HomeMy WebLinkAbout12803 (13) / r O � - --��
� - CITY OF DIAMOND BAR .
" � COMMUNITY DEVELOPMENT DEPARTME T
f �:..� 21660 E.Coplcy Drive Suite 190 �
(909)860-3195 Fax(909)861-3117 � PRESS
""' BUILDING PERTIITAPPLiCATION FIRMLY
o� 'JOBSITE �j ���N C�NY�/�' C7�"� DATE CA� !` /E? 6p' NUMB R �v #/C
ADDRESS�2/ o.S�D ('Y,�
r° APN LOT TRACT �7�5�� DA EE !G `��d ONST. GROUP
p OWNER _�� '
o ADDRE _�y U T.�I?��VCr- �� . ZONING SETBACKS EXPIRED . - . . -
� Z CITY��j�/Cf= ZIP�� TEl„�lD t 5[��iSr� . FROIJT RW ❑
� APPLICANT TEL _ REAR ❑
�� SIDE/SIDE STAEE RW ❑,
CONTRACTOR � � SIDE ❑
� ADDRESS � .. _
' � CITY�'���j.vn ZI TEL�.YJ� _ (.J7�i' PROPOSEDUSE
' w ARCH/ENG! � I y}7� �
z DESIGNER `
w � NO.DWEL NO. � NO.
= CDDRESS Z�P TEL UNITS STORIES BEDROOMS� �
_�
cn DESCRIPTION SQ.FT. FACTOR PSF AOJ.AREANALUATION
Q OWNER-BCILDERDECLARATION ---- SFR/ADD.REM
p , . . .
_-�HEaEev�mau ur�oca o�u_n oc vcauar nuT i Au ExnaPr►aor�n+E m�rFueroAs u- GaraqelCaiport
, W CENSEUWFOqTiEFOILOwIN4REA50N(SEG.7WI.SBUSMESSANDPROFE3310NSCODEANYqTYOH (n - � -
, U COUNTyWHIp1RE0U�RE5APERMRTOCONSTRUCLALTERddPROVEDEMOUSH.ORRE7AIRANYSTHUG W
w NRE,GRIOR TO ITS ISSUANCE,AL50 REIXIIRES THE M�LICANT FOR SUCH PERMIT TO FILE A SIGNED W PdtIOlD2Ck _ ' � .
� STATEMENT THAT HE Oq SME 15�ICENSED RIRSUANT TO THE PROV1510N9 OF T1+E CONTMCTORS l4 �
- CENSELAW(CIIAVTER B(COMMENCRJ[i MnTM SEtTION 7v0o)OF DMSqN 7 OF THE BUSME5511N0 FRO- PooVSva -
Q FESSIONSCOOE�ORiHA7HEORSME13E%EAIV77HEREF{IOM/JJDTNEBASISGORTNE.LLLEGEDEXE1dP- (� -
V T10N.ANYVIOLATqNOFSECTION7031.58Y�M'APPLIC�NTFORAPERMiT5U8JECT5THEAVPUCANT7p Z Re-Roat .
A CML PENALTY OF NOT MOHE 7HNi iR'E HUNOREU UOlURS(5500)):
❑t��Y�NEHOFTHEPRO7ERTY,OR4YE�PLOYEESWITHWAGE3ASIHEIRSOLEtOAl0EN5ATqN, Q
; Z Commercial � '
Wp.1.D0 THE wOR1C ANO THE SiRUCTURE IS NOT NlTENDED OR OFFERED iOR S�LE(SE0.7a�.&151- J
� NESSMlDCROFESSIpVSCOOE:TIIEWNTRACTORSLICENSEUwDOESNOTMPLYTOANUttJEROF =
• PROPERTYNM1108URDSORIIAPROVESTHEREON,Ml�YlNODOE4SUCHVJORKHiMSELFORHERSELFOq � � - �
� (= THqOVCHHISOaHEROMMEMPLOVEES,PROVIDEO7HATSUCHIMVPOVEMENTSMENOTMENDEDOq m
� OFFEREOWRS�LEIF,MOYlEVEF�THEBtMDIN00RIMPROVEMENiI55OlDWrtHMONEYEMOfOOMVLF � " i �
, Z TION,hfE OWNER�BUILDER WILL HAVE THE BURDEN OF PROVM6 THAT HE OR SHE D10 NOT BURO OR
� MOROVEFORTMEPVHPOSEOFSALEF -
- (L 04�30YMEROFiHE7ROVEHTY,AMIXCIUSNELYCONTMCTBJ�WITHIICENSE�CONfMCTORS.
'� � TO CONSTRUCT THE PRQIECT(SEG 70��,BUSWE54 AND OROFESSIONS CODE:THE CONiRRCiOR3 LF Valuatio� � ADJ.AREA � � � �
W CENSEUWDOESNOTAPP�YTOANONMEROFACROPERTVWVqBUILDSORIMOqOVESTHEREON,ANO
� WHOCONTRACTSFORSUCHvqplECTSWITHAOONTRACTOR(5)IICENSEDPURSVANfTOTHECON7MG QUANTITY DESCRIP710N �E ,
� mrtsucEHseuw.).
❑1 AM E%EMOT UNDER SEG B.8 C.0 Wq Tit3 RE1150N Q / I�v�� "��. O
� � DATE OWNER � . . H t J -• a
a W t��' - - � ..
.� LICENSED CONTRACTORS DECL4RATION W � J� ;s
� � IHEAE9YAFFIRMl.RJDERPEWLLTVOFPE0.IURYTHATIIWLICENSE�UNDERPFlOV1510NSOFCHAVTER Z 1 v /� ` '
"-�' Y(CdA1AENCMA WiT1 SECTION 70Do)OF OMSqN J Of THE gU51NE55 MA PROFESS�ONS COOE,M1D / � - (J( �
LLJ �LICENSEISINFl1LL.F'ORCEANOEFFECT. m n/�� O
� J
, � LICENSE CU15S� ���� LIC.NO. � l
' w oa� /Z�_/i�/_ /�^�oorrrn.aoroA,�y;�_.E"�th F /e'Er. a , 7 � �
� - / S �, t�-
� WORKERS'COMPENSATION DECLARATION ¢ s L � � O �
• N IHEREBYAFFlRMUNDEHPENQiYOFPE0.NRYDNEOFTHEFOLLOwIN6DECUMTqNS: Z / /S /4"E/ +�I� ! ��-
� _IMAVEANDWILLMAINTAMIICERTIFlCATEOFCONSEMTOSELFMSUREFORNOfiKERS a -
CdAVENSATqN.AS OiqVIDED BV SFCTION 77000i TME UBOF CODE,FOR THE OERLORUANCE C,.) / � /� �
� Q OFi11EVYORKFORYM1iIQiTXISVERMtT191SSUED. � � / � `G �
w �IHAVEANDWILLMARrtAMWORNERSCOMPENSATqNINSUFLWCE.ASREOUIRFOBVSECTION '
O __ 97000i7NELrBORCODEFOXTHEPERFaRMM10EOFTHEWOiiKFORY/HIQiiHISPERMRIS
, � ISSVED.MYWOPo(EH500MOENSATIONINSURANCECARR�ERI�yDPOIICYMIMBERME CONSTRUCTION - - - - - _
//
� C�RRIER_ ' II' �- /l1GY PLANREV�EW
Z va�crwue H /Z�/�s Z �-5`� EIECTFiIc _ .
¢
��� � �nasEctar�r�wieEoa.n�nocnE�raarsraqa�uu�a�noallts�S+ao�oa�ssF UMB �D /
Z 1 CERiICV THAT B!THE VEFFORlAANCE OF T1E WOi1K iOR w11ICN TMiS DERAaT 6�SSUED,1 MECHANICAL
' C7 SHALL NOT EMPLOY ANY PEHSON IN�NY MANNER SO AS i0 BECOME SUBJECT i0 THE_. _ i
_ ._ (fj _ _ _NORKERSCOMVENSA�IOryU'NSOFCALIFORMI�ANO�GREE7MAT�F�SMOUL09ECOME _ . INSPECTIONFEE __ ' - -- _ ___ __ .
� SU&)ECTTOTXEWORKEHS'COMOENSATqNDROVISION50FSECTiON97o00GiHEUBOR /�
. S coo�,i y+w,ronn�vnn�corar�r vnr nasE Pnohsans.� J ISSUAN � �j�j��
� W �f+tX►��`f�.���lL� SMIP � .. . ...
DATE APPLiCANT:
, �� WApNtN@FAILURETOSEWAENORKERSWIAVENSATpA1COVERAGEISUAIIAWFU,ANDSWU.LBE� ENERGYP/C
} SU&1ECTFNEMP�OVERTOCRIMRlALPEN11TIE9MlDCMLfWESUPTOONEFM1R.UREOTMWSNIO ENERGYPERMIT �iL��1998
DOLLARS(f 100.000).M ADDITON TO THE COST OF COMPENSATION.�AMAGES AS PROVIDED FOR IN ��
J� SEGT�ONl70lOFTHELABOFCOOE,R7TEREST,M1DAtTORNEY5fEE5. " ' - RETENTIONFEE: � � - "- ' ' ' ' - -- -
I O ' CONSTRUCTIONLENDINGAGENCY PRE•ALTFEE: CI � MONDI3
� IHEHEBVAFFIq1.lUJDEROENhLTYOFPERIURVTHATTHERE15ACONSTRUCTIONLENOIN(3�CENCY RUti.nrNc";AND SAT'E - � . �. �
� FOR7MEPERFORMANCEOFTHEWORKfORWHICF1THiSPERMITISISSUEO�SEG00%,CIV.CJ.
- Z- _ - ' - --. . „ _, �
W
� LENDEiYS NAME .
I F� LENDEtfS AWRE55�-� � - -�' � '- '� - - '
' � TOTAL FEES
. W ICERTIFYiHATIHAVEREA�iH15MOLICATIDNANDSUTETHATTHEABOVEMFORMATqNISCORRECT. �
p� IACRfETO�fAPLYMATHALIGTYANDCOUNTYORD�NANCE5M1D5TATEUNSRELATINGTOBUIL�ING� � " -
� CONSTRUCTION,/�NOHEREBYAUTHORI2EREPRESENTATtVE50FTH15COUN7YTOEN7EFU70NT11E -
N 2
Z ABOVE�MEMIONEU fROVERTY FOR INSPECTpN PURCOSES. . 7
o - COMMENTS ! I
� --' �J c! r � j�nJ�.�
5
�"- � OER IiTEE (PRINT) J -� ' . ._ . .- . .
CA /
� � SIGNA7VREOFPFRM' EE
� � RECPT.N0. PAID BY VAUDATION�
� - WHITE—Oepartment Copy,YELLOW—Finance Copy,PINK—Assessor Copy.GOLDENR00—File Copy,GREEN—Applicant's Copy • ,
, � N � ���
�Zm � t^ cnm
� � 9 p9��O � 0 9 Oqn �
_/ Ny � p O�v O�t� .aC�, � � y �
..._ m2QGG �� N9Oq � � ,.
. - NO mq� 0 � G� ZC� Z 5 m �z0 r � N
,� � m� 9 < �' mro� m�c�z�"r�{�m � ca '
'n -�` �z$' b -��m��N����4` va�%ym iof
2 y r,r.Y,r •o �� f Z C N G 2�.n� Z, �, l�. '` C�' �
n.` 1' r r = C� 9 %� y yNrvO �� 9 G� , v �-. ��% •
� •. .��'� :_'f .p r �n O -�f 2 T G �l Z t,�2 � '"� : �
� ' .✓,�?, � r .mY:2 Nr' � �� � G� Nn+ O .;� .'
'i �.�, ' / G n � N� �t Z � Z ' � Z ' `�'
cn ;� '., R► , ,?. � v� , , �' y =- �, ,� G
�
R�� " � �� ��': �j � �' %� � ��
�� , N r ..
�o v' � � �,}.
�� s� � �
G� "i ; � i'
N� � � � � � �� �f���/
m^m , ;,, ' , • sp�p
:�" ;� t� -�
;�� c: � �i �
,,, �� � •" - l' � ,� O I'
t, f �'�4 /r; � � y Q P Q ��
9 �1
�. ;.,1 ", ~ � p m A '2�?mo '° 9 T p p G7 �
� 1.� ,,- � .� � a2 °� c�� o -+ ��ro� �'� � O � .
� +, � �,�,.• �r. ..,, 00 0 ooNc� iv pZp�'nt� ooN , T 7�
m -n o r z y v o T � 'O �1
; /�r�: � -n � v2a r' r Z 2 2 � 9 •
'` . 0y � 22 p r O �1t�nr � 9 � y� m� � �G C� G �r .
- i Zm9mr � NmT m �za.nv 'v .(,1my ��n QZO n
- ` ' G r n 2 ., Y n a O O p � q CA�Y a � ' - -
' 9cm = �° �'� �' ��� ����, � �Jm -+ c. :
. ` . . . � N m�Z N p N N �i 7 2%i
r
b � Z�
_ � � i � Q ,n r � �) ��.� _ �� •
r �
� '.
t �� f � �
l' �
!� , . :� �.r, •.. , � .
i.
. , t' L� ��,.
� `��' � � �_
�� . Y'_ l� j •
�, .! l ( f,
���% �
�f� � '� _
` .. ' ,,j �i,
�
�
�
�
�
