HomeMy WebLinkAbout18540 �� CITY OF DIAMOND BAR
� DEPAR'I7vrENT OF CONIMUNTfY&DEVELOPMENT SERVICES
; � 21825 E.Copley Drive
'�� (909)860-3195 F�(9n9)861-3117 � PRESS
� ���� W BUILDING PERMIT APPLICATION � , � �.
� FIRMLY
o ADDRIESS��v�U�iJ�✓1 1'�1N� i� J DATECAT PERMIT �,I�I �� P/C
NUMBER �� �
� APN LOT T ACT �-- DATE \� � �) ` �` .�O ST. GROUP
p OWNE�__��./�'{Z�LU�)�l K.G.'� i
o ADDRESS ZONING SETBACKS
� C�N ZIP 7E '' �� FRONT RW n
APPLICANT TEL.__ REAR �
aSIDElSIDE STREET RW ❑
Q CONTRACT SIDE � —
o ADDRESS � _ —
CITY - . ZIP TEL. PROPOSED USE '�d
w ARCH/ENG/ ,� 11� -
z DESIGNER� `
� ADDRESS _ ���TSWE� N�� � NO.
� CITY ZIP_._ TFI.__ _
STORIES BEDROOMS
� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
p� OWNER-BUILDER DECLARATION
O SFR/ADD/REM
p I HEREBV AF�!RM UN�EF;7ENALTV OF PERJURY THAT I AM EXEMP7 FROM THE corvrancroas:.i� Garage/Carport
W CENSELAWFORTHEFOLLOWINGREASON�SEG.]o3t.50U51NE55AN�FROFE5510N5CODE:ANVCITVOF (f�
� COUNTYWHICHREOUIRESAPE:RMITTOCONSTRUGT,ALTER,IMOROVE.DEMOLISH,CRqEPAIRANYiTRUC� W Pd110/DBCk
w TUflE.PRIOR TO ITS ISSUANCI=,AL50 REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w
� STATEMENT TMAT ME OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THF CONTRACTORS LI-
� CENSE LAW�CHAPTER B(COMINENCING WITH SECrION 7000�OF DIVISION 3 nF TNE BUSiNE55 AND PRo- LL' POOVSp3
O FESSIONSCqDE)ORTHATHEORSHEISE%EMPTTHGFEFROMANOTHEBASISFORTHEALLEGEDF%EMF� �
V TION.ANVVIOLATIONOFSECTION]031.SBVANYAPP�ICAN�FORAPERMITSJ9JEGIS"fHEAPPI.ICANTTO Z Re-Raot
� A CIVIL PENA�TV OF NOT MORE:THqN FIVE HUNORED�OLL4R5(SSW).): �
O �I,ASOWNEROFTHEPROPERTY.ORMVEMPIOYEESWITHWAGE5A51HE1950LECOMPENSAiiON, 0 Commercial
Z WILL DO THE WORK,AND THE STRUGTURE IS NOT IN'EfJDEJ OH OFFERED FOH SALE;iEC.7046,BU�I- J
� NE55 AND PROFESSIONS GODE:THE CONTHAGTOqS LICENSE LAW DOcS NO'APPiY TO AN OWNcR OF ?
PqOPERTY WH0 9UIL�S OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OF HERSELF OF
� THRIXIGHHISORHERONMEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTEN�E�oR m
w OFFEREDFORSPLE.IF,HOWEVFR,THEBUILDINGORIMPROVEMEN'ISSOLDWITHINONEVEAROFC04PLE-
� TION,THE OWNER-BUILDER 1MLL MAVE THE BlJROEN OF PROVING'HAT NE OR SHE OID NJT BUILD OH
� IMPROVE FOR THE PURPOSE 6F SAIE�.
w CI,ASOWNEROFTNEPFOPERTV.AMEXCLUSNEL�CONTRAC71hGWl'iH�iCENSEDCONTRACTORS
[L TO CONSTRUCT THE PRQlECT(SEC.]aa4,BUSINESS AND PROFESSIUNS CODE:THF CONTpACTORS U- V3IU8IlOf1 � ADJ.AREA
W CENSEIAWDOESNOTAPPLV�"OANOWNEROFAVRO?ERTVWHOd'JII.fi50FIMPROVESTMEREON,AND —
� WHOCANTRACTSFORSUCHPR0.IECTSWITMACONTRACTOR(S�LICENSEDPURSUANTIOTHEGONTRAC- QUANTITV DESCRIPTION FEE
Y TORS LICENSE LAW.) _
� 1.1 I qM E%EMPT U4DER SE_C. __ __B.d P.C.FORTHIS REASON Q
� U
� DATE OWNER F-
Z — ----- U
� LICENSED CONTRACTORS DECLARATION W
¢
� I HEREBY AFFlRM UN�ER PENALTY OF PERJURY THAT IAM LICENSED UNDER PRUVi510N5 OF CHAPTER �
d 9�COMMENGNG WR4 SECTIOP!)000)OF DIVISION 30F THE 9USINESSAN�PF?OFESSiONS CO�JE.AND z
`X MV LICENSE IS iN FUII/FQ�C N FECT. (/^� � m
� �r �V Y ' V �
� LICENSE�L/1�S � � LIC.NC. �
� �11(� J
U DATE V�t 1 CONTRACTO � 6,
w �
� WORI<ERS'COMPENSATION DECIARATION Q
� I HEREBV AFFIRM UNDER PENA_TV OF PERJURY ONE OF THE FOLLOWING OECIARATIONS: U
� Z
Z _IHAVEANDWILLMAINT4INACERTIFICATEOFCONSEN7TOSElF-INSUREFORWORK[RS' ¢
2
¢ COMPENSATION,AS PROVIDED BV SECTION 310onF THE LABOft CODE,FOH THE PERFORMANCE U
OF TME WOFK FOR WHICH TNIS PERMIT IS i55UE�. �
�
w 1 MAVE AND WILL MAMTAIN WORKERS'COMPENSATION INSI/RANCF,AS REOUI{iED BV SECT ON
Q3]00 DF THE�_ABOR C.00E,FOR THE PERFORMANCE Of THC WORK FOR WHICH THIS PERMIT IS 0
ISSUE�.MV WOR ,c{py�q SATIOI ,U�R-A7N�C,,E RIEF AND POLICV NUMBER NRE' CONSTRUCTION '�. �
j c^RqiEp�[��y�.�V IV� PLAN REVIEW . ___
� `� —
Z POLICV NUMBEF���F_ ��2 ___ ELECTRIC
Q
� !iFi'�SSECTIONN'emIJOTBEOJMPLETEDOFTHEPERMRlSFOFONEM1rDRED�OLIAFlS(5100)OFlESS). PLUMBING �
W —
Z I CERTIFV THAT IN THE PER�ORMANCE 0=THE WORH FOR WHICH THIS PERMIT IS�SSI/ED.I MECHANICAL
CJ St1ALl NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BEGOME SUBJEfT TO iHE - —
(/J WORKERS'COMPENSAI"ION LAWS OF CALIiORNIA,ANp qGREE TMAT IF I SHOULD BECOME INS?ECTION FEE
� SUBJECTTO THE WOFNERS'COMPENSAIION PROVISIONS OF SECTION 3700 OF TNE 1A80R —
GO�E,:SHALL FORTHN'ITH COMPLY WITH iHOSE PROVISIONS. ISSUANCE
� —
p �ATE: APPLICANt: SMIP _ '���,
J WARNING:FNI�UPE TO SEGURE WORKERS'COMPENSATION COVERAGE IS UNIAWFUL,AND SHALL BE ENERGV P/C
J
�y SUBJEGTNN EMPLOVER TO CFIMINAL PENALTIESAND CIVIL FlNES 11P 1'OONE HUNORED THOVSANO ENERGY PERMIT
} OOLLAHS(St00000),INADOITIONTOTHECOSTOFCOMPENSATION,�AMAGESASPROVIDEDFORIN —_ _._.
J SECTION3Io80FTHELABORC�DE.INTEREST.ANDAT'ORNE�'SFEES. ` `'��,`
� RETENTION FEE: �
� CONSTRUCTION LENDING AGENCY PRE-ALT FEE �
Q I HEftEBYAFFIPM UNDER PENAI_TV OF PEFJUF�THAT THEHE IS ACON�THUCiION LEN�ING AGENC�
� FOR'HE FERFORMANCE OF THE WOFH FOii WHIGH 1HI5 VERMIT I5 155UEC(SEC.]09],CiV C.).
Z
W
? LENDEH'S NAME _ __ — —
�
H LENDER'SPDDRE55
� TOTAL FEES � •��) t �'�.
� I CERTIFV THAT I HAVE flEAD THIS APPLICATIONAND STATE TMAT TME ABOVE INiGRMATION IS GURRt[;I.
w I AGREE TO COMPIY WITH ALL C.ITY AN�COUNTV ORDIHANCESAND STATE UWS HELATING TO AUIL�ING
d
� CGNSTRUGTION,AND MEFEBY NU I HOHIZ�c REPHESENTATIVES OF THIS COUNTV TD ENTER UPUN THE
Z ABOVE�MEN110NE�PROPERTY FOR IN N PURPOSES. COMMENTS
� �� __
� _
m PER EE NAVnE
Q � '1 ___—
� r — -- � ^ r
� SIGN4TliaE O PE MI?TEE DA —
� ' RECPT.u0. _ PAID BY _ ' � VALIDATION
WHI —Department Copy,YELI.OW—Finance Copy,PINK—Assessor Copy,GOLDENRO�File Gopy,GREEN—ApplicanYs Copy
� � � .,� �,
�.-,_ � .,�� �� z"��� eA�� ,� y ��� ��� �
n,.�, �
� � � � �� `�,
� � .
x ..
; x .
.
� � "�~�+
��; ., ._ ��� .�
, ' �
�� � �j��
�`�� '���U ' _
% .
_ � _ , ��; � rm, � �� ,-��� _
-���: �: �� ���
�r���� _
_ ___ _ _.
_
__
.
_ _ _ ;
y E � �, � _
, . _. _
.�i�^�r�" ,:���� "f({f�J�f���)� : .. .. .. ... .. . .. ...... . ..
"��+gb1 '�a' � s�� i�, _
r���s ��� �h � ���� -4:q � �
��r � va, � g�s���� �� , �
f1 �
�' �: ^ ��. .. . . ..... . ... . . . . . . .. .. .. .. . ... ... _.... ._.. . ..._.. ._.. .
4�,�i
� ;
tt i
= i� , � i . . . . .._.. ... _ ....... .._. . . ...... ..._
�.�
d;. � : �� � . .._. .. .__ .._. ... .. .....
3 ' �k : . .. . . . . . . ...
I i
�'
��� .... . .. .. .
� � . . . ... .. . . .. .... . .. .
� v� ,_ _. ... . _
4 +
.
. ����,„��N �
ite�RrJ, . . .. ...... . ... . . ... .. ...... . ... .. .. . .... . . ... .. ... . .... .... .... .
Q
0
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNTfY&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(969)861-3117
BUILDING PERMIT APPLICATION
0
0
0
�
z
0
D
Z
m
O
0
D
W
U
Z
W
0
v
N
O
Z
Z
O
a
x
w
0
�
w
N
Z
0
v�
f-
0
Z
0
v�
z
0
0
vu
�
�
��
)
W
d
2
d
Z
W
S
Q
W
d
C'3
Z
J
m
Q
�/)
Cn
WHIT2�Department Copy,YELLOW-Finance Copy,PIN
PRESS
FIRMLY