HomeMy WebLinkAbout15392 (17) �� CITY OF DIAMOND BAR � �
DEPARTMENT OE COMMUNITY 8c DEVELOPMENT SERVICES
�� 21660 E.Copley Drivc Suite l90
(909)860-3195 Fax(909)861-3117 PRE$$
'�*^�� BUII,DINGPERMITAPPLICATION FIRMLY
JOBSITE �l i J 2 3 / APPUCATION� . � PERMR 5 a P/C
o ADDRE55 ocO,�O � � (7/�Gl�/��{fE DATE NUMBERL_ M
� ISSUE TYPE OCC
APN LOT T CT DATE CONST. GROUP
p OWNER
� ADORESS "� ZONING SETBACKS
� C(TY C��V/iVF� ZIP � TEL REf+R RW ❑
APPLiCANT TEL SIDE/SIDE STREET RW ❑
� CONTAACTOR � SIDE ❑
g ADDRESS � — V
PROPOSED USE --' ' � � � '
� C(TY��?,/�! ln/� ZI TEL7GD i�7 }�//L
ARCWENG!
� DESIGNER NO.DWEL NO. NO.
ADDRESS ___ . UNRS � � STOfl1ES BEDflOOMS
- - - -
� CITY - ZIP TEL
� �
� DESCRIPTION SQ.Ff: FACTOR PSF ADJ.AREANALUATION
� OWNER-BUIIDER DECLARATION SFWADD/REM
� 1 MEqE6V IFFYW UNDEq PFNALTY OF VERURY hIA71IW E%EUVT GHOM THE CONTRACTORS LL �3fag6�CdIpON
CENSEUWiORiMEfOLLOWMOREA50N(SEG.)W1.68USWE39ANDiROFE5510N50DDE:M1YCJiVOR ((�
COUNiYMIl9CMNEOUWESAGEiWRTO00NSTRUCT.AITERWPRDVEDEMOUSHORRcDNRN1Y5TAUG W patio/Deck
IURf,VRqR TO R9159UANCE,/�L50 REW IHES THE AOPLICANf FOR SULII VERW T TO FILE A SiGNEO W
STATEYFM T/ui HE Oq SHE l5 UCENSEO iU0.�UM(T TO iHE PROVISIONS OF iHE OOHTRACTOR4 LL
� CENSE UW(CIIAPTER i(COYMENCWO YATH SECTION 70001 OF DIVRqN]OF TME BUSwE55A181 FHO� V" POOYSDe . .. . ' •
HO
FESSIONS COOE)OR TNi�ff OR SME�S E%EUPT ri1EREFROY AND iHE 6W5 FOR TME ALLEGED f%E4P•
TqN.ANVVqtAilOyOFSECilON7Wt.6BYANYAFVIICANTfORAGERIMT6UBJECTSiMEAPPLILINTTO Z (jg-Rpp}
F A CIYIL YENALTY OF NOT YOfiE TwW iIYE MJNDNED DOl1ARS(isoD).}. .
� O�IISOVMEROF1HEDilOVERiV,ORYYEYPLOYEESWITHWAGESASMEIqSOL.ECDMPEN5AT10N, � �m0f�
W1LL 00 iTiE WOfYC At0 THE STRUCTUFiE IS fq7 WTENDED OR OFiEKD FOR SALE(SEG 70u.BU54 J
NESS MO iii0FE5510NS CODE:THE CaNTiL1CTOR5 LICENSe lAW OOES NOT A7iLY TO AH 6WNER OF -
N DiqPEATYMIliOBU4D501iYVROYESTMEREOKMDMA1000E55U(`JIWOfU(HIMSEIFOqHEfLSELFOR =
(= T410UONWSORHER0IN/EAIPLOYEES.PROVIDEDTIIATSUC314PROVEYFHTSARENOTliTENDFDOq m
�} .OFFFAEDiOHSKEIF.110NEVERTMEBtADYWOflMPROVEI�BrtI5601Dw�71wOMEYEAROFGOMPLE
� T10N,THE dNNEH-BUitDEA W41luvE ME BURDEN OF PROYWO iFfAT ME Ofl bHE DW NOT BUILD Ofl
WPFiOVE FORTME PURPOSE OF SHF} �
w OI�SOMMEROiTYIEiRODERil:M1EXf1U5N0.YCOHTfNCTNOWITHUCENSEOCONTiUCTO{l3
W CENSEUWDOESNDTAPKYTOANOWHEROF'AEGRO�ER NT48UlDsoAwvnovE��oN.�wo ValUetion AD.I.AREA
� n�aoonrrwcuconwa+rno.�crsvam�oorrtw,cro�s�t�r+scovw+surnrron�cartww - �OUAMI - �DESCRIPTION . �. .. . FEE- - -� -
_�4I TORS LICENSE UW.I . _
¢_ �
Q O IAA1 EXElAPT UDER SEG &i P.G WH TWS RE/SON
3 U , ,
� LL. ¢
wre aHmFa V
� IICENSED CONTRACTORS DECLAAATION -i
� w
INEHEBYAfFIPoJUNDERVEWLLTYOFVERIURYMATIAIAIICENSEDUNDERVROVI5qN50FCHM7ER r�y
� ��CpWENGNOWIMSECTqNloa01�OM5qN�OFTHEBUSWESSMWPFiOFES5qN5tODE.AND Z
X if/tIGENSE IS N FULL FORC ANO EFFEGT. m �
u� �
� ��� � �.No. !�A ��. � O FE
�+T�j /
aS �� WORKERS'COMPENSATpPfL'�ZSl�FiAi101Q a p
� U
� IHFAEBYAFFIR4lRAFNGENAL7YOFPERRJRTONEOFTMEFOLLO'NiNGDECIARAT10N5.
(/) Z
G �IWWEANDM'l1AMA1NTMN�LERTIFIGTEOFOQNSFNTTOSELiaNSUREFOfiWOR1(ERS' _
L OOMPQlSATpN,15VROViDEDBY6ECT10N�7000FTMELABOFiGODEFORTHEPEAFOFiMANCf U
Q OFTFIEMIORKFOHNtYCHTWSPEHAUTISI55UFD. �
0
O ��N/�yEµp ynLLµ�y(U�W WpRI(ERC CpdCENSATqN INSURANCE./S REOUIREO BY SEGTION
�700 OF THE I�BOR CODE FOR 711E PER WNAANGE OF TME WORK FOR N?/lp/THIS PERM(T IS �� �
� aSUEEp,yyWppKEqS'COAIPENSATqNWSUH�NLECMWEHAH�POl1CYM1M6ERAAE:
} �Eq� PLAN REVIEW
p pa�y�q S � �O�Z_ ELECTRIC
d
� (fllSSEctIONNE�No78Em.HFTIDOfhfPFA.(T6i0HWEH..►UfEDOat/ul5Rlao)ORtFSSI PLUMBING
Z ICEqTIFYiHATNTHEPEWOMAANGEOFTMENOfiKFOfiWH+CMTN15PEW.��TI5155UED,1 MECHANICAL
() SMAL�NOi EMPIOY ANY PENSON N ANY YMiNER SD AS TO BECOUE SUBIECT TO THE
N WOiYCERSCpAPEHS.�TqNUWSOFCAL�FOfWiA�NDAGREE71u71FI5MOlADBE00ME P FEE
S SU6IECTTOTMEVdO(iKERS'COMDENSAiqNPROri5qN50F5EGTqNa7ooOFiHElAiiOR i�(J
OODF.I&HLL FOHi}fYAiH COV�LY Mn7H iMOSE VROVI510HS.
O �
p pATE: AVRIGANL .
� WAWUNa FAIURE 70 SEd1RE WONCER3 COMPFNSATION COYERAGE IS UNUWFUI.AND SIul1 BE �ERGY P/C
� SUBJECTANEYPLOYERTOCRWW�LDENALTIESANOCMLFWESWTOONEIARIDREDTHWSANO �ryERGYPERMIT
pqy�Fis({�pp,pppj,W AppIT10N iOiHE COST OF COMPENSATpN.DMUGES AS PROVWED FOR W
¢ sEctannaocn+EueoncaoEwt�sr.u+o�tTow+tY'sFEEs. q�7��ONFEE:
W CONSTFUCTION LENDING AGENGY PRE•ALT FEE
a
O
� IHEREBYAFFIfiM1R�0ENFENALTYOFiEiiRJRYTHATTHEREISACONSTRUCT10NlENDwGAGENCY
FORTHEVERfORMIHCEOFTHEWOPI(F WHIWiMISVERAUTISI55UFD(SEG�oa7,pV.G�.
� ����
IENDER'S NAME
►= LENDERSADORE55 -
WIGEpTIfYTMA1IHAVEREADiMiSAVPLICATfONN&15TATETNATTIEABOVENIFORMATqNISCORRECT. TOTAL FEES � � .
� IAGREETOCOMPL�M7TMMLGfiTANDCaMTMONDWµCES�STATEUWSRELATWO708UlDWCs , . .
� CaNSiRLIC'TION.MWNEREBYAUTMORIZEPEVNESENTA7NESOFTWSCAUNiYiOENiERUPONTME �
ABOYE�A1EMqNFA PAOPENiY FOq WSPECTION M/RP0 S. COMMENTS
o � . � .
�
� FERYITTE E L
� ��
� 81pNA EE DAtE �
RECPT.NO. PAIO 8Y VALIDATION
� WHITE—Departmenl Copy.YELLOW--Finer�Copy.PINK—Assessor Copy.G IDENR ile Copy.GHEEN—App�canfa Copy
r, —- -I- �- _ � _ I ( - - � I - (. _i f -
e � I -- � - - -- - - -- -- --
��` ` I �
� � i , ,
� r� - '�
�r, ; : � ' � � ( i I. � •�
1�-,�, I " �
- _ _ I a � �
i � a1!{ - — — � � ��
, ,�; - - �
" � - -
_ i � o � :: -
. ^ � � : ;
�-- n,¢ w � �
o � ¢
� o v ¢ z .
, m Q : ,.I.�,��i ,, '� [C [•t p O 0 W�m U' p Z ¢ Z a y � Uj C7 z k_ � �I: ;•
. ���U� .�'nYt�� H p O w w z m � Z ¢ ¢ U U -� � Z u� a � u- a_ a� c:�,.. . , , �
• Z !L� �T''p � � .� � V o � z o C7 � Q w z ¢ O � a � Z t- w m i,�, ,
� a T.�I O O �. � m❑ z;p ¢ z c7 z w Z a o � W , . .
;; � ZQ ��Y� _ � � ¢ � z ri z w z � Z O O O iz � z � � O � `i W ¢ Y� . . - -- - . .. .,-- �-- -� �-- �-- .. ..
� w w a � m � t� = c� cn � oF- u. � _
zz � Wo 000 � w go �. wiow ;f:
. 0 � �u. � � 7 � � � mu- amctLLdaaO � u. ��
u. U -
' w
O �- �' i ,�_ -
� U � ,�� , ;
— r ,. ",
� .�
_ ,
�f: - t _ ,
,. � + � �l�
t t i �
����i �e 1) ��
_ , ��I- M I � Z� �� -
; �� - / Z � � ! I . . �,""�+A`i�!+ 1
s p I �;
i ...l..i W p �_ry � F - . F - , Z � - '�.L' :. W .� ..�..;�.} i.
i c�'y W Z z �� � J ' � V z W (7 Z O � � �C` � N W � r ._� .
, J;, J O `r � U � H Z p� F d. . � I
z •. � rn ¢ � w � � t=- w ¢ HU � mo � � q Y �Irz � m ' 1��- i �tv3 � J �
� � � aoW ¢ ¢ W � w » v� � � z '' w �' r= U � Z. z� .� r J��
Y ¢ U Q _`5 W W Z � J J � � Z Q "'S z Q W � � . W F-F_
• 4c� o � o [cOcn = c7oxwacr � � -� rF- ~ Ow � .� ,
Q u. �, z � aamzUsx = wg ? Ze ¢ Ua �.U = w a_ � Ua
� m v`� U � m a � �'- z �'- C7 C7 c7 � � W �= a 4�.,� � ...i ..� i ' � � . F=a. "��
c� w o � �-- oQo » � pF _I 'J � � n. uiu� ¢ ¢ a i aw
_. _
.
'� � �i J Q � W ¢ O ¢ O O O O = X ¢ W 2 W W W Q Z Z Z '�, .. O � � W W �'
, .: [n � W U' fn I- ^S' � LL Q CL CC � Ul W �j U ❑ fA fn U) U LL' lL Lt.i lL �. '. C.�, ' , ' V1 fA • -
�y