF DMSION J OF TNE BUSINESS AND PH6 V' POOUSp3 X� fES510NSCO0ElOfiTNA7HEOF15HE1SElCEMPTTHEREFRpAANDiHE8A515FORiHEALLEGEDE%EMP• (� � TIDN.ANYVIOLATqNOFSECTION70J1.lBYANYAPVLICANTFORAGERIAITSUOJECTSTNEAVCLICANTiO Z Re-Root � ACML PENALTV OF NOTMORE 7HAN iNE HUN�REU DOIURS(f5oo�.)� � ❑1A50V/NEROFTHEFROPERTY,ORIAVEYPLOVEESWITHWAGESASTNEIRSOLECOMPENSATpN, 0 Commercial Z WILI DO TNE WORK,AND THE STRUCTURE IS NO7 INTENDED OR OFFERED F011 SALE(SEG 70�1,BU51• J " N NESS AND PROFESSIONS COOE:THE CONTMCTORS UCENSE UW DOES NOT AVPLY TO AN OWNER OF � PROPERTY WIiO BU1lDS OR IMPROVES MEREON,ANDNHO DOES SUCH K'ORK MIMSELFOR HERSELF OR W THROUCHHISORNEROWNEMPLOYEES.PPAVIDEDTMATSUp11MPROVEMENTSARENOTPiTENOEDOR m � OFFEREDiORSALEIF,/10WEVER'�NEBU0.DINOORIMPPOYEMENTISSOIDYnTHINONEYEAROFCOA1PlE• Z iqN,TME OWNER�BUILDER WILL HAVE THE BUROEN OF PROVING THAT HE OR SHE DID NOT BUILD OH � U1PqOVEFORTHEVURPOSEOFSALE4 W ❑1�50MMEROFiHEGROVERTY,AME%QUSIVELYCOMMCTWGYATHIICENSEDCONTMCTOHS � TO CONSTRUCT THE PHOJECT(SEG 7a�,6USINE55 AND PROFESSIONS fADE:THE CONTMCTOFS Lb ValllefiOfl ADJ.AREA W LENSELAWDOESNOTAPVLYTOANOWNEROFAPROPERTVW1qeUILD50Rp.1PROVESTMEREON.AND � Mh1000MiUCTSiORSUd/VRQIECTSMATNACONTPACiOR(5)LICENSEDPURSUANTTOTHEGONTMG QUANTITY DESCR�PTIDN � TOfiSLICENSEUW.). FEE J � O IAM E%EMPT UNDER SEC. B.i F.C.FOF THIS REASON e( � U � OATE OWNER H Z U F LICENSED CONTRACTORS OECLARATION W � 1 HEREBV AFi1RM UNDEP PENALTV OF PE0.1URv THAT IAA1 LICENSED UNDER FROViSIONS OF CHAV7Eq � Q p, Y(MIAMENdNO WITM SECTqN 7000)OF DNISION 7OF THE BUSINESS AND PROFESSqNS CODE,AND Z `7� � � O � UCENSECUSS�LLFORCIAN�EFi t UC.NO. ���Q��� � V DATE � �+ CONTMCfOR '/ pJ, W � WORKERS'COMPENSATION DECLARATION a UJ U � I HEREBV AFFIRM UN�ER PENALTYOF VEfiIURY ONE OF7HE FOUAWING DECLAMTqNS: Z � _IHAVEANDWILLM MAINACEHTIFIGTEOFLONSENTTOSELf•INSl1RfFORWORKERS' a CdAP ,ASPROVIDEOBVSECTIONn000FTNEUIBORCOOE,FORTIEPERFORMANCE W Q WORKFORWHICMTHISPERMITISISSUEO. � � _INAYE�NDYALLMIUNTAINWORKERS'COMPENSATIONINSUMNCE.ASREWIRED9YSECTION � �700 0F THE LABON COOE,FOR THE VEN�OfUAANCE OF THE WORK iOR WHICN THIS OERMIT IS ISSUED.MYNqRKERS'COMPE A�UiW10EGRRIERAI:DPOLICVNUMOERARE: CONSTRUCTION jCAi1R1ER �� PLAN REVIEW Z va�cr rauMaea — ELECTRIC •� � � (R�SSECIIDNNEmNOTBECU.FLETEDOF7FEPERMT6PoRONE too� �Essy PLUMBING __ W Z ICERTIFYhUTNTHEVERFORMANCEOFTHEN'ORKiORWHI 5 0,1 MECHANICAL (J SWLLLNOTEAIPLOVAN PERSONNNIYMANNERSOAS �-uliJ ,OTH � WORKERS'�I.IPENS UWSOFCALIFORNI - H tNSPECTION FEE SU&IECT THE ERS'COMPENSATqNi 5 'S uoOFTH �ABO O COD FQ WITNCAMPLYWITM PP NS /� ISSUANCE , � L( W DATE: /�PgICANi: SMIP f/ -J WAPN�NC: ILURET SECUREWORKERS'C01.1PENSATqNCOVERAGE�SUNUWFUL,AN�SHALLBE ENEFiGYP/C LL SUBJECTANEMPLOV RTOCRIMIWU,iENA�TIESANDCMLFINESUPTOONEHUNDR[OTHOUSAN� ENERGYPERMIT � OOLURS(S t0o.0ao�,IN ADDITION TO iHE CAST OF COMPENSATION,DIMACES AS PROVIDEO FOH IN SECTpN770sOFTNEUBORCWE,NTEREST,ANDATTORNEY5FEE5. RETENTIONFEE: ___ oCONSTRUCTION LENDING AGENCY PRE•ALT FEE: � IHEREBYAiiIRMUNDERPENALiYOFPERtt1RYTMATTMEREtSALONSTRUCTIONLENDINCACENCY . FOR TME iERFORMANCE OF iHE WORK FOR WHlpf THIS PERAl1T IS ISSUED(SEG 70Y�,CIV.C.�. � � LENDER'S NAME C LENDER'SADDRESS � ICERTIFYTMATIHAVEREADTHISMPLICATIONANDSTATETHATTME1100VEINFOFMATpN15CAHREC7. TOTAL FEES •�� � IAGNEETOCAMVLYWITHALLCT'ANDGOUNTYORDINANLESANOSTATEUwSREUTINGTOBVILDIN6 � CONSTRUCTqN,ANDMEREBYAUTHORIZEREPRESE TIVESOF7HISCOUNTYTOENTERUPONTHE Z ABOVE�MENTIONEOP FOflMSFECT S � IC1 S C L COMMENTS _ m VERM�7TEE NAIAE(PNIHT) � c �Z��� (/� SIaNAiUREOFVERMITTEE pAIE � RECPT.f.0. PAID BY VALIOAT�ON HITE—Department Copy,YELLOW—Finance Copy,PINK—Assessw Copy,GO ENROD—File Copy,GREEN—Applicant's Copy ' . ' ' '"",'. •..:, )'��.� ..1�•..�..��y.�,�•.;.w"". . . . M 1 ✓ ?�.•��;.\ ' 1� -'IY;,J.':'r, �'iJJ.� . � � ... �...n ._ �...._....,.....,. .-.. . . 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SEPTICTANK LANpSCAPE/IRRIG. � SEEP PIT/L.L. ON SITE IP�IPS. GAS AIR TEST FINAL ZOPJING FINA�CONST. �IRE DEPT. FINA! FINAL HEATING � � HEAI�TH DEPT. FINAL FIIJAL ELECTRIC �_ _. �� DE4'. FEES PAID FINAL PLUMBING ,j�y/L _ E�dERGY � cl:�r�t' ��I= T,���.,"• � CUMMENTS _._. - SEPTIC TANK SIZE SEEP PIT/U SIZE �►�� �'� I �, � - ,r�'r� _ ,� . .., _`