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HomeMy WebLinkAbout14573 (30) CITY OF DIAMOND BAR ' �_ � �� --� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICE,�/T" s��so E.co�i�y nri��s�c�i90 �/ � (909)8G0-3195 Fax(909)861-3117 PRESS ����%'�� SUII.DING I'ERMIT APPLICATION FIRMLY y�, JOBSITE I;111. r(.l Y e. � 1� Y • APPLICAT�S'.�N.I-vl� NU BER� S(/ k/C o ADDRESS W� �L DATE �-��L � ISSUE TYPE QCC APN LOT TRACT DATE CONST. GROUP � OWNER �r1 C� �� v�r �(1 p ADDRESS J�� F6.�t-� r • �4 ZONING SEfBACKS z CITY.��'c�ndn�l B�� ZIP A 1lSc��TEL i FRON7 Rw ❑ g APPLICANT 7Et„ REAR ❑ � SIDE/SIDE STREET RW O CONTRACT k.✓ ,�- �r�V r.c I SIDE ❑ p� ADDRESS • • ' � CfTY MGYI k htl I_o ZIP��OTEL. "721'1 Z`I S PROPOSED USE o ARCFI/ENG/ � DESIGNER NO.DWEL NO. NO. ADDRESS UNITS STORIES BEDROOMS CITY ZIP TEL � OESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION � p� OY+MER•BUILDEFl DECLAAATION SFR/ADD/REM O p I HEREBY AFFIPoA UNDER FENALTY OF PERR1iiY THAT 1 AM E%EMPT FFOM THE CONTMCTORS U- G8f8g8/CflfpOR W C8i5EUWFOfITHEFdifTNiNC1NFA50N(SEC.70.17.6BUSINE59ANDiHOFE551oNSCODE:�tiYGTYOR (n � GVIMTTWMA/REOUIRESAVERMRTOCONSTRUCT.ALTFR�PROVE.DEMOL191.OFlREPNHMfSTRUG W patio/Deck 7Ui�,pRlOq Tp IT$ISSUMlCE,AL50 REW WES THE APPLICrNT FOR SJp1 FERMIT TO FlLE 1151GNE0 .� STATfMENT TMAT HE OR SHE IS LICFNSEO DURSUANT TO THE VROVISIONS OF THE CONTRACTORS U• � CENSE lAW(Ou➢TER C(COMMENqNa VATH SECiqN)OOD)OF DIVISION 7 Of THE BUSINESS AND PR0. � PooVSpa FE55qN5 CODE)DR 71UT HE OR 511E IS E%E/APT TNEREFROM AND iNE BASIS FOR TXE ALLEGED E%EAIP• 710N.AHYVIOL�T'DNOFSECTION7W1.68YMIVMGLICANTFOR110ERMRSV6IECTSh1EAPVLICANTN Z Re-Roo1 � AC7VR.PBULTYOFNOTMOAETI/NFIVE/M�D{i[DDOlUR5N50o1.1:- ' � ❑4�+�MMEROF7HEGROPERTY.ORMYEMPLOYEESN1h1WAGE5A5THEIRSOLECOMPENSATIDN, 0 CpmmBfCl81 ' MALL DO 7HE YYORIC AfA THE STRUCiURE IS NOT INTENOED OR OFFEHED FOR SALE(SEG 7oN,BU51• J N NE55IND VROFESSIONS OODE TME COHTMCTORS IICENSE UW DOES IXJTAPPLY TO AN OYYNER OF ? VHOFEHTN 1M10 BULDS Oq MVROVES THEREON,M�WNO DOES SUpI WORK HIUSELF OR HERSELF OR [C T/ROUGHMISORHEHOVMEIIPLOYEES,P(30VIDEDi11AiSUCF/MPROVCMENTSAAENOTINTEN�EDOR m � OfFEREDiORSKEIF,/qWEYERTMEBUtDWOORWPROVEYENTIS50LDWITIUNON[VEAROFCOMPLE- Z TqN,TME OWNER-BUttDER WILL HAVE THE BUii�EN OF PROVINO TUT HE OR 6NE OID NOT BUIID OR � MPROVEFOiiTNEPURPOSEOFSALE} W ❑I,ASONHEROFTHEiROPERIY,/J.�ExCLUSNELYCONTMCTIN�WfTHUCENSEDCONTMCTOiLS � 70 CANSTAU(,T T11E VROJECT(SEG 7uN.BUSiNE55 AND PROFE55lON5 CODE:TNE CONTRAL70R5 l4 Valuatlon ADJ.AREA CEN6E UW DOES NOT APPLY TOAN OMR�ER�F A PR07ERTY MT10 BUM1DS OR MPfpyES iHEREON.AND MFIOCOHTAACTSFOFiSUp1CROJECTSVATNACONTRACTOR(5)LICENSEDVUFiSUAMTOTMEWHiMG OUANTITY DESCRIPTION FEE � fnas uc�uw.l. J O I AM EXEE�PT UNOER SEG B.l V.C.LOR 7HIS REA50N � � �=" OA7E OYMER V � W UCENSED CONTRACTORS DECLAAATION ' � � w I HEHEO`/AFFIWd UNDEH OEN�LiY OF PERRJi7Y M�.71 AA1 LICENSED UNOER Di10VI510NS OF CHAPTER � •(COMM[NCMO NATH SECTION 10001 OF DMSION J OF TNE BUSwESS AND DpOFE5510NS CODE,AND Z l r h C � ��' � X WLIGENSEISNFULLFORCEANDEFiEGL � m � 11J � UCENS� SS ��� LIC.NO. � � �1� �� � � J o�ts ' CA] Corrt _ � a W __ __ � WORKERS'COMPENSATION DECLARATION ; -� _ � . 4 � IHEREBYAFGIMIUNDEflVElU17YOFVEfiNfiYDNEOFTHEfOLLOYfiN6CECLAMT10N5: �• U � � � Z Q � �IHAVEN7UW�LLMAtt�t1A8dAC£RfIFICATEDFCONSENTTOSELF-INSUREiORM/ORKERS' S � COMPENSATION,ASPROVIDEDBVSECTION]7000FTNELABORCODE.FORiHEPERFORMANCE W OF iHE WORK FOR YMIp/TM15 PERMIT IS ISSUED. .� O IHAVEAND WILL VAWT/uNN'ORKERSCOAIPENSATION INSUMNCE.Ai REOUIREDBY SECTION O J7000FTHEU80RCOOE.FOHTHEPERFORMANCEOFTHEWORKiORWHIqITHISPERMRIS � ISSUED.AIYNVR R5COAIPENSATIONINSURANCECARRIERANOFOLICYMIMO:RMG CONSTRUCTION ? �qaEp PLAN REVIEW � POLICY NUA9ER J� B 1 �.� � 1 7 ELECTRIC ��ly�� / � �sEcna+��r+�rsEm�rmancvEw.rrsax+wcwor�nocuuis�sioo�a+�ss? PLUMBING / � w MECHANICAL Z I CERTIFY T/U1T pl THE VEflFOF1MANCE OF THE VIORK FOR WM�CM TMIS PEaNi1T IS ISSUE0.1 � (7 51ULLLNOTEMPLOYMlYPERSONWANYtAANN[RSO�STOB[COMESUBIECTTOTHE rr(► 1 ��� y WORKERS'COMPENSATqNlAW50FGLIFOFNI/�ANDAGHEEiNATIFIS�KKADBECOME INSPECTIONFEE ��L � SUBJECTTOTNEN'OPoCERSCdADENS PROVISIONSCFSECT 770o0FTHEUBOR � �� cop�.iuwtcoan�wnrcouvi wi tasEaarntsaus ISSUANCE �i�V � ��,` SMIP 11 1 ��!::tJ:'.L t _♦ p DATE:�'�'v�J AVPLI �. - � ENERGYP/C �t���Ii`iG a. .�.`ic'i+ WAqMN6:fAllURETOSECUREY/ORNERS'COA�PENSATIONCOYERAGEISUNUVlFULAND � lBE � SUBJEG7MlEA1PLOYERTOCRnARIAVENALTIESMtDCMLFINESUPT00NEM1NbRED �D ENERGYPERMIT DOLUfiS(it 00.000).N FDDITION TO THE C0.ST OF COMPENSATqN.OAUAGES AS OROVDED FOp IN ¢ SECTIONJ7oEOFTNELIBORLOOE,NTEREST,AN�ATfD1iNEY5�EE5. ' RETENTIONFEE: OCONSTRUCTION LENDING AGENCY '�� pRE-ALT FEE: � IHEREBYAFFIPoAUNDEflPENALTYOFPENUMTHATTHEREtSACONSTRUCTIONLEN0�N6ACENCY Z FOR TME PERfORMMlCE OF iNE WOHK FOR WHlpi T115 PERMIT IS ISSUED(SEC.7097,CN.C.). W � LENDER'SNAME � LENDER'9ADORESS � W1 CERTIFYTNAT I HAVE REID iMSMVLICATION M10 STATE iHAT iHE AOOVE N(ORIAATqN IS CORHECT. TOTAL FEES � d I AGREE TO C01A7L�VA7H ALL UiY�ND Cd.1HTY ORO�N�NLES AND STATE UNrS NEUTNO TO BVILDIN6 CONSTRUCTION.AND HEREBY AUf110RIZE REPPESENTATNES OF TMIS COUNTY TO ENTER UPON THE � ABOVEJAEMIONEDGROVERTVFOHINSPECTqNPUFPO'SES. ��, COMMENTS � ,� n� G 1�tn �t �11 C.�'L. ' m oE EruuErywrn� ' �. Q / � OF RMITTEE DATE�.' �� RECPL NO. PAID BY VALIDATION WHITE—DepaAment CaOY.YELLOW—finanee Copy.PINK—Asseesor Copy,GOLDENROD--File Coq/,GREEN—ApplieaM'e Copy - ci��� or- �i�.r�aorw�n ���L� �,, � E���r-ec�:�rti �����s;� --� �.. .____._ _-...._ __ -------�_._____.___---(------- ------- ------- ---- __---------- --- -- -------. . . �i�'t'-�:� .�..�..�r���L .��'��`.Q, .�l.�["Ja����_. �.��rf� ff���n.�«C�,�';��:11" E.",�.'1'('�. �1��'�J��.:_!�.,�IG�1�� S�T 6F,CiC � _'_ ' ; � . 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