HomeMy WebLinkAbout11268 ��� --� CITY OF DIAMOND BAR � . /
COMMUNITY DEVELOPMENT DEPARTMENT �
z��o�.coP�ey�n�es�;c��90 , � - PRESS
� • (909)8643195 Fax(909)861•3117 ' .
�''"' BUILDING PERMIT APPLICATION FIRMLY
o ADDRESS �3�'z 1 r1(L�t': `it�YU�1 Ot� DATECATION�� � � -R�NUMB R r ' p/C
c� ISSUE TYPE OCC
.- APN LOT� TRACT DATE CONST. GROUP
p OWNER �� S u�2
LL ADDRF�SS • 3 R-�S T � �+J ZONING SETBACKS
0
Z CITY ��� ZIP G� GS TEL.�44�^C�� . FRONT RW ❑
g APPUCANT • � �"� TEL_b�t7��!"l�,I' REAR ❑ •
SIDEISIDE STREET RW ❑
¢ CONTRACTOF� �l t.E F/�✓G SIDE O
� ADDRE fS •-� '.i LL[%" (�
� CITY �• T'Y ZIP �TEL =� �yj� PROPOSEDUS� { UfF 51��1� �.�5:'p�� C
� o � w �l �o • hLT '� 'L S
w ARCH/ENG/
o . � h �h. LiT �_!>GC
Z DESIGNER NO.OWEL NO: � NO.
� a ADDRESS UNITS I STORIES � ' BEDROOMS �
} � CITY� ZIP TEL
N DESCRIPTION SQ.F7.' FACTOR PSF ADJ.AREANALUATION
. p� OWNEfl-BCILDERDECLARATION -� �-� ---- � SFRlADDlREM ' �
O '
� 1 HE0.EBY AFFIRM UNDEH PENALN OF PE0.AIRY TMAT 1 M1 EXEMPT FROA1 THE CONTRACiORS LL GaragelCarpoA -
W CENSEUWFOR7FIEFOLIOWWCREA50N�5EG7at1.6BU51NES5ANDVROFE5510N5CO0E:AHVGiYOq (n � � '
_ U CWNTYWHIp1RE0U1RE5AVERAIRTOGONSTRUCT.ILLTERMPHOYE.DElaO1.15H.OqREPNRMIYSTRUG W P2tidDBCk - � � � -
- � 7UHE.PRIOR TO RS ISSUANCE.AL50 REW iRES hIE APPLIGM FDIi SUCH PEiu1lT TO FILE A SIGNED W -
STATEMENT TNAT ME OR SNE IS UCENSED PURSUMIT TO THE PROVISIONS OF TME COfITRACTORS LI-
� CENSELAYf(fMAPTERY(COMMENGWOWITNSECTION7000�OFD1Y15qN90Fh1EBU51tiE55ANDYRO-� � � POOUS� _ _
FESSIONS CODE)OR THAT HE OR SHE IS F�(EMPT TMEREFPAMAND TME BASIS FOfl ME ALLEGfD E)lEMP•
� TION.ANYVIOLATIONOFSECTION70.t1.6BYANV�DPL1UNiFOqAPERAUTSUBJECTSTXEMPIICANTTO Z qe-Roof
A GVIL 7ENAL7Y OF NO7 MORE iHAN ifVE HUNDREO DOlURS(t5oo1.):
� ' OIASOWNEROFTHEPROVERTY.ORMYEMVLOYEESVATHWAGESASTHEIRSOIECOMGENSAiqN. � �m0fGi21 �
Z WILL DO 7HE WORK AND THE SiRUCNHE IS NOT INiENDED OR OFFERED FOR SALE(SEC 70N,BU51- J
� NESS ANO VRDiE5510N5 CODE THE CONTRALTORS IICENSE Uw DOES NO7 APPIV 70 AN DWNER OF ?
VHOPERTY Wl10 BUNDS OR UAPROVESTHEReON.AND WNO DOES SUGH WOfiN HIMSELF OFiHERSEIF OR
� THfi0UCH/u50RHEROwNEu�LOVEES,GROVIDEDT1uTSUCMU,IDFOVEAIENTSAAENOTWTENDEDO(i m
QOFFEREDiOR5ALE1i.f10wEYEi�iHEBUIIDwOORUAPROVEYENT65IXDVnTwNONEYEAHOFCOMVLF '
Z Tpf7,THE OWNERAUILDER WILL HAYE iME 6UFDE7i OF PROYWO TMAT FIE OR SHE DD HOT BUqD OR
i � I/ADROVEFORTFIEPURDOSEOFSALE}
O l���ER OF iHE 7ROGERTY,MA E%CLU51VElY CONTHACTWG YATH LICENSEU CONTHACTORS
¢ i0 GONSTRUGT TME Pq0.1EGT(SEG 70N.BUSINE55 AND PROFESSIONS COOE:TME COHiRACTOFtS LF V3111d(IOfI 7���� � qpJ,qqEq
I W CENSEUWDDESNOTAFVLYTOANOWNERDFAPROPERTYWMOW0.DSORwPR0YE5TNEpEON.AND
� WLIOCONTf1ACT5FOR5UG1PR0.7ECi5W1THACONiRACTOH�S)LICENSEDPURSUANiTOT11EWNTMG pUANT17Y DESGRiPT10N FEE
Y roRs uc�r+se uw.G
� OIMIEXEMPTUNDEHSEC. B.tP.C.FORTWSREMON Q
� �i - � - - U _ . -
� ` -
LL' DA7E OWNER �' — - . . •
Z U - -- _
� UCENSED CONTRACTORS DECLARATION w
� IHEREBYAFFWAIUNOER�ENALTYOFiERIURYTHATiAA1LICFNSEDUNDERPROVISqNSOFGHAPTFq Ur �
d i(COMUENCWO Yl1TH SECTqN 7000�OF DMS10N 70F iME BU51NE5SANO DROFE55lONS CODE,AlQ7 Z -
' X NY IICENSE IS W FULL FORCE AND EFFECT. � m
�v (; �
L
0 UCENSE CU55 ` • LIC.N0. � �)� �
I C.�') DATE �( ' � CONTPACTOR �r� � a
W �'� /r�
� WORKEHS'CAMPENSATIONDECLAfiATION �� -�
¢
NIMEHEBYAFFWAIUNOERPENALiYOFPERIURYONEOFTHEFOLLDWWOOECIMATpNS: Z �
� �IMAYEANDWILLMAW7AWAGEHiIFIGTEOFGONSENTTOSELf-INSUREfORYARI(ERS' . . . _ -.. __ _._-_. _.. ... . __ _' - .
COu�ENSATqN,ISCRDViDEDBYSECT10N77000FTNELABORCD0Ei0RTHEPEHFORYANCE U
Q _ OF iHE WORK FOR WHICH TMIS PERMI_T IS ISSUED. - �
� _ .
' W _IHAVEM1DNnLL►WNTAWWORNF0.S'COMVENSATIONINSUfUNCE,ISRFOUIREDBY5ECT10N
_Q 5700 OF i}tE LAdOR CODE FOR iME PERFORMANGE OF iHE WORK FOR WMIG1 iM15 PEFMIT IS �J.
ISSUED.MY WORKE�RS'COMGENSATqN INSURANCE CARRifAAND GOL�CY NUA/BEHARE CANSTRUCTION L(/
j caawEa S�►t-��. ���� � PLANREVIEW
z VOLICYNUAIBEA �R I.Z[-V.2 � ELECTRIC
d
� (iH55ECipNNE�tATBE�iE7EDOF71EPEpJ(t6PoaONEIu�DFED00.LAtlS(f�m�OHLE55� PLUM8ING
Z I CERTIFYTHAT W THE CFRFOfUWiCE OF THE WONC FOR WHICFI THIS�ERMIi IS ISSUFA.I MECHANICAL
(f SNALLNOTE�PLOYANYPERSONWANYwwNERSO�ISiOBECOME5U8JECiTOTHE
� � riOWCERS'GOAIPENSAi10NUW50FCALIFORNIA,ANDAGREE7NATIFI5F10lADBECOME INSPECTIONFEE -
SU8IECT TO THE WORI(ERS'COMPEHSATION VROVISIONS OF SECTION 77D0 OF THE UBOR 1
COOE,ISFMLL qTHW1iHCOMPLYWITH E� VIS �— ISSUANCE
p �ATEd�7 l� APPLICANP. ��✓K SMIP �
J wAHNINO:FAILURE fO SECURE WORKERS'GOMDENSATION COVEMGE IS UNIAWFUL,AND SMAl1BE �ENERGY P/C
� SUBJECTAHEMPLOYERTOCRudWAIPENALTIE5M1DCMlFWESUPTOONEHUNDREDTHWSANO �ERGYPERMIT
� DOlLAH51i10�.00D1,W ADDITION TO TNE GOSTOF G0IAPENSATqN,OM/AGES AS PROYiDEO iOR IN
� J �SECTqN97oaOFTHELABORC00E.NTEREST,ANDATiORNEY'SiEES. '" RETENTIONFEE: � � � � � �
Q
a CONSTRUCTION LENOING AGENCY PRE-ALT FEE -
O
� IHEREBVAFFiRAAUNDERDENALTYOFPERNRYTHATTMEREISACONSTRUC7qNlENDINGAGFNCY
FOR TME VERFORUANCE OF TME WORK fONNMICM TMIS VERMIT IS ISSUED(SEG]oY7,GV.C.).
� LEN�ER'SWWE ' � •
I-- lENOER'SADORE55 �,!
� TOTAL FEES
I w I CERTIFY TNAi I HAVE READ THIS APPIJGipN AND STATE TMAT THE ABOVE W FpqMA7qN IS CARRECL � �
� IAGREETOCOA10.YNATHALLGIVANOCOUNTYORDWANCESINDSTATELAWSPELATNI(iT0&14DING ���D �/ / �O
CONSTRUCTION,ANDHEREBYAU71qRIZEREGRESENTATIVE50FTH15GOUNiYTOEN7ERUPONTHE 1 1 n
ZABOVE-AIEMIONED VR0 RTY FOR WSPEGTpN PUHPO5E5. i y' �
0 COMMENTS
_' rJ �t.. J`I'C�
�
� m PE rr ouuE�vqwn � _,�„_
c¢i� , 4���1�-C a r, � ,
'� N S�GNATUAEOFGERWTTEE . � - DAtE ' �
� ` RECPT.N0. PAID BY VALIDA710N
WHITE—Oepartment Copy.YELLOW—Finance Copy,PINK—Assessor Copy.GOLDENROD--File Copy,GFiEEN—Appficanfs Copy
�`
- �,
. . , .. ; .. , � -: - u - .- �
�
, - -- - - ,_ -, - ; - - _ _ ____------- -- - - - - -- - -- -- - - -- -- -,, - -- - - --
i
. _ . . ,
r � -�
, ._ � `- _ i _- � ' _ ;
i j �
i �� _ i: - � i : - _ � , - �
, . i I_ . -I _ -_ . . _ i
� - 11_ � �; - _ �
' - � _ �i ` i< �- , -
- i � - '''
� � ' , _ I
- - - - ,� - � � . ( '�
. �.- . � . . J� �
- I
k- '
I " x
'i
- F � _
. O � �
�'; _... • F Q Q w ; J� _ .
_ �`
i U
� m
�
Q '
O
C7
L� . e ' � O 'Z O a � . � ,
d��� ' � V � Z ¢�1 < W � � U C7 ¢ ' ¢ �- � " _ �. �
m 0 ' � � O O o W m C7 ' O Z � z ' a p� � vi � Z � ¢ ' _ _ � '
� F- �n O O u. m m Z 4 � t' � Z u7 a Z LL n. a � s
_ �_U cn r- o o-w w � p Z ❑ '� ¢ ¢ w z a � o c7 n- � z � o cn � _ � ; �
Z'W ` I• � � � LL 'c� Umz pa z � � wzw h. zq pa w y ( e ,' , '•
�� O'� ; - ,� � Q J . O (L1 Q = _ � W L� L� F- Q W f� F- N O I- li � \ -i"
. CC � W W �- d � m J � U C7 = J J _7 [n CJ _1 � - J J � ' _. '" .' ' _ _ __ _ _ ' '_ __ ' .
��:. � . __._ _ � �_
_ ''. ' ____ ._ ._" _
_ ._
' �.Z � Q p .p LL! W p .Q W Z � � O O O LL ❑ a Z � Q W Q > W . � „t:.'._' _ .
�,� Q;p � = z z ¢ ¢ _ � za� wo ? 000u. w ? zZ ¢ ww z . •
0 � u. > > LLu. � m � am ¢ � aaaOo � � ou_ u. xo w - - -- - -
L� U ` I �
O W � - _
� a � I - - f � I -- . _
� U�� � - - ' - - � � �
I -I
. I
I
i
i
i
� i � ; I i ;
� � �' - - - ! �� � � � :s _
�� l �; � � .
��; �
-_�i
��j�;
�I
�� �
: � � N � � I ' I i �J � '
� z � I
i r �j ' O I ' I'' i ' i ,
k' W Z Z � � ¢ � !, V � � Z O � �, �I ' � i ; , N W;
�� e � � m �w z -� � C7 ¢ Z w Z p t- Z ', ' V �(7 - -.�.. � i i (A N�.
F I Z F g � '� - (7 z � Y CA,
� � � � U = Z ¢ F- U � m � ~ � Q I�. Y ~ F= Z F o] i F" j � . Z
� C7 � pw ¢�¢ W w ¢ w � � in � cnZ ; z '� � cnF- t� � Z I • � ; ¢�'
� Y ¢ U °" ¢ �.w,w � > W .� � � x � z � ¢ c� rZ ¢ w � �W -- F-F_�
o O ¢ � ¢ a � v=i z � x T x W ~ ? � a rt U a � � ? w a � i._ V o-.
:: � a �- � zc7 rt - � z w - a J J .� � , i ►=a�
� � � a c7 t7 c� � � — a '��
. I w � � � � w < o ¢ 00000x {- JJ � 3a~. wcna ¢ ¢ ¢ - n.w _
)( ¢ W CL W W W < Z Z Z Z �� . W W:
�v� � wc9u� t- 3 � u. cr ¢ ¢ ¢ cnw3c> ov� <ncnc� � � � LL U _ u�cn