HomeMy WebLinkAbout18278 (11) �•--
�� CITY OF DIAMOND BAR `� �
DEPARTMENT OF COMMUMTY&DEV�LOPMENT SERVICES ' "' �
,i �
�� 21825 E.Coplay Drive ��—���/ � —
�� (909)860-3195 Faac(909)861-3117 �r��� PRESS
����° BUILDING PERMIT APPLICATION F MLY
� JOBSITE ���j'� {_'CLyI•� lf,��QI Ll 'r)�'�%�� APPLICATION,...:/f.� , PERMIT P/C
r
o ADDRESS__ �"I l� �� � �✓ DATE �` � � �' NUMBER
�
�1 TYPE OCC
r° APN I_OT�--�-- TRACT DA EE � CONST. GROUP
p OWNER C�r�)'V !J/�;���IIi� �� l� �LG.
p ADDRESS� � ' L �� ZONING SETBACKS
z CITY � M�i/�_ ZIP � __��i TEL„R%'�'' '17�J!p � FRONT RW f�
o APPLICANT _ TEL. REAR r-
Z SIDE/SIDE STREET RW C
Q CONTRACTO,f� :� ` � � � ��a�!' _ SIDE C
Q ADDRESS G• 1 • - ) �— 1y�' _
� CITY���( , t } ZIP TEL.` Z.. � ; PROPOSED USE Z � S�LK, � t,�C ��I�-C ���ILDI/I�((7
o ARCH/ENG �
z DESIGNER ��
� ADDRESS NO.DWEL. NO. NO.
� UNITS_ STORIES BEDROOMS
� CITY ZIP TEL.__
� DESCRIPTION SQ.FT. FACTOH PSF ADJ.AREA/VALUATION
p� OWNER-BUILDER DECLARATION
p SFR/ADD/REM
p I HEREBV AFFIRM UNDER PENALTV OF PERJUPY THAT I AM EXFIAPT FROM THE CONTRACTORS LI- G2f8J8/C2fpOft
W CENSELAWFORTHEFOLLOWINGflEA50N(SEC.]031.SBUSINESSANDPROFESSIONSCODE:ANYGTVOR (n
ZCOUN7VWHICHREOUIRES4PERMITTOCANSTRUCT,ALTER,IMPROVE,DEMOl15H2ORREPAIRAI:VSTqUC- W patio/Deck
w 7URE,PRIOR TO ITS ISSUP,NCE,ALSO REQUIRES THE APPIICANT FOR SUCH PERMIT TO FIIE A SIGNED W
� STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRAGTORS ll�
� CENSE LpW(CHAPTER e(COMMENCING WITH SECTION]000)OF DIVISION 3OF TNE OUSINESS AND Pq0- � POOVSP2
O FESSIONSCOOE)ORTHATHEORSHEISE%EMPTTHEREFflDlAANDTHE6ASISFORTHEALLEGEDE%EMP- (�
V TION.ANYVIOLATIONOFSE:GTION1031.59YANYFPP�,.ICANTFORAPERMITSU&lECTShIEAPPLICANTTO Z Re-Roof
� A CIVIL PENALTY OF NOT MORE THAN FNE HUNDRED DOLLARS(SSoo;�.):
� OI,ASOWNEHOFTHEPFOPERTVORMVEMPLOVEESWITHWAGESASTHEIRSO�FCOMPENSATION, � CDmmBfClel
Z WIIL DO THE WORK.AND 1'HE STRUCTUFE IS NOT INTENOFD OR OFFEREO FOR SALE(SEC.]ad4,BU51- J
� NES$AN�PROFESSIONS C:O�E:THE CONTRACTORS LICENSE lAW DOES NOTAPPLV TO AN OWNEFl OF ?
PROPERTV WHO BUILOS OR IMPROVES THEPEON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
� THROUGHHISORHEROWHEMVLOVEES,PqOVIDEDTHATSUCHIMPROVEMENTSAftENOTINTENDEDOR m
QOFFEREOFORSALE.IF,HONIEVER,THEBUILDINGORIMPqOYEMEMI550L'JWITHINONEYEAROFCOMPLE�
Z TION,THE OWNEF-BUIL�ER WILL HAVE THE BURDEN OF PROVING THAT ME OR SHE DIO NO7 BUILD OR
� IMPROVEFORTHEPURPO5EOFSALE).
W
❑I,AS ONMER OF THE:PROPERTY,AM ExGLU51VELV CONTRACTING WITH LICENSED CONTpACTORS
¢ TO CANSTRUCT THE FROJI_CT(SEC.7D44,B1151NESS AND PfiOFESSIONS CODE THE CONTRACTORS LI- VelUetlOn ADJ.AREA
W CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTVWHOBUILDSORIMPFOVESTHEFEON,AND
= WHOCONTRACTSFORSUCHPROJECTSWITHACONTRACTOR(5)LICENSEDPl1R5UANTTOTHECONTRAC- QUANTITY DESCRIPTION
~ TORSLICENSELAW.). FEE
Y �'i
� ❑I AM EXEM7T UNDE�7 SEC. 8.8 PC.FOfi TMIS REASON Q � ,V�� ,Y- j/U � $�Ja
� onre OWNER F ! � '���i� C- r C�
z � ' � .�W� v � ��.. .
� LICENSED CONTRACTORS DECLARATION � r �G''r/ �,, ���� .
� (SV
I HEREBY AFFIRM UNDE{i PL=NALTV OF PERJl1RV THAT I AM LICENSED UN�ER PROVISIONS OF CHAPTER � ,)��
'� d 9(COMMENCING WITH SECf10N 7000)OF DIVISION 30FTHE BUSMESS AND P90FESSIONS CODE,AN� � S(yJ� L1I� �t y
WWV LICENSE IS IN FULI FORCE AND EFFECT.
� LICENSECLA,ss_C� �'( L� �77�'(� 7 % -: ' C- c�.JYN.-f�`,
� F- s-_._ LIC.NQ . �
� � ..- � C�N�.,
wDATE_-_�'r�(�I�7'�j' CONTRACTOR � +� {16�'L� � �t� � �C •
� W9RKEA5'COMPENSATION DECLAAATION C J ��. y� ,. • �
� [ri -N � .
� IHEREBYAFFlRMUNDEHP[NAL7YOFPERJURYONEOFTHEFOLLOWINGDECLARA710N5:
� I HAVE AND WILL M/JNTAIN A CEFTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
¢ COMPENSATION,Af'�PROVIDEDBYSECTION3�o00FTHElABORCODE.FORTHEPFRFORMANCE
Q OF THE WOPK FOR WHICH THIS 7ERMIT IS ISSUED.
Qw �1 HAVE AND WILL MiJNTAIN WORKERS'GOMPENSATION INSURANCE,AS fiE�UIREO BV SECTION
3�00 OF TME LABOR CODE,FOF 7HE PERFORMANCE OF TME WORK FOR WHICH THIS PERMIT IS
ISSUED.MY WORKERS'/Cy��MTPENSATION INSURA�NCyE�CaA1 R�R AND POLICY NUM9ERARE� CONSTRUCTION
j c.4RRIER � r�"1 l C �1.7/v� PLANREVIEW '
� POLICV NUMBE47_��.�_""�I..T�"' ELECTRIC
Q
� (iFIISSEC:KKJNE�IJOTBE00MPLEfEDOFTHEPERMRISFORONEHUN�REJ�OLLAR5�y10J)ORLESS} PLUMBING __
W
Z I CERTIFY THAT IN THE PERFORMANCE OF THE WOfiK FOR WHICH THIS PERMIT IS ISSUF�.I MECHANICAL
C} SHALI NOT EMPLOI'ANY PERSON IN ANY MANNER 50 AS TO BECOME Sl/BJECT TO THE
(/J WORKERS'COMPE�ISATION LAWS OF CALIFORNIA,ANO AGREE THAT IF I SHOULD BECAME INSPECTION FEE
? SUBJECTTO THE WORNERS'COMPENSA710N PROVISIONS Of SECTION 3]00 OFTHE LABOR
CO�E.I SHALL FORfHWITH COMPLY WI7H THOSE PROVISIONS. - ISSUANCE �
0 T /
�`p OATE:�'_�f'l'� APPLICANT:� `� � L.� ��� � SMIP .._
� �� ENERGY P/C
J WARNING FAILURETO SECIJRE WORKFRS'COMPENSATION COVEFAGE IS UNLAWFUL,AND SHALLBE -
� SU6IECTANEMPLOVERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDRE�THOUSAND ENERGYPERMIT
DOLL4RS(f 100,000),IN ADOITION TO THE COST OF COMPENSATION,DAMAGES AS PROV'.DE�F09 IN
J SECTION 3�OB OF THE LABOR CODE,INTEREST,ANO ATTORNEV'S FEES. ��
OC RETENTION FEE:
w
O CONSTRUCTION LENOING AGENCV PRE-ALT FEE:
� IHFREBVAFFIRMUNDEfiPf:NALTYDFPERJURVTHATTHEREISACONSTRUCTIONLENDINGAGENCV
FOR THE PERFORMANCE 01=THE WORN FOR WHICN THIS PERMIT IS ISSUEO(SEC.309�,CIV.C.). -�� -�
Z
W
� LENDER'S NAME
H LENDER'SADDflESS
w I CERTIFY THAT I HAVE FEAD THISAPPLICATIONANC STATE THAT TME ABOVE INFORMATION IS CORRECT. TOTAL FEES , )� �( /
� I AGqEE TO COMP�V WITH ALL CITV AND COJNTV OR�INANCES AND STATE LAWS fi[I.ATING TO BUILDING V�� �'
� CONSTRUCTION,AND HEREBV AUTHORIZE RE!'RESCNTATNES OF TNIS COUNTYTO ENTER UPON THE
Z ABOVE�McNTIONEO PROPC3TV FOR INSe ECTION PUFPOSES. COMMENTS
� -��L4� \! �C-lI2.G� --
m P RMITTEENAME(PRINT)
Q �� � �. ...-
� ,� �_S� � 2--� . ,�
� ATU FPERMITTEE �� DATE�
� ; RECPT.NQ PAID BY VAUDATION
. WHITE—�epariment Copy,VELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD--File Copy,GREEN—ApplicanYs Copy
i 2°�.� "S
a � ��� ��
_ � > I `'�rb i d'�ki.� , �"��i6�#�#��'�W X'.a 9`d
, '7-�S'dZ� .
$-� ro�- �
�/;��r�- � � �
_ ,�
,
Z �a��- ��� -
�� �� �
f. � ..� g . .a. g 4 ._ ,�,
. . ... ... .. . . ..V — : '9R ���... if ''L�'�` ' .. .. ... .... ._ .
'�-&�6�- �'�i�wue�� �� S�d�2.��.�tM>i�-� Gw�d�ri�;;t«1.'''( �r" ."1�td��L. �.:��*'t R�+�a'iC�''
'1-��•rz �tt?�c �cxrnv°c.r-n S�- I���-5 ,�t5St�5 A-�!!J �-c f���V��
.1.�c�-ot, nrt�t� Punww,� kP�Ro�- � K� t�'���
N� .
-Z_23•r:tZ �F i(�.� p�c�.x� �tw�.�) F,.{c,p.� ;:,,�; c�i�- Tc �u,5'V�c.c- Z"_ S���yc ���.. �EOt!> �Ea€�£��S
�j�-2�t•O� i.x�l (lJ3.Dd`� '7-2S�r,Z- (�x>�3cX- Stdc--�J 5� �".(�4 c5� _ ;
7-Z2-c>2 Q�.,"'��- � ��'Y ���- °� �
�; � . _ _
� ; � s :'� , --
� ��,� � ���� a�����aw�Q" ������� �
� � � �� ��€
� ��� �
� �
� �� ? � � ���� ;
�� _ ��� �� � ��r�� � _ _ _
� �� � �' p���� e _ _
,
,
� �'�5Y1." �4� ��"'�L„d ..
i ,. S � �ii�'��a�' . � . ..... . . .... .. . _.. .. .._. .. .. . .. ._ . -. .. _.. �.
-�p�
� � _ � � yss��� � .
���; i� �' �4'�' T> '��. ��.
yz <.,., i f le�. aS, `" . .. . . . . .. .. . . .._. .. . ... __ ... .. __. .._. . _.. - . ��,
�' � �� .... .. . .
� � � � j s � .� .... . . .... . .. .. . ... . ... ... .. .. ..._ —.. . .... . .. — .... .._ . . .
....���� ry �� il� "�'�'.�$ - �.
n' �' _ `
-" •' -
',..;���r Wk � p31q=.�4u:,`� . .... . . .... . .. . ..... . ... ... . ... .. .. .. ... .... .. ...... .... . ._. ... . .... . .
ADDRIESS SpR� 1 DPP'V
APN LOT
TRACT
OWNER 7CV,U,
ADDRESS/T7[L
CITY ZIP I T EAI
APPLICANT TEL.
CONTRACTQR iA/a 4F w L!'
ADDRESS C j- )dVa�
CITY ZIP TEL. � I Z.
ARCH/ENG
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQUIRESA PERMIT TO CONSTRUCT,ALTER. IMPROVE. DEMOLISH,OR REPAIR ANY STRUC-
TURE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).):
0 I,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044,BUSI-
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OFI IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE. IF,HOWEVER,THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE.
TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
^ I,AS OWNER OF THE PROPERTY.AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHOCONTRACTS FOR SUCH PROJECTS WITHA CONTRACTOR(S)LICENSED PURSUANTTO THE CONTRAC-
TORS LICENSE LAW.).
^ I AM EXEMPT UNDER SEC. R. &P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT
47t) ((7
LICENSE CLA S C-I V
LIC. N0.
DATE CONTRACTOR 4A t16�'L
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS'/CQ\MPTENSATION INSURANCE C R AND POLICY NUMBER ARE:
CARRIER
POLICY NUMBER__(' '• ��•"
(THIS SECTION NEED NOT BE COMPLETED OF THE PERMR IS FOR ONE HUNDRED DOLLARS($100)OR LESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE.I SHALL FORTHWITH COMPLY WITH
THOSE PR
OVISIONS-S
IT
-T
DATE
- 2'
70
C
APPLICANT
/
L.
WARNING: FAILURE TO SECIJRE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV.C.).
LENDER'S NAME
LENDER'S ADDRESS
CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INS ECTION PURPOSES.
(c u,.j
-1� L.t
P RMITTEE NAME(PRINT)
ATU FPERMITTEE DATE
CO
Er
0
LL
w
W
0
Er
0
in
W
0
z
W
n-
cn
CO
Er
0
W
U
W
0
I
Z
0
Q
Er-
a
X
W
0
U
W
CO
CO
CO
0
uJ
W
J
in
W
Z
co
0
W
J
J
W
CI
0
Cr
d
W
H
cc
UL1
d
CO
m
C/)
C/J
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
PRESS
FIRMLY
PICATION' °t,.�PERMIT P/C
DATE NUMBER#
ISSUE^TYPE OCC
DATE/CONST GROUP
ZONING SETBACKS
FRONT RW
REAR^
SIDE/SIDE STREET RW EI
SIDE 0
PROPOSED USE 2� S�L t C(�C SOLDrj(�r;
N0. DWEL. N0. N0.
UNITS STORIES BEDROOMS
DESCRIPTION SCI. FT FACTOR PSF ADJ.AREA/VALUATION
SFR/ADD/REM
UO Garage/Carport
W Patio/Deck
ILL
Pool/Spa
0
Z Re-Roof
Commercial
19
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
EAV L'
I- �- �> v
w ryv v.NE2. .
A iic�
1
6
19
CONSTRUCTION
PLAN REVIEW
ELECTRIC
r•'
PLUMBING y
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES 325 .'3 0
COMMENTS
RECPT. N0. PAID BY VALIDATION
WHITE-Department Copy,YELLOW-Finance Copy, PIN
jf�
-&-b�_S�reLr�e�+Sr4Bi� E+t. b 4 E G71Ad(r•r N'U
7-16-02- +Ikrk .-Vcur�V-SIy-IQ--f-S Mc5�l,4411b k---f gt44ft
-7 11 0 L-. ?Lk kf ff4%6-r a. r w5dl co
"Z ^?-3 c !F i i.-P2ae-cam e c. rtA)F-J-S;c'+V- •T-c v5 oLx- 2 5 ac Pc!-X. $ E06t) 1�4
j Y 7 25-C> Z-Pcx y S tDc-70 5(-PO-c„�
La-
7-z-crL o"i -I6L FLCCC-0