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HomeMy WebLinkAbout10754 " CiTY OF DIAMOND BAR ,f•'J'" ��'` COMMUNITY DEVELOPMENT DEPARTMENT,.�'�,.._;-� J �,,.� . 21660E.CopleyDriveSuitet90 ✓ PR�SS (909)86D-3195 Fax(904)R61-3117 � (� "'"'� BUILDINGPERMITAPPLICATION ,` �`._--/�' �/ FIRMLY � � JOBSITE /�+ � r APPLICATION PERMIT r /C � a ADDRESS �.0 C�"'"Z' J �Ci/CC,��i P �°�� U� , p DATE NUMBER # � � APN LOT TRACT �SSUE TYPE OCC � p OWNER ��-�i c:N j�,q„C'C. L�LC� DATE _ CONST._ GFiOUP p p ADDRE S ��� ���`'� �h-' I • '" � ZONING SETBACKS � w � �� FRONT RW__ ❑_.__,____ � cirvd.[,=1� � h�E ziP� �a� TEL.�I '���2.��- � o APPLICANT _ TEL. S DE/SIDE STREET RW,_. Cl_ ____ E ¢ CONTRACTORs'"'�` d N r t) C�fe76`I SIDE _ u.___ _ � � ADDRESS:3G?3 �� E29cN'n S� PROPOSED USE _ � � CITY`'�c•��4++f�: IIP��.:� TEL.�' " .+.� �tit�— w ARCH/ENG/ , z DESIGNER , w NO.DWEL. NO. NO. a ADDRESS � CITY ZIP TEL. UNITS ___ STORIES BEDROOMS i � — — � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BI:ILpER DECLARATION SFq/ADDlREM O p 1 HEREBV AFFIRM IINDER PENALN OF PERJURV THAT I AAA[%EMPT FROA/THE COMRACTORS U� G7fa9B/CHipOfl W CENSELAWFOflTHEFOILOWIN�REA50N�5EC.�oJ1.58U31NF_SSANOPROFESSIONSCODE:ANYCITYOR (n U CAUNNWHICHREOUIqESAPERMITTOCONSTRUC7,AL7ER.IMVROVE,DEMOLISH,ORREPAIRANYSTRUG � w TURE.PflIOR TO ITS ISSUANCE,AL50 REQUIRES THE APPLICANT FOR SUCH VERMIT TO FILE A SIGNED W PBt10ID8Ck STATEMENT 7HAY HE OR SHE IS LICENSED PUNSUANT TO THE PROVISION&OF THE fqNTRACTORS ll- �, CENSE LAW(CHAPTER e�COMMENCING WITH SECTION 700a)OG�IYISION 30F THE BUSINE55 ANO PRO� � V' POOVSp2 FESSIONS�E)OR THAT HE OR SHE IS EXFMPT TMEREFAOM AND THE BASIS PoH THE ALLEGED EXEMP• ,s � TION.ANYVIOLATIONOFSECTION7031.58YANVAGPLICANTFORAPEPMITSU&IECTS7HEAPPLICANTTO � Re-Roat 'J � A CIVIL VENA�TY OF NOT MORE THAN FIVE HUNOqED�OLLARS(5500).): Z OI,ASOWNEROFTHEPROPERTV,ORMYEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, Z WILL DO THE WORK,AN�?ME STHUGTUR[IS NOT IN7EN�EU OR OFFEREO fOR SALE(SEG 7044,9U51� , J C'01nRIBfCidl � NESSAND PqOFES610NS CODE:THE CANTRACTOHS LICENSE LAW OOES NOT APPLY TO AN OWNEfl OF j PROPERTY VJHO BUILDS OR IMPROVES THEREON,AND NRiO�OES SUCH WORK HIMSEIF OR MERSELF OR � THROl1GHHISORHEROWNEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMENiSARENOTINTENDEDOR , m W' OFFEREDFORSALE.IF,HOWEVEH7HEBt11LDINGORIMPROVEMENTI55IXDWITHINONEYEAfiOFCOMPLE- 9 '0� TIDiv,TriE OWNER�BUIL�LR WILL HAVE THE BL'RDEY bF PRC`JING THA?HE OA SHE DID N.OT BU!LO OH "— p � IMPROVE FOR THE PURPOSE OF SALE). p ,w ❑I,ASOWNEROFTHEPftOPERTV,AMEXCLUSIVELYCONTRACTINOWITMLICENSE�CONTNACTOR3 — - � •�• TO CONSTRUCT THE VPp1ECT(SEC,7064,BUSINF55 AN�VqOFESSIONS CADE:THE WNTHACTORS LI- VBI�dt10� _AQI.ARF.A__._,_�___ � W CENSELAWDOESNOTqPPLVTOPNOWNEflOFAPROPERTYWHOBUILDSOHIMPflOVESTHEREON,RNO �; \YHOCONTRACTSFOHSUCHPR0.IECTSWITHACONTRACTOR(S)LICENSEOPUPSUM77TOTNECONTRAG pUANTI7Y DESCRIPTION FEE �. TOflSLICENSELAW.). � 0 ❑I AM EXEMPT UN�ER SEC. ____ B.8 P.G FOR THIS REASON U � � � " _""_ "__""_ � u"= DATE__ oWNER__ _"....._—'_ � U z` � W 1 ¢, LICENSED CONTRACTORS DECLARATION ` W 2 I HEREBY AFFIRM UNDER PENALN OF PERJURY THpT IAM LICENSED UNDER PNOVISIONS OF C���QQQ TEfl ; � � 9(C01AA1ENCING WITN 5ECTION 7000)OF DIVISION 3 OF THE 6USINESS AND PHOFESSIONS CD� Z x; MY LICENSE IS IN NLl FOFCE AN�EFF[CT, m � LICENSE CLASS�'���-S _ LIC.NO.���� ___ � � � ~� DATE '���'�''��, ._ CONTRACTOR�`✓Y/�G:°WY��j^��d�_ .', d U •W., � �� WORKERS'COMPENSATIONDECLARATION 7/1�/ " � � � � � IN[RE6YAFFIRMUNDERVENALTVOFPERJURVONEOFTHFFOLLAWINODECURATIONS: Z i '—'_ �' _IHAVEAN�WILLMAINTAINACERTIFICATEOFCONSLNTTOSELF�INSUREFORWOftKEfli' _ � Q CAMPENSATION,AS PROVIDED BV SECTION 370a OF iHF.LABOR CODE.FOfl THE PERFORVAANCE �U OF THE WORK FOq WHICH THI5 PERMI715155UED. � � x � �;_I HAVF.ANO WILI MAINTAIN WORKERS'COMPENSATION INSURANCE,AS RE�UIRED BY SFCTION � O 3?0o OF7HE L4BOR CODE.FOR THF_PERf-0RMANCE OF THF WORK FOR WHICH THIS PENMIT IS _ — ISSUED.MY WORKEfl5'CAMGENSpTION MSURANCE CARflIER AND POLICY NUM9ER AflE: CONSTRUCTION � S > cnaaiea �L�%�L/-' A ���� _ -- PLAN REVIEW - ---C���_.�S� --� ---- '1 � POUGWNUMBEfl_,_�7.ja�_.. ELECTRIC "�� � � � ¢� 1 ""_" —" _ w: (fHS5EC1%7NN��NOTBECOMPLETEDOFTEPEMYTISiYNiIXJEFIUWREDWUJJIS(f10U)OR } PLUMBING ,�-- Z 1 CERTIFY THAT IN THE PEFfOflMANCE OF TtiE WORK FOR WF71CF1 THIS PEflMIT IS ISSUED,I MECHANICAL ._.�5,,_____�: 'v ,_(},, SNq�(.NOTEMPLOYANYPERSONINANYMANNERSOASTOBECOAIGSUBJECTTOTHE (/� WORKERS'(:OMPENSATIONLAW50FCALIFOHNIP,ANDA6REETIiATIFISNOULDBECOME INSPECTIONFEE _.____. � = SU&IECTTOTHEWORKEHS'COMPEN5ATIONPROVISIONSOFSECTION37000FTHElAf3OR �-�--r� CADE,ISHALLFORTHWITHCOIAPLVWITF/ E VISIONS/`� ISSUANCE ,__ '�_��__,___�'�.�__ O //'��' . p DATE: I��`� APPLICANT: �'���4 SMIP _"___'._____'__��_ 'J WARNINGFAIWRETOSEIXIREWOpKEFiS'COMPENSPiIONCOYERAG[ISUNLAWFUL,ANDSf7ALl8E ENERGYP/C ____._______.___ _ �y„ SUBJEC7ANEMPLOYER70CRIMINALPENAL7IESANDCIVILFMESUP70�NEHUNDREDTHOU6AN� ENERGYPERMIT � DOLLARS({1o0,00o�,INAD0ITIONTOTHECOSTOFCOAIPENSATION,DRMAGE5A5PFiOVIDEDFOflIN -------�----------- �/ �' SECTIDN31a90FTHELABOflCODE,INTEREST,AN�ATTORNEYSFEES. RETENTIONFEE: T / � � ___'"" -'___ O CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � �. IHEREBVAFFIRMUNDERPENALTYOFPEflJURYTHATTHEREISACONSTqUCTIONLENDINOAGENCY _ _ _________ _ FORh1E PERFORMANCE OF THE WORK FOR WHICH THIS PEqM1715ISSUEO�SEC.3097,CIV C J. Z, W ___ __'__"__" LENDER'SNAME_ __ _^ _—___. �� LEN�Efl5A0�RE55 ___ �_ ��' ICERi1FYTHATIHAVEqEADTHISAPPLICATIONANDSTATETHATTHEABOVEINFOHMATIONISCORRECT, TOTAL FEES �W' I AQREE TO COAIPLY WITH ALL CITY AND COl1NTV OROINANCES AND STAtE LAWS REL4TING TO BLIILDING � CONSTflUCTION.AND HEREBVAUTHORIZE RLPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE �----��/ , � /� -/ / ` n L ABOVE-MENTIONED PROPERTY FOR INSPECTION PUHPOSES. Aw.. /1 I.I i flMMENTS ;{.__...�.,.�..� �� n q i[i-�•. � C'�►�-�s ���6.e r7� �k^'�'� ' ---- � -- -- m PE E(PflIM] � �,�R3 /'���- �' �'-'�`t .:� -- � . (n� 5 IITURE F PERMITTEE OATE I � RECPt NO.._ _ PniD BY ` ALIDATION_ �� . 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