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HomeMy WebLinkAbout17058 (40) �� �� CTTY OF DIAMOND BAR � � DEPARTMENT OF COMMUNTIY&DEVELOPMENT SERVICES .�4y 21825 E.Copley Dritie (909)860-3195 Fax(909)851-31 l7 PRESS ��'-� BU[LDING PERMIT APPLICATION FIRMLY � JOBSITE �1 1�, APPLICATIO PERMIT P/C o ADDRESS �I as� F��ri"�1 ��'�+1�tS�r� DATE �' NUMBER l OS g � ISSUE TYPE OCC � APN LOT TRACT DATE CONST. GROUP p OWNER �� mr -�✓�L''7�. " ADDRESS ��T v �•�- �-% !'' /� ZONING SETBACKS z CITY L����++ �3� ZIP"�/74"S- TEL. s%S'�� '"/7 FRONT RW ❑ g APPLICANT TEI. REAR ❑ SIDEISIDESTREET RW p � CONTRACTOR �RDo �e ST SIDE p � ADDRESS • .i r •'v � CITY s, ZIP `)/7c I TEL.1 L;t/.f'�/�j 4'/ PROPOSED USE .� Y/1. �o."�, o ARCH/ENG/ W DESIGNER NO.OWEL NO. NO. = C�ESS ZIP �L UNITS STORIES BEDROOMS cn rn DESCRIPTION Sa.FL FACTOR PSF ADJ.AREANALUATION p� OWNER•BUILDER DECLP.RATION SFWADD/REM O p 1 MEREBY AFFIRM UNDER PENILTY OF PERIURY THAt I AM EXEMPT FROM TNE CONTMC70R5 L4 GdfB�'dCd�OR W CENSEUWFOR7MEFOLLOWINGREASON(SEC.70]I.SBUSINESSANDVROFESSWNSCODE:ANYCITYOR (n U �pUNTyWNIpiREOUtRESAPERMiTTOCANSTHUCT,ILLTER�Pp�YE.DEMOU5FI,ORREPARMrvSTPUG W PdtiO/DBCk Z 111RE.DRIOR TO RS ISSUANCE,A150 iYE�U1R[5 THE A7VLICMR iOR SUCH VEHMIT TO FIIE A SIGNED W STATEMEM THAT HE OR SME IS IICENSED iURSUANi TO TME PROVISIONS OF THE CONTMCTORS LF w � CENSE UW(tl1APiER 0(COMMENCINO WITM SECTION 700C�OF DINSION f OF TME BUSINE55 ANO DRO- � PooUSpa � fES510N5CODE)ORTHA7HEORSNEISE%EMPTTMEREFpOMulDTHEBASISFORTMEALtEGEDE%EMP� (� V TION.M7YVIOlATIONOF5ECT10N7W1.58YANY1IPPLICAYTFORIIDERMITSU&IECTSTHEAPP�ICANTTO Z Re-Roof A CML PENA�TV OF NOT MORE THAN iNE MUNDRED DOLURS(f5oo)�� � Z ❑LASOWNEROFTMEVROPERTY.ORMYEM7LOYEESWITHWAGLSnSTHE�R50LECOM7EN5AT10N, � COrtIfi�8fCi01 WILL DO iNE WORK IJJD THE STRUCTURE IS NOT MTENDED OR OFFERED FOR SAIE(SEC.7at.BU51- J � NE55 AND iROiE5510N5 CODE:THE CANTMCTORS UCENSE UW DOES NOT A77LY TO AN OriNER OF � VROCERTY W110 BU1L05 OR IIA7ROVE5 THEREON.A4D WNO DOES SUCH WORK NI45ELF OR HE RSELF OR CC THROUGHHISORHEROYrtiEMPLOYEES,PROVIDEOTHATSUCHpAPflOYE41ENi5ARENOTINTENDEDOR m � OFFEREOFORSALEIF,V/OWEVER7HE0Ul�INGORIAIPROVEMENTI550LOWITkNOhEYFAROFCOMPLE• Z TION.THE ONR�ER-BUILDER WILL MAVE THE BUROEN OF pqOVINC THAT HE Oft$NE OID NOT BUILD OR = IMPflDYEFOqTMEPURPO5EOF5ALE�. O I.AS ONMER OF TME PROPERTY,AM EXCLUSNELY CONTMCTINC N'ITH UCENSEO CONTMCTDRS Q TO CONSTRUCT THE PRQIECT(SEC.70N,BUS1NE55 Ml�PROFESSIONS LODE:THE CONTRRCTORS LI• V21U8SIOfl U ADJ,AREA w CENSEIAWDOESNOTAPP�YTDANOMMEROFAPR07ERTYWIqBUqDSOR1I.ICRWESTHEREON,MlD `L NM1IOCOMMCTSFORSUp1iROdECTSri'ITHACONTMCTOR(SjULE!lSEDPURSUAhTTOTHECONTMG QUANTITY DESCRIPTION FEE x TO0.SUCENSEU1w)- � ❑IMAEXEIAPTUNDfRSEG B.aV.GGORTNISREASON q � U � � DATE OWT:ER U z �„ �Q UCENSED CONTRACTORS 0[CLARATION W [T. IHEREBY�FFIRMUNDER>ENALTYOFGE0.IURVTNATIAMLICENSEDUNDEFPROVi510N50FCHAPTER � d 9(COAIMENCINOWRXSECTION70o�)�FD�V�SION]OFTHEBUSINESSANODROFESSIONSCO�E,AW Z X 1AYLICENSEISWFULLFORCEANDEFFECT, 0 �y 3 v� s4. � � LiCENSE CLASS G' J� LIC.NO.�Q��� � V DATE �-S'C r corrrancroA�2 uc 4.�c S'f a w nS WORKEFIS'COMPENSATION DECLARATION ¢ = U � IHEREBY�FFIRMUNOERPEWLLTYOFPERIURYONEDFTNEfOLLOWINCDECLAMTqNS Z � _IHAVEANDYVIIIAAAINTAINACEHTIFICATEOFCONSENTTOSELFiNSUREFORYVORKERS' _ COAIPENSATqN,A4PROV�DEDBY5ECT70N77ooOFTMEUl80RCODE,FORTMEPERFpRMANCE w OF THE WORK FOR NMICH TMIS PERMIT IS ISSUED. � 0 w �IMAVEMlDWILLIAAIN7�INN'ORKERS'COIAVENSATIONINSUtUNCE,ASREOUIqFDBVSECTION Q 37000FTHEV�BORCOOE.FORTHEPERFORAIANCEOFTHEWORKFORWMICM7HISPEf1MIT15 y/� yQ ISSUED.MYYlORKrERS'q�PENSATIDNINSURANCE.ARR�ERMlDGOlIC1'MJMB[R�liE: CONSTRUCTION /O/ . ¢ �J't,t,.r�Ci F`^-C'� � �, CARRIER PLAN REVIEW z POLICVNUMBER��S � �' ELECTRIC 4 p fn+issEcrarrr�mNOTeEcor.s�Er[ooFnFVEcartsia+ah�a.wru�oauRSR+acla+�[ss� PLUMBiNG w .'Z 1 CERTIFY THNT W TME PERFOfiMANCE OF THE K'ORI(FOR WHICH TNIS GERAIIT IS ISSUED,I MECHANICAL - (!7 SMALL NOT EMPLOY ANY PERSON IN/JIY MAf�NER SOAS TO BECONL SU0.)ECT TO TNE — '--� l 1`� � (n WORNERS'CO/.�PENSATIONLAWSOFCALIFORNIA,ANDAGREETHATIFIS�KIlhDBECOME INSPECTIONFEE -•�""' �T�� � 1 �?L^-�� S SUBJECTTOTMEYJORKERS'COMPENSATION7ROVISKKJSOfSECTiON77000FTMELA00R _ , • -- ' - WOE,ISNNLFORTIWITHCOMD�YMAT/THOSED O �ONS. �SSUANCE d ��- � �p��JffT SMIP � � . O p DATE: � � ' APPLICANT. � J WARNINC:FAILUflETOSEWREWORKERS'COMPENSATqNLOVEqAGEISUNLAWFUL,ANDSHALLBE ENERGYP/C ' � J SU&IECTANEMPLOYERTOCWM;N/LLPENALTIESMIOGMLFMESU7TOONEMUNDREOTHWSMIO � � DOLURS(SIOO,OOaj.IN/�DITON TO TNE COST OF CO�oENSATION.DAUACES AS DROVIDED FOR IN ENEFiGY PERMIT - -- � SECTIDN770BOFTHEUBORGOOE.MTERESLANDATTORNEYSFEES. C��"'�= - 'i' � O�+ RETENTION FEE: i.�:'-�..-- � -- J. pw_. CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � IHEREBVALFIRUUNDERVENALTYOFOE0.IURVTMAT7HEREISACONSTRUC710NlEN�INGAGENCY Z FOR THE VERFORMPNCE OF TME WORN fOR WHlpl THIS�ERMIT IS ISSU[D(SEC.109),LIV.C.). W Z� LENOER5NMIE S � LENOER'SADDHE55 W 1 CERTIFYTHAT I MAVE READ TMI511PFLICATION M!�S7ATE TMAT THE ABOVE NFOftMATqN IS CORfiECi. TOTAL FEES �3�, /o � IAGREETOCOMPLVWITHALLCITYMIDCOUNIYORUiNANCESANDSTATEUY+SR[UTINGTOBVILDINC � CONSTRUCTION,N:D N�REBYAUTMOW2E REPRESENTATIVES OF THIS COUNTY TO ENTER UPON 1HE Z ABOVE�MENTbNED VqOOERTV iOR INSPECTION VURPO5E5. COMMENTS � � � � ' J �. � � m VERMI7iEENAME R'�N7)/J tn � �t�. � �-j�Z' / � SIGNATUREOFPEiiMITTEE DATE , � FECPT.NO. �s PAID BY ��7 YALIDATION WHITE-Department Copy,YELLOW-Finance Copy,PINK-Assessor Copy.GOLDENR06-Fiie Copy,GREEN-ApplicanCs Copy . � , .. �. .,�, . ., ..,. , . . . . • ,. ..._ ._ ... �. .. , - � . . .-.. , , . - . . .. ,.�f�_`..., �.. . .��I f�t',�_i-3'.., :_�/—'.i . f i'�._ . '1_ . , i l r f�; i"....-_...t.�,S: Ya _ _r '��,, �--__ - --... _ !. �ir �'3 ' (.1►,� ,, :��� :, I,�Ed;w': f ���4 .._.. . �`'` '^.___=..,X.'.-�1-,- - -- _____.,.�,.r-_. ._-•---I`;�-���,- ----- I E . I . .. =i. .t 'CC;1�3 . . - ..:... __ . SET BF�CK �- ----- ------------ . . �LOC�f3,J:�1S� � , ---- -- -- -- ---- - -- - -----__ --�-- - -- FTG�'FORP�1S,STEEL FH„ RE�^;�TS ; - --- - - ELECTRIC GR�Uf�.D ; " r- � - ---- --- --- --- � , U���1�R . 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