HomeMy WebLinkAbout15566 (9) _1�_ CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
�������W BUII.DING PERMTl'APPLICATION ' � � FIRMLY
� JOBSITE APPLICATIO � PERMIT f P/C
o ADDRESS ��b�3 Lt�� {�� C�e- DATE NUMBER ' #
� APN8964" ^t.OT I'�I TRACT 33205 ISSUE n G TYPE OCC
DATE � CONST. GROUP
p OWNER �r �'ru P h
`� ADDRESS ���a3 Gl¢� PP.o�C ZONING SETBACKS
Z CITY D.0.�t�P�P�' ZIP CJk TEL. �09 39(0'�41� FRONT RW ❑
g APPLICANT F�'}vn.�. Cha�'► TEL. REAR fl
� SIDE/SIDE STREET RW ❑
CONTRACTOR_ SIDE ❑
� ADDRESS PROPOSED USE
� CITY 21P TEL.
oARCWENGI
� DESIGNER NO.DWEL. NO. NO.
ADDRESS UNITS STORIES BEDROOMS
� CITY ZIP TEL.
� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREA/VALUATION
�
Q OWNER-BUILDER DECLARATION SFR/ADD/REM
0
� I HEREBY AFRRM UNDER PENALTV OF PERJURV THAT I MI EXEMPT FROM THE CONTRACTORS LI- Gd1aJe/CalpOlt
W CENSEUWFORTHEFOLLOWWGREASON(SEC.�o31.5BUSINESSANDPHOFESSIONSCODE:ANVCITYOR (n
C.J COUMVNMICHREWIRESAPERMRTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRAHYSTRUC- W py�l0/DBCk
�Z TURE.VRpR TO 1T9 139UANCE,AL50 REQUIRES THE APPLICANT FOfl SUCH PERMIT TO FlLE A SIGNED W
STATEMENT 7HAT HE OR 5ME IS LICENSE�PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
� CENSE UW(RIA7TER 9((%kAMENCINO WIT1 SECTION 7W0)OF DIVISION 3 0F THE BUSINESSAND PF0. � POOI/Sp8
FESSIONSCODE)ORTHATHEORSHEISE%EMPTTHEREFROMANOTHEBASISFORTHEALIE�EDEXEMP- (�
TION.ANYVIOLATIONOFSECTION7IXi1.58VRNVAPPUCANTFOflAPERMITSU&IECTSTHEAPP�ICANTTO Z Re-Raof
� A CML P ALTV OF NOT NORE THAN FNE FRINORED DOLURS(t5ao).):
� �ONMEROFTHFPNOPERTV.ORNYEMPLOVEESWITHWAGESASTHEIRSOIECOMPENSATION, ❑ COmmefCiel
Y/ILL DO THE WORK,M1D'fHE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.70!!,&ISI- J
NESS AND PROFESSIONS i^�E:THE CONTMCTORS LICENSE lAW DOES NOT AVPLV 70 AN OWNER OF
� PROPEHTVWFiOBUILD5091MPROVESTHEREON,ANDWHODOESSUCHWORI(HIMSELFORHERSELKOR �
Q THROUGHHISORHEflOWNEMVLOYEES,PROVIDEOTHAT5UCF11MPROVEMENTSARENOTINTENDEDOR m
QOFFEREDFORSALEIF,HOWEVERTMEBVIl01NGORIMPROVEMEMI550lDWITHINONEVEAROFCOMPLE-
Z TION,THE OWNEH-BUILDER WILL IUVE THE 9UHDEN OF PROVING THAT HE OR SME DID NOT BUILO OR
� IMP1iOVE FORTHE PURPOSE OF S�LE�.
O 1,AS OWNER OF THE PROPEHTY,AM E7(CLUSIVELV CAMRACTING WITH UCENSE�CONTRRCT�RS
� 70 CONSTRUCT TME CRQIECT(SEC.Io11,BUSINESS ANO PROFESSIONS CODE'.THE CONTMC70H5 LI- V21u81iOf1 ADJ.AREA
W CENSEUWOOESNOTAPPLY70ANONMEROFAPROPER7YWHOBUILDSORIMPROVES7HEREON,M7D
� WNOCONTRACTSFOHSUCHPROJECTSWITHACONiRACTOR(S�LICENSEDPURSUANTTOIFIECONTRAG QUANTITY DESCRIPTION FEE
Y TOPSUC NSEUW.�.
� I AM EXEMPT UNDf:R EC. �� Q
O B. P.C.FOR REASON
3 � �
LL DATE ��LS'C� DWNER E EhI U
W
� L.ICENSED CONTRACTORS DEGLARATION W _
� I HEREBV AFFIRAI UNOER VENALTY OF GER111RV THAT I AM LICENSED UNDER PROVISIONS DF CHAPTER � .1 /� � -
d D�COMMENqN(iWITH5EC710N700o)OFDIVISION30FTHEBUSINESSAN��ROFESSIONSCODE,ANO Z L G�
X MY LICENSE IS IN FULL FORCE AND EFFECT. m
LL1
O �
r IICENSE CLASS_ LIC.N0. _ J
V DATE CONTRACTOR a
W
� HlORKERS'COMPENSATION DECLARATION Q
� IHEREBYAfflRMUNDER?ENALTYOFPERIURVONEOFTHEFOLLOWINGDECLARATIONS: U
� Z
Q
O I HAVE ANO WILI A�AINTAIN A CF.RTIFICATE OF CONSENTTO SELF-INSURE FOR WORKERS' _
� COMVENSA710N.AS PROVIDED BV SECTION 370o OF THE LABOF CODE,FOR THE PERFORMANCE w
OF THE WORK FOR NM1IICN THIS PERMIT IS ISSUEO. �
0
W I MAVEAND WILL MAIMAIN WORKERS'CAMPENSATION INSURANCE,AS REQUIRED BY SECTION
Q 3700 OF THE LABOfl CODE,FOfl TNE PERFORMANCE OF THE WORK FOR WMlqi THIS PERMIT IS
ISSUED.MY WORYERS'WMPENSATION INSUflANCE CARRIER AND 70LICY NUMBER ARE: CONSTRUCTION
jc..qqiEa_ PLANREVIEW
Z ao��crnuMaEA_ ELECTRIC
¢ �
� (iHISSEC�I(.YINE6JNDTBEOOM14LEfmOFTiEPEFMTSFOFiaNEFRN�DREDDOLIFAS(E1ao)ORLES54 PLUMBING (
W
Z 1 CEHiIFY THAT Ih THE PERFORMANCE OF TNE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
() SNALL NOT EMVLOV ANV VERSON IN ANY MANNER 50 AS TO BECOME SUBJECT TO TFIE
Uj WORKEPS'COMPENSATION lAWS 0F C/LLIFORNIA,AN�RGREE TMAT IF I SHWLD BECOME INSPECTION FEE
S SUBJECTTO THE WORKERS'COMPENSATION 7RONSIONS OF SECTION 310o OF THE LABOR t!'�� �
CODE,1 SHALL FG�RTHWITH COMPLV WITH THOSE PROVISIONS. ISSUANCE
� SMIP
p DATE: _ APPUCANT'.
� ENERGY P/C , -_
� WAFNINO:FAILURE TD SE CURE WORKEHS'COMPENSATION CAVERAGE IS UNUWFUL,AND SHALL BE ., �
�y SU&IECTANEMPLOYERI'OCRIMINALPENALTIESANDCIVIIfINESUPTOONEHl1NDREDTHOl1SAN0 ENERGYPERMIT �"�� ,"�4�'
DOlURS(5100.000).IN AU�ITION TO THE COST OF COMPENSATION,OAMAGES AS PROVIDED FOR IN
J SECTION 3�OG OF THE LAI30R CODE,INTEREST,AND ATTORN[YS FEES. RETENTION FEE: -
2 .. - ' ' . . .,..��
O CONSTRUCTION LENDING AGENCY PRE-ALT FEE: ; � �, �_��.�� �.: k_. ______
��
� 1 HEREBY AFFIRM UNDER PENALTV OF PERIURY THAT TNERE IS A CANSTFil1CTION LENDING AGENCY
d FOR THE PERf-0RAIANCE OF TIiE WORK FOR WNICH THIS FERMR IS ISSl1E0(SEC.309],GV.C.).
Z
W
� LENDER'S NAME . __
I_' IENDER'S ADORE55_ �/
� ICERTIFYTHATIHAVER[PDTHISAPPLICATIONANOSTATETHATTHEABOVEINFORMATIONISCORPECT. TOTAL FEES ��' /
W I AGHEE TO CAMPIV WITH ALL CITV PND CAUNTV ORDINANCES ANO STATE LANS RELATING?O BUILDMG �
� CONSTRUCTION,ANDHEREBVAU7HORIZEREPRESENTATIVESOFTHISCOUMYTOENTERUPONTHE
ZABOVE-MENTIONE�PROPERTV FOR IIiSPECTION PUPPOSES. COMMENTS
Q —___"_—.___._._._._"-_— _
� FaR-�uwl�E �'9{E►�
�
m PERMI N PRINI) 1
N ���4S'� �
� SIGNATU E PERMI L"E DATE ,
= RECPT.NO. PAID BY VALIDATION
~ WHITE—Department CoDY,YELLOW—Finance Copy,PINK—Assessw Copy,GOLDENROD—File C
opy,GFiEEN—Applicant's Copy
�[�� �� �}���`����� � �
���������� ��.����
. � . r ; � . � �, , � �
4,,� r��,;;:r � �.,�� �: ;,rv,,�.�
,
� , ., . .
�-- _ ��_ .___ � __. ._.�_._. __ ._a____ � � __
_ — _ _ ---_ � --
_ _ . _
r ��:��.s �G�F-th�'ti,r�s� .� ' ��;- � , "t"��
� a
, _ _. _. _ __ �_ . _ __ . .._;_ _ ��.
� � 4'�'" s?°�:' G�(� "--0 ' l i�. i '�. : �;{, � ( , �
.�
� �- . _ ` _� _ __ ___. __.__. ,__ i . _ _ .___ _ _ . �
- - -.. _ h
� r-,.�r n �� t e s�,� ', �t�� ?f i�'
,, �, � a
, � , , _ ��
,_ _ _ . _ - -- � _ _ -____ _ � _ — � -- - ..�_- — - -- — �
1 .^,,i '4t ^!.`= . ?` if.'s �Ls'�,�,•i,L' "'i � .
!`ir,- v �.
� _ .._ . _. .._.. "_ — .,-.—_-._ .._.,...._....._.�_._.. m ...... �' _- __ ..____' '—'_ .__.__.__ ._.
,. : - � ,., s . � . -.
� ��,���' .�u`�e_�? � __ s �`�t, °at�,,,� r s 1� �
,___:�__ � _.— , _ _._'�.__ _________--- -- ---- � ---- _- �.-- ._.. _ ____—��.
f �ft��"? i-,...Gi35 �"'.Y- i ,iF:' �.' .-'( rtiE� ..t*;9 � '�,
..� . ...r .. .. ,�
_,-.. ._..,.� _. _..... __�.�.. '_ . _ _ _._. -.
_ _ ' " '
�, "_.. -. _ .. w� .__ ,
} '!:,f '"�.6 ��t �: a � � '�' +,��rt;" c-��f`"�
�- --- - .� _. �_.. ._. _ ��_ _ _.___ � '
— -- -�._ _ _--- . __ __.._. .__ _
E ?��'�r�tr`,�`,� �t� - �t€'�< ��� � �` �TC�',i����� ��� '�
��, � �,_,..
. _, . .
E_ ._... __.._. _. --.. ._.. ...... _.... ...._ .. _.._. ..._. ._ . . . ._.. ......_ .___.. _.. . ..
,
� �"tr�; � ' ,'r` '� i t - �� l�ie�r _, —_��. �
� --� � �— � -- - �-----_. � ...__._ .___._ _. . �� �
z
:�.i€ �� �}r�A� ' �� ��_��� ��,at
��� : .___.___� _ - —
_ .�u.__
� _ _ _ _� . __� _ _ _� __. _
i �-'t���3{� S �:Z..� t �d3„ - ` ad�L ,z�`'.��-tr�.,��`d-:� . -
_.. .._ ... .,... , . _.._ ..__. ..... .. .. . ... ...._. .._ ___ _..._ ..__.. ..__.
i'4:. . _n . ,`.,.�'�l�ai; . ,P*�i ; �„ '.
._. _ .... . .. �. , _._. __.____....___.�.,....._.._ _. ._._._�_..._ __ _._ ___. . __._. _.._..._.._.___.. ..�._ __
[
. �:z 3 _�C. �i`. „ i� �'F��.. �� r?`�f�i.i =
. . .. ..._`- -- --._ _ .__._.._ ,.._..._..__ .<-, . . ...._. .__—.��... �..,_______ ...._. _,_ .....'—...—
�� ``��� t EP.C� �-_�� _ ��'�a:.�aF�ia, ��._
� n � 4
x _ _ _ __ --- - - -_ _ _ ,_ —.. --- - __-- _ _ ��
�
, 5,,�;�; ���:t �a ,.,`,. � _ _ <"vf��E �� ��
_ ,_.. _ __._.�._ ___ -- — _._ _ _�_ __..__ ___.__ .� _
.-, F; �r, h � �.r.. ,
. , t. , . _ .�r
�. �-- — _ � .._. .._ ___ . —.. _ _ _ _ � � ,.
��3 s _ ��� _. . . r:.t�a;-s
_ _ _ _ _ . _ _.__ _ .__ , __ ___
� ,,. �;r � F�a.
__ _ _ >- --- — __ .__, ___- - - -- -____. _ --- -_ __. ._____ ,
� . .a�` � � .. o;'.� ;�',r, �
_ _ � .� _ __ m ...- --- . . _ ..___ _
_
r� o � - - - -� - -
:
� �: ,� .
� __ ___ _ __ �_-- __ _ ___ __ ___ _ _
� , � . _ � �
- - --_ __ __ ___ __ _� �_ _ _
- - - _ --.
� __ .� _ � �
__ .- � - _ � _ .
�___
- _ __.�_ _ ____ --� --
� � -� ���
_ _ ._ . ���,� � . , �w �:
� �a��z���,��� ���� � _
r .y a bnt� ._
- _,._— _ _,_. __�_ _ - _ --- _ _. __ . � _ _ _
� �--� ��a( � � � � � �����
� _ � -- -- ,���s--�_ _ __ _� ___ �---��..�_ _ _ __
F__ _ _ _._ _ . _ _- __ ___ ---- _ --_ _ _ ___ � __ _
, -
__ __ _ _ _ ____� ____ _ __.
_ __ _ _ __ _ _ �
�_ ___. __ _ :
3._'— __-. . .__. '—_' �_��..___ _._ ...'"""....,__.__"". ........_.._._. � __.._.�_..._._..__.._�.___ ...... �.
._. _ .. __ ..V___" __ __. _ ' "_'".. ,_.... . ... ..... ..._..___..... ..... .._._. ....._ .,. ,.,__ _"__ ._..
�...�,_ . .�`�.'� . n.>.., ''�.
__.V_.,.. ..,..
,��..�.r �,�., ;. _... __... ___...__..._ ..__ _ _...___._ __.. .._. ....., . _.. ...... _._ .......,_ ......, _._
� .".. . . . .. _.._ _.�_ '.
; '4 tdiP!i. Sty'ryt !`i ._.. ...... ._ ...... . .._.. _._ . . .._.. ��.
� �..
S, '__. _' __. .._. . ..__
r� �
ti
6
�: _... ........... . .... ..._ . . _...... _.... _._. . _____. __._ _... ._.... _.__ ._._ ...... ;
t
i
� t '' I�
� + �' ���� � .. ...... .__ ....... ... . . . .... . ... .. _.._. _..... _.... .. ...._ ... .. .... _
i
; 3.
: ' _
� ��i .._ _ ,_.._� . ...._._,_. _ .__. ..... . _ . ._.. ,.
a �
� . , . . . ,. ,. . .._ . ..__..__. ,,..._,....._ _._. . __. _._ __ .... ... . ._. .. '
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
PRESS
FIRMLY
JOBSITE
I�
p^' ^'e
t
-+�
ADDRESS�Ltoti3
APN8'164' ^L-OT 14'1 TRACT 3320s�
OWNER For�vr..� �h
ADDRESS�I � � 3 2o)c
CITY���'ZIP CJk TEL.09 3q(o'241�
APPLICANT FQ-I"vti..�.Ch.a�'-TEL.
CONTRACTOR
ADDRESS
CITY ZIP TEL-
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFRM UNDER PENALTY OF PEiLA1RY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REOUIRESA PERMR TO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY STRUC-
TURE. PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR 5HE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISK)N 3 OF THE BUSINESS AND PRO.
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TK7N.ANY VKXATION OF SECTION 7037.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CML�ALN OF NOT MORE THAN FNE HUNDRED DOLLARS(5500).):
Qfl AS OWMER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATKNJ,
MALL DO THE WORK,AND'fHE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7011, BUSI-
NESS AND PROFESSKNIS CODE:THE CONTRACTORS LICENSE IAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS 09 IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
TNROUfL/HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF HOWEVER THE BUILDING OR IMPROVEMEN715 SOLD WITHIN ONE YEAR OF COMPLE-
TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SME DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
0 1,AS OVMER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PFIO.IECT(SEC. 7011, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY 70 AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONiRACTOR(S) LICENSED PURSUANT TO THE CONTRAC-
TORS UC NSE LAWJ.
I AM EXEMPT UNDER EC. �0 B. P.C. FORT REASON
L
DATE- (5�'�OWNER��IE[I}IEY�I,
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERIURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
D(COMMENCING WITH SECTION 7000)OF DIVISK)N 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
LICENSE CUSS LIC. N0._
DATE CONTRACTOR_
NIORKERS'COMPENSATION DECLARATION
1 HEREBY AFFIRM UNDER?ENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE ANO WILL MAINTAIN A CERTIFICATE OF CONSENT TOSELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BV SECTION 3700 OF THE LABOR CODE,FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
_I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MV WORKERS'COMPENSATKX�INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER
POLN:Y NUMBER
(TIi15 BECKON NE6J ND78E CCNRETm OFTHE PEPANT S fOR ONE HUI,ORED fXX1AfiS(E100)OR LESS
1 CERTIFY THAT Ih THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANV PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION IAWS OF CALIFORNIA,AND AGREE THAT IF 1 SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATK)N PROVISIONS OF SECTION 3700 OF THE LABOR
CODE, 1 SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE:APPLICANT.
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER 1'0 CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(5100,000),IN ADDITION TO THE COST OF COMPENSATK)N, DAMAGES AS PROVIDED FOR IN
I SECTK)N 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
I CONSTRUCTION LENDING AGENCY
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CANSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV.C.).
I
LENDER'S NAME
LENDER'S ADDRESS
I I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITIi ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
�CONSTRUCTlON,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTK)N PURPOSES.
Foa-�uN,E�'9'tE-J
� PERMI N PRINT)
�9-is-ao
0 SIGNATU EU�PERMITTL"E DATE
WHITE-Department Copy,YELLOW-Finance Copy,PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Gopy
..�a�.