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HomeMy WebLinkAbout16189 (20) ..,..----. � CITY OF DIAMOND BAR ,•��"� DEPARTMENT OF COMMiJ1vITY&DEVELOPMENT SERVICES °,✓ : + ' � _ 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS � 9M'�� BUII.DING PERMIT APPLICATION FIRMLY ''�N JOBSITE iy� c ��^ �7 APPUCATION °� �� PERMIT � ���� P1C _ �'� ADDRESS�l v�J C'�,1�GN�g�(�U� �K.> DATE �..c�` I NUMBER-,����-'-"--i # �a., ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p� OWNER C a�; ADDRESS O L.�/� U Q ZONING SETBACKS w� a FRONT RW ❑ CITY A ZIP ��i TEL�'�, f ���I ' �=, APPUCANT � ecE'�t���"-5��� , REAR o SIDElSIDE STREET RW ❑ CONTRACTOR �.- A't� r� �. SIDE ❑ �` _ _ �• ADDRESS � � �- CITY L.14�C��``+� ZI O 1 TEL �' PROPOSED USE o=: wo^ ARCWENG/ Za; DESIGNER NO.DWEL. NO. NO. a,. ADDRESS UNITS STORIES BEDROOMS _` CITY ZIP 7EL. �� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION �: �'.s_ OWNER-BUILDER DECLARATION SFR/ADD/REM Oz p', I HEREBY AFFlpM UNOER PENA�7V OF PFRJl1RY THAT 1 AM EXEMPT FROM THE CTORS Lb �, � Garage/Carport - W.-r CENSELAWFORTHEFOLLOWINOREA&ON(SEG7031.58USINESSANDPROFESSION. E:ANVCITYOR. Ut-COUNT`lWHiCHflEWIRESAPERMITTOCON3TRUCT,ALTER,IMPFiOVE,DEMOLI REPAIRANYSTRUG - W P&tiO/D6Ck �� TURE PRIOH TO ITS ISSUANCE.AL50 REWIRES THE APPLICANT FOfl SU RMIT TO FILEA SIGNED ; W M STATEMENT THAT HE OH SHE IS LICENSED PURSUAN7 TO THE PROVI 5 OF THE CONiRAC7oRS U� . . . . CENSELAW(C�1hPTER9(COMMENqN�WITHSECTbN7o00)OFDI N90FTHEBU9INESSANDPflO� - u' POOVSPe � FESSIDNSCODEjOR7F1ATHEORSHEISEXEMPTTHEREFROM EBASISFORTHEALlEGEOEXEMP- (� _� TION.ANVVKKATIDNOFSECTION703/.58YPNYAPPUCANT RA7ERMITSU&IECTSTNEAP7LICANTTO . 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VhpCOMRACT flSUCNPRQIEC7SWfTNACONTRACTOR(S)LICENSEOPURSUANTTOTHECONTRAG .QUANTITY DESCRIPTION FEE � TORSLICENS WJ. � � ❑ EXEMPTUNDER SEC. 9.&P.C.FORTHIS REASON �'�� Q: � � , �=- DATE OWNEA V . W o! _�� LICENSED CONTRACTORS OECLARATION , �j - �- ;�HERE6YIIFFIRMUN�ERPENALTYDFPERJURYTNATIAMLICENSEOUN�ERPROVISION30FCHAPTER � - -- _ d ;.0(COMMENCINOWITHSEC710N1aao)OF�IVISION30FTHEBUSINESSANbPROFES510NSCADE.AND - Z S< ',MY UCENSE IS IN Fl/LL FORCE AND EFFECT. - � m I `� ��,UCENSE CLASS ��d� L�C.NO. ✓ ��1 L D��. - j- -- l H V �:pq7E CONTRACTOR � W . � : WORKERS'COMPENSATION DECIARATION - Q � -I HEREBYAFFIRM UNDER VENALTYOF PERIURY ONE OFTHE FOLLOWING DECURATIONS: � N Q � .-_IHMEANDWILLMAINTAINACERfIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' _ - ' � COMPENSATIDN,ASPROVIDEOBYSECTION370oOFT}7EtABORCODE,FOflTHEPERFORMANCE �U � OF THE WORK FOR WHICH THIS VERAIiT IS ISSUED. � W I HAVEANU W1lLMA�MAIN WORKEFlS'COMPENSATION�NSURA�CE.AS REDUIRE�6Y SECTION Q 57900Fh1E LNBOR CODE,FORTHE P[RfORMANCE OFTHE WORK FOP WHICHTHIS VEiiMIT IS ISSUEO.MYWOPo(E Sp'CO P S T INSU CECARRIER POLICYNUM9ERARE: CONSTHUCTION � CARRIER `�\��� `p�` �Q" PLAN REVIEW Z Pa.icYNUMBER � �� O ELECTRIC ¢ O (IFRBStCfIONt��NoieEWhPIEtIDCF'niEPEaharISFOROMeMNmREooalARs(51co)atLESS? PIUMBING W MECHANICAL � 1 CERTIFY 7HAT IN TNE PEflFORMANCE OFTHE WORK FOR WHICHTHIS PERMR IS ISSUED,I (3 SHALLNOTEMPIOVANYPERSONINANYMANNEfl50ASTOBECOMESU&IECTTOTHE � � �WORKERS'COMPENSATIONlAW50iCALIFORNIAPN�AOREETHATIFI5HOl1L08ECDME INSPECTION FEE SU&IECTTOTHEWOFiKER3'COMPENSATIONP SIONSOFSECTION37000FTHELABOA ��/� � E, SHALL F RTHWITH COMPLY WITH VIS . � ISSUANCE ___.,_ � j SMIP p OATE:���� APPLIGANT: __— J, ENERGY P/C - . J WARNINQ:FAIIUflE TO SEGURE WORKERS'COMPEN9ATION CAYERAGE IS UNUWNL,AND SHAl1.BE � SU&IECTANEMPLOVERTOCRIMINALPENALTIESANDGVILFWESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT �OLLARS(S1o0.000),IN PDDITION TOTHE COST OF COMPENSATION,DAMAGF.S AS PfiOV1�ED FOR IN J. SECTION 37080F THE LABOR CODE,INTEflEST,ANOATTORNEI"5 FEES. RETENTION FEE: _____ " ° � W, . _ .. _ ...._ �w.c«mwvaadum'. .-z.:..� . d: CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � IHEREOYAFFIflMt1N�EflPENALTYOFPEHJURVTHATTHEf��}GACONSTRUCTIONLENDWGAGEtdCV - FOR THE PERFORMANCE OFTHE WOPK FOfl WHIC lSRERMIT IS ISSt1E0(SEC.3097,CIV.C.}. W. I � LENDER'S NMAE ------- I h LENDER'SAOOiiESS --- ( , ' ' , i � )� � ICEflTIFYTHATIHAVEREA�THISAPPLICATIONANDSTATETHATTHEABOVEINFORMRTIONiSCAfiRECT. TOTAL FEES {,(�" � - � - ; W IAGNEETOCAMPLVWITHALLCITYAN�COUNTYORDINANCESANDSTATELAWSiiELATINGTOBUILDING . � � CONSTRUCTION,ANDHEREBYAUTHOR¢EFlEPRESENTATIVESOF7HISCWNTVTOENTERUPONTHE � _ �� � - -� ! z ABOVE-MENTIONEA PROPERTY FOR INSPECTION PURPOSES. COMMENTS f � �� � �. c�c� ; m PERM EE NAME RINn ---- . �I � � ������/ ' � 91O A7U OF PERMIITEE �ATE - �.i RECPT.NO. 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