HomeMy WebLinkAbout11431 (5) ;--�,
• �'`�- CI'I'Y OP DiAMOND BAR
�'f-.1-
"' ' ' COMMUNI'I'Y UEVELOPMI;NT DEPARTMP,NT
� A1 �-:.¢ ' 21660 L.Copley Urivc Suitc 19Q
(909)860-319.5 Fax(909)8G1-3117 PRESS
� BUiLDING PERMl'1'AYPLICATiON FIRMLY
r JOBSITE . M1 r a � Sfi?I � APPLICATION � � `., C, pERMIT�� P/C '
a ADDRESS_����� C������.sA�C;�'� �y � � (
� c� — --r--�� DATE ----..._..._lY -- NUMBER.. - ---- # _`--
� APN LOT_ _ TRACT.... ISSUE 7YPE OCC
'- DATE __.,_.,___.._CONST._____ _._____ GROUP
� p OWNER �JS��_ �/zYI __ —..�.
`� ADDRESS Cs" ��'L. " �� C
o �;,�i� r%`��y�_�(-'F' /h!�__1f�__ ZONING SETBACK
� RW L]
� z CITY /jil�A.1�;w9�;e.�'yy/,�IP�Cy. TEL�i_` .��;, FRONT _
� APPLICANT �-,--��� TEL." ` �:fl�>.7'1 REAR -__------- n --
i � �_ -- ! SIDE/SIDE STREET----,--_----_— RW LJ-._----...._
m CONTRACTOR__�.
� � ADDRESS���t;k�� -�-- .� - --` SIDE ----------- ii---.—--
� CITY_br� ' _ ZIP�v�,S'A` TE ��.__��/ `�j�] PROPOSEDUSE ` _ __` __�
w� ARCH/ENG/ ^�``� �� :_._....� _.�l ---..._..- --------,._.__...
� DESIGNER�L-- r-� •--�G/vG,- -- ---- -------
a ADDRFSS �- � NO.DWEL. NO. NO.
cn —--- --- ��-;— UNITS___ STaRIES ____________BEDROOMS
� CITY_...----- ZIP----- TEL��/��✓;�,--�-�'� —
� ` DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
o. OWNER-BI;ILDER DECLARATION SFR/ADD/REM
1 HEREBY AF'rlqM UNflffi PF.NALTY OF PERJURY THAT I AM F%I:MPT FROM THE CONTNACTORS LI� Gara B/Cal Ort
LGL CENSEiAWfOHI!if�OLLOWINCHEA5ON�5:'C.'lnY158USINESSANUYfi0F�5510NSC01)�ANYCITYOP (n 9 P
•U (,`OUNTVWHICHRE�UIHFSAPCf1MITTOCONSTRUCT,�IIER,IMPROV[,DCMOLISH,ORREPAIRANYSTRUG �JJ patio/Deck
� NFlE,CRIOH i0 ITS ISSUANCE,Al SO fi[pUNES THE APPLICAN7 FOR SUCH GFRMIT TO FILE A SIGNED w
� �� S7ATEMENI III�YH�p(i SME;5 LICF.NSEO PUHSUANi TO THE?ftOV15{ONS OF 71{E c;ON1RAC�ORSII- � - —
. jCENSE LAW(CHAPTER 9(COMMLNCING WITX SECTiON�o]o)OF DIVISION 3 OF THE OUSINt55 ANJ PRO• POOUSp2
' FESSiONSCOUE)OiTHATHEOR511tISCXCMP�7'H�REFflOMANDTHtUA:iISf'ORIHLAU.EGf:DEXEMP� (� --
X V TIOY.ANYVIOLltTIONU�SCCT1047031.58VANVAPPLICANTfOHppER1.11TSU0JeCTSThIf:APPLICANTI'D Z Re-Roaf
� ACIVIL P�NA?iV OF NOT MGHE THAN FNf Hl1A�flED DOLLAHS(5500�.)' -
O ;,71,ASOWNEROFIH'cPROPERN,nRMYEMPIOYCLSWITHWAGESASTHFIRSOLECOY.Pf'NSATION, � COfllmefCial
��' W��l DO THE WORK,AND THf',5(Rl1CTURf IS NOT IN7 ENULD Ofi OFf-LRCD FOfl SALE(3EG 704<,!fU51, _J
� NFSS pNll VfiO1�ESSIO�S CODE.THE CON IRAC7(1p^IICENSE LAW DOEG Nf)'f APP:Y 10 AN OWNLR OF
PROPEfiTYYR10dI11LIlSOfiIMPFOVESTHEREO�,nNDWliO[IOESSUCHVJORKHIMSELFORlILFlSEIfOR �
wiHROUGtIHiSOflHEFOWNEM2LOVCCS.1'ROVIDEDTHATSUGI!I4vppVCPAE`1TSAIiENOTMTENDE�OH m
OFFEpEU fOH SAL E I�,HOWEYER.TI IE BUII.UING OR iMPflOVEMENT IS SO:D WI i IiIY ONE YGAH OF COMPLE-
0" TIO^!,rHE OVlNER 7U!!flf:W.WIIL uAVF.THE BURDEN(Jf PROVIN,THAT HE OR SHE 010 NOT HlII1.D OR
z IMPHOV[f041HE PURPOSE O�SALE).
� �I,ASnWNLHOfTHEPpOPERTY,AM1IEXGI.USNfIVCONTftACTINGN'IIHLIC[NSEIIIX).YTMCTOFiS
W: -
(L. TO CONSTFUCTTHE PROJtCT(SEC.70A4,BUSINES^u MU Nf70FE$SIONS CODE:THE CONiRAG10H5 i.l- V81UBti0n AUJ.AHEA.________
� A W CLNSCIAWOOFSNOTAPPIVTOANOWN[f10FAPROPERTYWIlOHU11.1)SOf11MPROVESTHEREON,AN� _.-- - ----
�; WHOCONTRACTSFDfiSUCHP{iOJECTSWITHACbNT(IACI�R(S)LICENSEDPURSUANITOTIIECONTflAC- QUANTITY DESCRIPTION Uu � ,,Q FEE
IORS I.ICENSE LAW). ;
� ,Xe. .. .. -.. ^• �>y+ i
y /' _,
,Q: �I I AM EXEMPT UNDF.il SEC,_._ __ _,_, __ B.8 P.C.FOR THI5 REASON Q a!'O yd • YK � �� • � �•
� � ,-%��� �'E G G
�' -..-----.._ _.. .__..... � / +� � �1 , ;•v , r
-- ---
� - DATE__... ."_" '. _GWNLFi..'_ " . . _-_" �--
0; / ' �
� ¢. LIC[NS[D CON'fRACTORS DCCLARATION ' � � � � � �. ,-ti/ �
� CL I NF.f1CAYAFFIRM UNDEfl P�;NALTV OF PERJURY THAf I AM LICFNSED UNDER PROVISIONS OF CHAf'TEP �
��, 9�COA!MEN(:INCWITHSECTION7oG0)OFf11VISIUNJOFTHEBl151NE5SANCPHOfESoIONSCOD'c,AND
X� MY LICENSE IS IN FUI L 1 OHCf AYD EFFECT -
W✓ ' �
; �'. UCENS[CIAFS C.``Y�'.._.. __LIC.NO._�'y�.�,/�___.....
. U'. DATE._._��,�7 �__.� CONTRACTOR �� [G`"[���_ _
ttl' / q
� � WORKFRS'COMPENSATION OECLAFlATION �I�'�� � Q
��
� IHEHfRVqf�IFlMIINDERPENALI'YOFPF.fiJURVONEOFTHEFOLI.OWINGDECLARATIONS:
�.
j0 __ __I1IAYCANqWIILMNNiAINACI�NTI�ICATEOFCONSfNTIOSCIF-INSUREFORWORN[fi5'
] � COPANf:N5AI104,ASPROVIpEUBVSfCTION'S7UUOF711E1A[iC�1C07�'rORTHePERFORMANCF
U�TI IE WO(iK FOR WHiCH�HIS I'f.RMIT IS ISSl1EU. A
� � ' V' � �• + .
W __IHAVEANDWiLIMAINTAINYIOHKCHS'COMPENSATIONINSUf1A�(:E,ASRE�LIIRE�BY5EC7iON
Q3/UUOFTHELIIPOIIGODE,FORifIEPFfifORMANCEOFTHEWOHK�ONWHICHTHISPERMITIS
_ ISSUED.MY WOi1NER5'CONPENSATION INSURANCE CMRIEH M1NII I'OLICY NUMBERAflE�. CONSTRUCTION `
e .., e _,..___
. _ "
` '___ __.. .
jcn�N;c��- �-- -- --------.... __.--- LAN eW v� G .�'(' ` � -
� - ...�- -- � .-- ._ .._ :
� POUCYNUMBER �
' .z .- -.._ _._._...._ ELECTFIC ---.. t C.i , �
Q — '-
� �IHi55[CIIONNC-mNOTBEW.Nfi.f(EOOFTHEPEfUA(1'ISIOR(YJfIIUYGRED�OlL1qS�S100JORlE55J PLUMBING _,__._ _ ___ _
Z ICERTIFYTHATINTHEPERFOHMA�CfOFTHEWORK'rOpWH1CIVTHISPERA�ITIiISSUEU,1 MECHANICAL
. C� SHALLNOTEMPLOYANYPEflSONINANYMANNFflSOA5T06ECOMf5U8JfCTTOTHE --"---
.._ _ •
Q, XE,IIS�L'F�T�APPLOICANT:W�HIT�E�PR�VISIONS.TNAT�FisHou�ooEcoMr:......ry � ISSUANCONFEE __-,�t� p�;`' �; "_ �.�,._.�
� DATE; SU�&'ECITOTHI.WUfiKERS'COMP�"NSATIDNPROVISiD�50F51:CilONa]ooOFTHEIABOR �+A
O • ' r--^�""""_.""---+•_ SMIP Y. . [i .,
� ENERGY P/C
4
�, ._� U.ti!:'� �----...--
� WAIiNING�f'AILURE TO SEf.URE WORKER�CUMPINSATION COVEftAGE IS NL4WFUL,AND SHALL BE �yiy'}, E ___ _
SUBJeCT n�J[MPLOYLfl TO CRIMIN�L Pk�NALTIES AND GVIL FINES UP TOONE HUNORE�TVIDUSqNO 11 p '
� i)Ol1.ARS(5100,000�,INAUDIT70NTOTh1ECOSiOfCOMPFNSAiWN.DAMAGFSASPFOVI�EDFOHIN ENERGYPERMIT __ [ .
J' S[CTIONi7080FTHELAUURCO�E.IN71:fiLS7,ANDATTORkEY'Sf[ES. �+ �
; o� RETENTION FEE: .____ ._ Z,s�
�` CONSTFUCTION LENDING AGENCY pRE-ALT FEE:
O' - ---- ---- --------
� �. IHER�UYAI'FIfiMUk�ERPENMTYOFPERJURVTNA7TI1Efif:ISACONSTRUC�10NlE.NUINf,AGf.NCV
� �' FOH THf f'[(i�OPMANCE OF T11E WORK Poq WI�IIC11 T1i15 f'ERMIT IS ISSl1ED(SCC 3091,(:IV C.). '-""' ' ""-""""-
� .-_ -
: W '"'"_ ' ...—.. .."_
_� LENDEfi'SNAME_ �
� __ _ "_'"'_
H L[NDER'SA�UHE;S _-""--'--'—
w� ICEHTIFYfHATIHAVERE�D1HIiAPPI.ICATIONANUS�ATE7MATTHEABOVEINFOHM��lON15[:OfiR�CT. TOTAL FEES .(7
�� IAC3FiEETOCOMYLYWITiIAI.I.CITY�N�COUNfYORDiNANCESANUSTA�EIAVdS(if:LATINGTOBUILDINC
CONS�Fil1CTION,AND HEHEf3Y AUTHOFIZE ftEPHLSf NTATNES OF THIS COUNTV TO f:Nl l:R UI'ON THE
�� AAOVE�MENTIONF.0�fiOPERTV FOR INSVECTION�URPOSES
Z,
n MM�NTS
� --- � -- -..'----.._.
.� , . �,,--�,,�@, �.
� - ---- -- --
--- —.�ilC_. '�,�;... .__ --
� .. -----
� PERMITTEENAMF.�PHIYT) _ _ _ _
pJ �___'� `..�"' "'
"_—_
- � _-__ __ _ _ ____ _ __ ,
, _-_
� SIGNATUREOFPERMITIEE pATI: . --
_ � a"-G � RECPT.NO. __ ''� ___PAID BY �- VALI�ATIO��__
~ WHITE—DepartmeM Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENRO�File Copy,GREEN—Applicant's Copy
9____.,.�_..,,�.� . T m . . _ __ .... , . . _... , .
� F , t�� .i `____I_ i ._�e ..�,_ � � "" I r � a v� � i (s� � ' ! � i ���� x y�,�� ' T" � i i €
�"e tY � � � t ,r ,� � �; � 1 ' l r,�'� �.1 C�,.1�1 ,� r��r j � I ���^ .
t I � l.. .�. f J t I i.:{ � x
E .�, 1 � ��, . 'c , i I 5 .!y 1 � f ' i "1 9 i� ��'[t �
j � t) I , . . � � � '4'�4 ; 1*�` t � ` l kt! �. )� � �k�
e - • )I � � ' f � Y�� � 71 F �
} ` I '- ;' i h 4 � � � ,I r � _� �,��c r ,���i � o-, � � G
� �f,. 'R' ?��, �� � � . � � � fL � r ,L,"� s.� _ d . C' T _ t i 1 i 9 r � J i
� lE ,
� .C' � � � r : .s.
� � �.� � � I i` i ( � ( �i I z ' �,r �� ��' I � i ry' ��;t�
� � - � i ��� °, � � r.��s
�� .
i ' I - i � I � � � � � I ' ' i ( � � �
� � .� � � � j : � �� � , ��-- t - � ---,� - 5
, ��. � � � 1 ; ; � ' � -� , �
I � ; , � ; � � �,� ; , ( � � ,��; � � � ��,
: � , IR I I � I I `I`n I ' I I � ' !
� � �^i � � A\.k i �� ' � � I � _
S I � � � I � � i ! I I I �A 5
I fI � I
� � ' i � (! �$ � � ," ' " I ' � ( , 'n� � '. ..i—.� �._
' � ; � ( � � F ' i � � , � i ; 1� � � � � i , . t . f i � � .,
� � � ` C � , . �� � � . � �� I . , � � � ! � � � , • ; d�a��.
I I � ' i � � ' i � I � ' i � ( ( ! I�, { I � . I �.'.,a
! � I j � € I � I ! �� . ( • I I � �� ( : � � . . � ; � i ( ! i , i � e��
I � ; i � � ! , ; � � I ' i � � i �cs�"i �
-
, �
, ;
�i � " � � � � ( I � � ( � ' � ( �- '� ��w �
, ; i ; � 4 -
! i � , - -- �u
, ,
� i � l � j � � � � � � � � �
; f ' � � ! � i ( � ��- C . � - -� ' l T , �
' 1 E � � I � � � 6 � C � 4: i . 5 'i t I.' y 'fy` i ' � ' ��
� � I`� '. y l�-, � :t '3 . �^' [—
1 � � � � - . ; � rp�.+� 9 3 � � i: � a�� c i -_ r �s `w � 4' �r� t 5�'�� �'
' : i - �, ! � i I, • , ; ��.r� I .(" � ' r � I .. � � I ; ,�
r4 ) I ` �' � I.0 � CF�i-! F � .� � �`
! ( � , .
� �dn
1 � I ! I F � 31 i . �. ,a I'i !' 3 1 , -, xJ f�I I=I " 7 �y.. Y 4g',�
� i % � � ( j I I �� IYf? I �;' 'I � �; r,i�r ' �' 7ir� : �� ��� � `t-, t � �� �� s
� , r I r, ,,a a
� ' � ' f j � � � i i '��-� _'f c. :�E� ,3 e ,;�a � �I �C' ,a Ti� �i����I {� . �`
� , i � � � . I � ) . � � � � a� y ( _� � ;C ��' � �� �� � .
� I ;
i � j j i ' � � ; i , I i , -�. �� ��' «
i � � - _ i Cn I r �
I , � ( ! I � , I ,
I . F . I I � , I �. i f mm I � � � � � Y,Z� �.
+ ' �
'' i '
� ! i � ��, ' , ; I � I � . : i �, , i i I ._ ..
' � � � '. : . I ; : � ' i �. I , .
� � � j � � ��, � � i ! � � � _' � _� _i � � - � �--� - .1_ �� � �
d�
i �
� � � � � i � I � . 1 � �� I I � � ....fi "�� � � . T �� r � --., � , �' .
i � � �` ( I I ; I i � � ( I i� ��
� ! I � � ' . ( ! ,i ; � . I � � i � � i I ' . � , I � � � I ' � '. i ��
, �
j I I �
{ � i i i i i
i
; �
, � , ; � - - - - ; - - , I :
I ; ! � � �
E . I ' I i , , .. I � l � � � ii � �
� f ' j I � I
� , ti I i � Ii � , iI Ii ' ) � ' � , � i ) �.
' I i i � j I i � I i ( ! � i � I i . ' � � I ' � i i I i j i � i �',°
' ' ! � i I � : ' ! i I . � � I � ( I . 1 �i , I I i � ,_ i � I i � •� �
� � ! i I i I ; � i i I I ! i ' ' ', I ( � I I , , i . I i � . i i j �` .
1 � � �
I
;_ f , , I I ' . . � �
_ .__._;__�_ . .._.�.__! .._.._��_� .� ._,.___�� ---_ __.i_�__� ._�. ._�.�_ _.__..'_.! ---__�__�._.�_�_� ..4._.! .I__,_.._!.--'�---_I__�._."..__.._I._.__.___ � E ." , " _