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HomeMy WebLinkAbout15565 (23) �� CITY OF DIAMOND BAR DBPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES ° ��'� 21660 E.Copley Drive Suite 190 (909)860-3195 Fas(909)861-3117 PRESS �Y`'�' � BUII.DING PERMIT APPLICATION FIRMLY ¢ ADDRI SS ��� �.�C�.�G•�" �� APPLICATION ��t�'' PERMIT�C P/C p DATE NUMBE --� lY c�, ISSUE lYPE - OCC APN LO7 TRACT DATE CONST. GROUP °� OWNER a� LL ADDFiESS `' � �/+�` X�P4° ZONING SETBACKS � C1TY ' , �- _, ZIP �s�y 3'TEL. ��.� FRONT RW � APPLICANT TBl. REAR ❑ SIDEISIQE STREET RW ❑ �j CON7RACTOR C, - ` SIDE Q � ADDRESS � f � �; �' pFiOPOSED USE � �d' ,�L �.� CITY ' G. ZIP ?2i�w/TEL � �� w ARCHlENG/ � DESIGNER NO.DWEL. ` L NO. N0. � '�' ApDRESS � CITY Z!P TEL. UNITS � STORIES BEDROOMS t�_ � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION �_ �� OWNER•BUILDER DECLARATION SFWADD/REM d I NEREBV AFFlflM UN�ER PENALTV OF PERJURY THAT I AM EXEMGT FHOM THE WNTR�1CTOfl5 LI- G&t29BICdfPOfl W CENSELAWFORTHEfOILOWINaREA50fV(SEC.7031.56USMESSANOPPOfES910N5CO0E:iWYdTYOR� . (/� � C� COUNT'WHICHHEd11RE5APERMITTOCON57RUGT,AL7ER,IMPROVE,DEMOLISH,OqflEPA1RANY5TRUG W PgtiO/DeGk li �C 7UqE,pRlOfl TO ITS ISSUANCE,AL50 RE�UTAES THF APPLICAN7 FOR SUCH PERMIT TO FILE A SIGNE� - � � STATEMENT THAT HE OR SHE IS IlCENSED PUR6UANT TO THE PROVISI�JS OF THE CONTRACTORS ll- � _ ' �CENSE UW(GiADTEfl 9(COMMENCINQ WITH SECTION 7000)OF OIVISION 3 OF THE BUSINESS AND Pp0- V' PooVSpa - FESS�DIISC�OE)ORTHATHEORSNEISE%EIAPTTHEREFROMANDTHEbA515FORTHEALLEGEOE%EMR (� � TqN.ANYVIOLAT10NOF5ECTION7031.58YANYRPPLICANTFON�PERMITSU&lECTSTHEAPPLICANTTO � Z Re-Roo1 � �� C "�/� � �: �„_. ACMIPENAL7YOFNOTMORETMANflVEHUNDREDDOLLAq3(5600),I: . � p1,ASOWNEflOFTHEPROPERTY,ORMYEMPLOYEESWI7HWAGESASTHEIRSOLECOMPENSATION, 0 COffllflefCl81 � � ;' WILL DO THE WORK.AND iHE STPUCTURE IS NOT INTEND6D OR OFFfRED FOR SALF(SEC.70a4,BU51- ...I � � NE55 AND PHOFEE$SIONS CODE:TNE CONTMCTORS UCENSE UW DOES N�T APPLY TO AN OWNER OF� � � PROPEFRY WF108UILDS OR HApROVE57MEPEON.AND VlHO DOES SUCH WOflN MIMSELF�R HEpSELF OR � �THilOU6F1HI50RMEROWNEMPLOYEES,PROYIDEDTHATSUCNIMPROYEMENTSARENOTINTENDE00R m �' 0 OFFEREDFORSKEIfiHOWEVEF�hIEBUILDIN00RIMPROVEMENTIS50LOW17}IINONEYFAROFCOMPLE• Z TION,THE OWNER�BUIIDER WILL HAVE THE BURnEN OF PROVMG TI1AT NE OR SHE�ID NO7 BUIID oH �_ � IMPPOVEfORTHEPURPOSEOFSAL�. O I.ASOVRIEROF7H[PROPERiY.0.N EXCLUSIYELYCANTflACTINp WITH IICENSED CONiRACTOR3 �, Q TO CONSTHUCTTHE PR0.IECT{SEC.704t,BUSINESS M1D PflOFES510N5 CODE:THE COMPACTORS LI- V81178tI0f1 ADJ.AFEA W CENSEUWOOESNOTAPPLYTOANONMEROPAPROPERNYYHOBUIlD30qIMPROYESTHEf1EON,AND , � i WFWOONTqACTSWRSUCHPpOJECTSWITHACONTRACTOR(Sj�iCENSEDPUR3Ul1NTTOTHECONTRAG �� QUANTITY DESCRIPTION FEE � �— TOHSIICENSEUW.} �� ❑IA1A EXEAIGTUNOER SEC. 8.&P.C.FORlH15 AEASON Q - � U �t� ¢ OATE oWNER V 2 W � LICENSED CONTRACTORS DECLARATION W � ���-,IHEPEBYAFFIHMUNDERPENALTYOFPENURYTIfATIAMLICENSEDUNDERPROVI510NSofCHAPTER � � '9(COMMENCWQ Wlhl SECTION 70oo)OF DIVISICN 30FTHE BUSINESSAND pROFESSIONS COOE.AND Z �� 'MY UCENSE IS IN FULI,FORCE ANq EFFBCT. m � ��UCENSE CLA35���� L�C.N0.� x j � U DATE ������ CONTRACTOq a W � . WORKERS'COMPENSATION DECLARATION Q � V � IHEREBY�FFIRMUNUERVENAL7VOFGENURYONEOFTHEPoLLOWINGOEGLARATIONS: � 2 � � �_IHAVEANDWILIMAINTAINACEfiTff�CATEOFCONSENTT05ELF-INSUREFORWORKERS' 2 - COMGENSRTION,ASPROYIOEOBYSECTION's7000FTHELA80RCODE.FURTHEPERFOflMANCE U � OF THE NtlOHK FOR WHICH THIS GERMIT IS ISSUED. � G W __I HpYE MIO WILLMAINfA9J WORKERS'fAMPENSATION INSURANCE,A5 RE�LIIPED BYSECTION (� � 37ooOFTMEI..ABoflCODE,FOATHEDERFOflMANCEOFTHEWORKFOHWHICHLH19PEflMRIS - ! � `7� 1S5UE0.MY WOqNE CONP NSATION INS/Ugt�CE CARRIEq AND POLICY NUMBERAflE: CONSTRUCTION 1 �� G a CMRIER �' �����I"+ PLANREVIEW ��--- � � � POIICYN�iBER �� l � j ELECTflIC __. __ _ ¢ � (RassECt�aur��N�7eE�PlEfEDaFiHEPERhtl1'pf'ORONeH1xJDpEoOatAA3�$taalontESS? PLUMBING � I CERTIFY THAT IN THE PERFORMANCEOF THE WORK FOR WHICH7HIS PERMR IS ISSUED,I MECHANICAL SHALL NOT EMPLOY ANY PERSON Ih ANY MMINER SO AS TO BECOME SU&IEC7 PO THE � WOfiKERS'(:OMP,ENSATIONIAWSOFCALIWRNIqANOAGREETHATIFISHOULDBECOME INSPECTIONFEE ""� r SUBJECTTOTHEWORKERS'COMVENSATIONP IONSOFSEC710Na�000FTHELq90q � f� isN Foan+wintcoMP�rwiTM ovis ISSUANCE � � €",�� ; p e'"�''8��j �� �,,,. p DATE: APVLICANT. . � 6� SMIP � . . j � ENERCaY P/C � - J WARNIN6:FAILi1PETO5ECUREW�W(ERS'CAMPENSATICNGOVERAGEIS U1WFl1L,AN MAILBE � SUBJEC7ANEMPLOYEFiTOGRIMINPLPENALTIESqNDqYIIFINESUPTOONEHUNDflEDTHOUSAND ENEFGYPERMIT i3L..S @ C� � � DOLLARS(5100.000),IN ADDITION TO hiE COST OF COMPEN5ATION,DAMAGES AS PROVIDEQ FOR IN J SECTION 3708 OF TNE LABOR COOE,INT[flEST,AND ATTORNEY'S FEES - �� +' v=� "` OC. RETENTION FEE: .�s„.���-�--r_=f_r..'"._.�-:`.k.t�Ja�_,__�.�_ O- CONSTRUCTION LENDING AGENCY PRE-ALT FEE: x T' �"`a ,�,.'y r�`t'"'• r �r-,�,-x`0e—q?�'ia����--� — � IHEREBYAFFIRMUNOEflPENKTYOFPERJURYTHATTHEREISACONSTRUCT�ONLEN0INGAGENCY FORTHE P[PFORMANCE OF TNE WOqN f-0R WHICH THIS 7ERAUT IS ISSUED(SEC.3o97,CIV.C.). Z W � LENDER'S NAME . _ _ __ F-. LENDER'SADDFlES$ - � ICERTIFYTHATIHAVEREMTHISAPPLICATIONMlDSTATETViATTHEABOVEINFORMATIONISCOFRECT. T07AL FEES � a j � IAGFEETOCAMPlVW1THALLCINANDCOUNNORDINANC65ANP5TATELAWSFEUYINGTOeUIL01NG CONSTRUCTION,PNDHEREBYAUTHORIZEHEVHESENTATVE50FTHISCOUNTYTOENTERUPONTHE ��� �✓J �"� ZABOVE-MENTIONFDVNOY RiYFORINSPEGTIONPURPOSES, COMMENTS �� 1 � ' ���'-� � ! (f�``d`� �`� _ m PERMITTEENAME(PHi 4 §��" tn � `' s�/ �� I � 310NATUREOFP E + OATE � � RECPT.NO. 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