HomeMy WebLinkAbout1351 (17) _ -�
'"� CITY OF DIAMOND BAR PRESS
� - DEPARTMEN'Y OF BUIIDtNG AND SAFETY p�RMLY
'� BUtLDING PERMIT
JOBSITE APPUCAl10N -"?�, ��01� NU BER ��CO E ` I
ADDRESS ���`�� �� ��"'�� ����� DATE � �.
ISSUE TYPE OCC.
Q APN _ LOT TRACT DAl'E ��� CONST. GROUP
o` CROSS S ET �-�-��� SETBACKS ��"rs
°�°i OWNER � � t ZONiNG FRONT RW CI
o ADDRESS L` o�✓� � REAR C.�
W CITY � P .0 EL. �+��~��� SIDE/SIqE STREET RW �
p APP4ICANT �"' TEL. SIDE O
z
, � CONTRAGTOR � SEWAGE � PUBLIC PMT�
W; CDDRESS—�� zIP TEL. DISPOSAL (❑ PRIVAtE SQ.FT./1Q0 GAL
z STATE
�++ GRADING CJ CU.YDS EXC. CU YDS FfLL
y; LIC.NUMBER ;_
s.�=ia_ARCH/ENG/ �l �3,TYI�� .�S`� F�' �AG`;�II�:F i A�,#� 'R��KlV'`�.1,� Tl '_P+� �
`" DESIGNER �� ����r`"'" �- 1 �
';�, ADDRESS �; 2 " .
'= CiTY ZIP TEL. (�,. 3
:� PROPOSED USE %°�'� �'� �� 4
� �; GARAGE.
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a NO.t�WEL. NO. . —�""" � PORCN
y UNITS�...,�_STORIES_L�BEDROOMS m;
� LOT DIMENS{ONS '� VALUATION ADJ.AREA
o' NO.OF BLDGS HOW f�i1AN7t7�'.;DESCF�IPT`IL��";. .. ':�E . ." _
-� ON LpT USED �; ' t .
W � � � Q � � �7
�
_ LILENSEO CONTflACTORS OECLAflATION:i he�e6y alfirm that I am licensed mdar D�o�isions nf Chapter 9(commeircing
��� ith Section 70U0�of Uivisian 3 of�he Business and Professions Code,and my luense is in wll fu¢e and eHect �,_ _ _ -
3 t;f°
��: (hVNER-BUIlOER DECLAflATION�I heie6y atfi�m tAat I am eKemDt Irom�he ConlracWrb Li�ense Law.br�he fdlowing - ...
x
- r¢xon!Sec.7031.5,Business and Protessions Cade�Any city or cnumy which reqaires a permit to cnnstruct sf7� - � � � ^�4 ��'�
:'O� elter,impmve,demolish,or repaii any�mcNre;prior to ifs is5uance,also requrt¢s lhe applicam for such permit �; .. .
r1--�, to file a signed statement tha7 he is licensed Oursuant ro the pmvisions of ihe ConUador'S License Law(Chapte� a�J:
:�; 9(canmenting with Section 7011U1 of�iv�sion 3 ai the 8nsiness and Pmfessinns Code)ar thai he is e�empt�hereLan '�:;
�-n.-- and the basis for ihe aileged exempGon Any violatron ot Sxtion 7D31.5 6y any appticant for a permR suhjecn ,'�'�,
� ,`W�- ihe applicant to a civil penal�y ol nat mote than five hum0ed dollers(S5D0�.1: ;�-
�-` ❑I as uw�rer of the praperry.or mY emo�m'ees with wages as Mefr sole comoenution,will dn the work,and
�: ihe stmcrore is not intenAetl or o�fered for sale�Sea 7044,&isiness and Pmfesswns Code�.The Contracm�'s Grente
�-.. taw Aoes not apply m�an ovmer ot properly who 6uiMs or improves thereon,and who tloes such wo�k himself �y.
� W= or through his own employees,Dro�ided�hat suc6 imprwements are not intended ar oftered for sale.If,however �i,
�m�. �he 6uiltling or imprnvement is soM within one year ol canpletion.!he mvnerhuilde�will have ihe bwden of pwvin9 eQ;
y� that he did not hmitl or improve far ihe purpose of sale.i .. 3��
�/i. ❑I,as owner nt the pmpeny am exdu�iuelY�ontrecting with licensed temractws to tonstruct�k p�aj¢ct�Sec �{y}?
:0, 7D44,Business antl Professions Code:Tl�e ConlraCiars Lic w doet not apply ta an owner af properry wh
6mlds or imD�o�es thereon,and who controtts for;uc ect �t a contracrorls)Iice ed pmsuant to the Coniractoi s
�' L1Ce���aw� „�CONSTRUCTION __,
a
- �, ❑1 am exempt uMer Sec.� .B.6 P.C.IAttach-Certifioate) �P�N AEV�Ew
0 oe,e � ELECTRI ,..� �..,�Q
�',WORKEPS'COMPENSATION OEClAf1AT10N�.I hme effirm that I heve a ureticate of wns¢nt to s¢It-insure,a
- a certificate of N4rked Campensation Insuranae,w a ceriified capy ihereof(Sec.3800,La6.C-1. 'PLUMBING
_Q ❑ce<<�rra�anv�s ne�eav i���:n�a. ..�.�;MECHANICAL
p,� �Cefti(ied Copy is filed Wit�the BUikling InSpecli0n OeDartment m Oepar�ment �-:•GRADING
a'
��CERTIFlCATE OF EXEMPTpN FROM WORRERS'COMPENSA7IINJ INSUflANCE Thie seclion need not be completed �"�uA(V^L'`E �� r�
�', if ihe permit is for one hunUred(5100)ar less 1 certify that In tM1e pe�immance of!he work tar whzti this �s.:,..
p peimft is iswed,I shall npt emD�W a�V Gerson in any manner ta a5 to betame suGjtct W Ihe Nb�kHs'Cm',qensation . S'M -
O' Laws of Cali�omie. �PARK �E�
p: Date A%��L3'"'� lE�-,,SCHOOL F�ES
W�r f.OTiCE TO APPIICANT:�If,after making Nis CertiLcate of EnmOtion,you sMuld hecame subjec�to ihe Worker s
���.Compensat�on pmvisions af the La6or Code,you must�orthwith comply with such qmisuns a itiis pe�mil shall �?
'�-- he deemed rewkttl. ��'�'y �
� � �
�- OIVISION Of IN�USfNIAI SAfETY PEPMIi CERTIFICATi[Md. �y� �k.�� j;i�i ,
ua
a` ❑1 heiebY cenBy that na eKcavatwn five(5)or more teet�de�f mt6—wAu`fi a persan is required co descer�a
s- will he made in cv�ection with work authw¢ed 6y Ihu p¢�mu,and Mat�w Wildi�g svucture,steftdding,tdseWorF -
� or demolition ar dismanOiM ihereot,wiN Ge more Man thirry�siM 1361 feet M1ph.IChaD.3.2,Gry 2,Art 2,Sec .-.�'�� �
Z' 341.Title B.CA.G.I. .
x ��,� °��� ����
3� ❑As uwner�euilde�,I will nm-empby anYoce to da, Which'` repu�e�a�permit�ham Ax GV6ql1 OI .
p..�� Industrial Safety,as noted above.unkss such person has a permit ro do such work lrem me Aivisinn. .
� .. _.. .� .;. -
.W-❑Ovision of Indushi�l Safety Permil No. .- �� � ��- - T�TAL FEES .�(�''y
� CONSTflUCfION LEND�I�pGENCY:1 harehy aflir�.tl�aj{hera�is a unstuCuo0.leMdip.agertcV�dor tlM perk�mznee �v
= al the work fw whuh�his permit is issued(Sec.30,97,Ctr..G{;��-���-�^' ' ' ��
� tender's Name COMMENTS
m Lender's Address � �
'� CERTIFICATE OF COMPLIANCE ANU AUTHOflIZATIpI OF ENTRY:I cntify 1 Mve rcad this applknian�nd state � ,
v� that the��rfamation given is torceq.I agree m mmpfy with all stal¢lewa arid�M ordinances rebtsp to 6uiMing .
� construpion,and autAorize yp�eu �re of the Dryar�ment at Buikiny ad Sateiy to Ier�qon prope�ry , �
= for wArth I Aa�e ap � or Mis per t �Me qxpou M making inspections. ��
r , - ��I � � � � 'L,
X �l REGPT NO. � t �a_�___ ✓
��, ��� �4 PAID BY VALIDATION
WHITE—D rtment Copy,YEILOW—Finance Copy,PINK—Asaessi�r Copy,GOIDENROD—File Copy.GREEN—Applicants Copy _, ---
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