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Home My WebLink About11-302 (5) �� CITY OF QIAMOND BAR DEPARTMENT OF COMMU1vITY&DEVELOPMENT SERVICES 21825 Copley Drive,Diamond Bar,CA 91765 (909)839-7020 Fax(909)861-3117 Building Inspection Hotline(909)839-7027 ��E$$ �� BUILDING PERMIT APPLICATION FIRNiLY N JOBSITE �t� DATE CATIOPL. � `� ( 1 l NUMBER "� vU#lC I 1�- � ��1, o ADDRESS�„ ll`is/ C�Ii�G/V �SP�I/YGl�� . � f• I `� APN LOT�TRACT DA EE �- / O ST. J,r OCC _._�__�_ GROUP p OWNER • i ST11v ��L '� �G4-7V ��1�4�� n ��j ZONING SETBAC S o ADDRESS ' Z cirv��YAt.�►11�IT ziP 'If7�9 TEL. REOART RW p❑ p APPLICANT TEL. SIDEISIDE STREET RW ❑ m CONTRACTOR �Z' " � SIDE ❑ ¢ AooaEss - ' �T ,mP�P�u�rnEnJr ,F�� cc 't PROPOSED USE� r � CI � •�� 14tZ� ZIP�'f� TEL.�i S��L GV L:� ,f'L�Tf-11L z DRSIGNER/ ��'`�� NO.DWEL NO. NO. � ADDRESS 4if'�: Y��I.dT � UNITS • ' STORIES BEDROOMS � CITY �L n7L�N�� ZIP �� TEL.��:�56�7'I 1S( � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDEA DECLARATION SFWADD/REM, O p I HEAEBY AFFIRN UNDEA PENALTY OF PERNRY THAT 1 MI E%EMPT FROA1 7ME CONTRACTORS l4 Garege/Carporti ' W CENSE U'N FOR THE FOLLOWINO REASON(SEG.7031.5 BUSWE55 PNO PROFESSIONS CODE:PNV GTY OR (n ZCOUNTyWHICHf1EWIqESAPERMITTOCONSTFUCT.ALTER,UAPROVE,OEA1011SH.ORHEPAIRANYSTRUC� {jJ P8t10/�BCk w NRE,PRIOF TO ITS ISSUANCE,AL50 FEOUIFES THE APVUCANT f-0R SUCH PEWIIT TO FILE A SIGNED w � STATEMENT THAT IiE aFl SHE IS UCENSED PURSUPNT TO THE PROVISIONS OF THE CONiRACTORS LF � CENSE LAW�C/iAPTER B(fAMMENGNG WITN SECTION T000)OF D��SqN 3 OF TiE BUSINE55 AND PRO- LL' PooUSpa O FESSIONS CODEj�R THAT HE OF SHE IS EXEMPT THEREFROM AND THE B�1515 FOR THE ALLEGED EXFJAP- (� • V TION.ANY VIOUTpN OF SECTION�o]t.5 BV ANY APPLICANT FOR A PER41�T SU&IECTS THE APPUCANT TO Z Re-Roof � A C1V1L PENAITY OF NOT MORE TH�N FNE HUNDRED DOLURS�SSoo).): _ 0 ❑I,ASOWNEROfTHEPROPERTV,ORMVEMPLOYEESYATHWAGESASTHEIq50LECOlAPENSATION, � COmm0fCl01 Z WILL DO 7HE WORK.ANO TNE STRUCNRE i5 NOT INTENDED OF OFFERE�FOR SAIE(SEC.�oa�,BU51- J . � NESS AND PROFESSIONS CODE:THE CAMRAGTORS LICENSE UW OOES NOT APPLV TO AN OWNER OF � � FROPERN VhlO BUILDS OR IA/PROVES THEREON.AND NRiO DOES SUCH WORK HIMSELF OH HERSELF OR [L TriROUGH HIS OF HER ONT!EMPLOYEES.PqOVIDED THAi SUCH UdPROVEA7ENT5 ARE NDT PiTENOED OF m w OFFERmFORSPLEIF.HOWEVEii,7/1EBULDINGOqIMPqOVEA/EMI5501DWfTHWONEVEAROFCOMPIE- 0 TIDN,THE OWNER-BUILDER WILL HAVE 7NE BURDEN OF PROVING THAT HE OH SHE DID NOT Bllltp OR . Z IMVFOVE FOR THE PURPoSE Of SALE� � ❑I,AS OWNER OF THE PROPERTY,AM EXClU51VElY GON7MCTING WITH IIGEN5E0 GONTRACTORS � To CONSTRUC7 THE PROJECT(SE�.7oa�,8U5INE55�NO PAOFESSIONS COOE:TME CONTMC7oR5ll- ValuBtiof� �1 ADJ.AFlEA W CENSE LA'N DOES NOTAPPL�TO AN OWNER OF A PROPEFTY WHO BU�LDS OR IMPFOVES THEREON.AND Z WIbCONTRAC75FORSUCHPROJECTSWITHACONTRACTOR(S�LICENSEDPURSUANTTOTHECdNTRAC- QUANTITY DESCRIPTION FEE F— TOR5l10EN5E V+W.). . ]C J '/,r ..{. I � ❑I MI EXEM7T UN�ER SEC. B.6 P.C.FOR TNIS RE0.5C1N Q � �N k. ( uG 4 � � C t� a L ' � DA7E OYRIER U W � LICENSED CONTRACTORS DECLARATION �j � � I HEAEBY AFFIPJA UNOER PENALTY OF PERJUFV THAT I AM LICENSE�UNDER GROVISIONS OF CHAPTER �. d e(CDMMENCW(3 WRH SECTION 7000)OF DIVI510N 30F THE BVSINE55 ANO GROFESSIONS CODE,AN� z `X IJY UCENSE IS IN FULL FOFCE AN�EFFECT. ,a^��ry m � LICENSE CLASS LIC.NO. �L J �' I � F-- !��/�' l V DATE CONTRAGTOR�/-/.F�:r G'l.�I 4- . W ¢� WORKERS'COMPENSATION DECLARATION � r 6 � � 1 HEi�BY AFfIRM UNDER PENAL7Y Of PERIURY ONE OF TNE WILOWiNG DECV�RAT10N5: � - � � C/� / Z Q � v I HAVE AND wlLl MPJNTAM A CEFTIFICA7E OF CONSENT TO SELF�INSURE FOR WOHICERS' S Z COM7ENSATION.AS 7ROVIDED BY SEGTION I7oDOF THE V�BOH CODE.FOR Ti/E PERFORMlWGE `U ¢ OF THE�NORH FOR WHICN TNIS PERMIT IS ISSUED. � � w I HAYE NdD YIILL AIAINTPJN WORKERS'COM7ENSATbN INSURANCE,AS REOUIRED BY SEC710N Q 37no OF hIE IABOR COOE.FOR THE FERFORAIANCE OF THE WORI(FOR WMICH TNIS PEHMIT IS �i�: `L'� ISSUED.MV WOR)(ERS'CANPENSATION WSURNJCE CARFlIER AND POLICY NUMBER ARE CONSTRUCTION G7 G �� v " j PLAN REVIEW � '"1$� —1 S CARPoER Z aoucv wuueEa ELEC7RIC ¢ Q (i}{15SECfpNNE�FqTBE071.RLET�OF11-EPEPo.4TBFOiiONFF�FE�CU1!�If��'� PLUMBING y w MECHANIGAL �f Z 1 CERTIFY THAT W iHE PEP�-0RMMIGE OF THE WOa(FOF WHICH THIS PERMIT IS ISSUED.I (,'} SHA�L NOT EMPLOY M!Y PERSON IN AHY MANNER 50 AS TO BECOME SU9JECT TO THE � � 'MDRKERS'COMPENSATION LAWS OF CA�If-0RNIA,/�ND AOFEE THAT IF I SHOULD BECAME INSPECTION FEE SU&IECT TO THE WOFiKERS'C0IAFENSATION PROVISIONS OF SECTION J7o0 OF THE IPBOR . � e.i sfwl.wanivnM eornv�v win+��'+(��se a�ao��s`an�s,. ^ - �J ISSUANCE ^ �/—��, � Da7E: ��"_� TiT Y✓✓ I — �� L�/ SMIP � �YL� 0 APPI.ICANT: � . w ENERGY P/C --� WAqNWG FAILUqE TO SECURE WORKEAS'COMPENSATION COVERAGE IS UNUWFUL./�NO SHAl10E J � SUBJEG7 AN'cAIPLOYEA TO CHIMINAL 9ENALTIES ANO CNIL FWES UP TO ONE HUNORED THOUSANO ENERGY PERMIT Dd1AR5(5100,D00�.W AOOiTION TO TNE COST OF CAMPFJ�ISATION,DAMAdES AS PFOVIDED FOR IN J SECTION]70e OF THE I.eBOA COOE.INTEREST,AND ATTORNEY'S FEES. RETENTION FEE: ��O� � . w CONSTRUCTION IENDIN6 AGENCY ' P AlT FE � � � ��n� � 1 HEREBv AFFIRM UNDEF PEN,LLTV OF PERIURY 7NAT THEPE IS A CANSTRUCTION LENDWO AGENCV FOp TNE FERFORIAANCE OF THE WORK f-0R WHILH THIS PERMIT IS ISSUED�SEC.3087,CIV.C.�. Z W � LENDEFYS NAME � IENDER'SAOOFE55 �� J �� /� wI CERTIFY THAT I HAVE REAO h115 APPIICATION M1D STATE THAT THE ABOVE INFORA/ATION IS CORRECT. TOTA L F E ES �� 1/ d I AGREE TO COMDLY WITH ALL CT'Ni0 COUNTv OROINANCES IND S7ATE Uw5 REUT Wa TO 9UILOINO / CANSTRUCTION,AND MEREBY AUTHORIZE REPRESENTATIVES OF 5 CWMY TO ENTER UPON THE . ZnBOVE�MENTIONED PROPERIY FOR INSPECTION PURPOSES. COMMENTS . � �� L � ��' . J `. � - m PERMI�AME(PRINT) � ,-✓�n�✓►�+'�..�- �=i 1�'�I� t� G cc'i ' o � 'L vj SIGNANR�7ERMITTEE �AT� RECPT.NO. PAID BY � VALIDATVON 2 � WHITE—DepaAment Copy.YELLOW—Flnance Copy,PINK—Assessor Copy,GOLDENF Flle Copy,GREEN—Applicant's Copy . �� ,�E�� ,�� 9�V��'��`��'3�� 3D a � �,� .a� _ ti� „` �' � � . � , i. ' a� ;. m . "', , . . • . 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