HomeMy WebLinkAbout16778 , - -
1�F�� �S L� CIIY OF DIAMOND BAR
��' DEPARTMEM OF CO'vIMUNTIY&DEVELOPMENT SERV]CES
� � /
.�` 21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117 PRESS
��-� BUILDING PERMIT APPLICATION FIRMLY
N JOBSITE t� /� /� APPLICATION PERMIT P/C
o ADDRESS ,�„� �I 3y"I ���11���l.0 SK tJ�� DATE NUMBER�a
c� ISSUE TYPE OCC
APN LOT TRACT DATE CONST. GROUP
p OWNER _ �L 1'H i 1�t�{,� ►�-Wf-S
ADDRESS . ZONING SETBACKS
Z CITY 21P 3TEL. �G�- .7�( FRONT RW -
o APPLICANT C- TEL. REAA _
� SIDE/SIDE STREET RW _
'_ � CONTRACTOR L 3TT}� ►�t/L SIDE _
ADDRESS II C f__1tit S r �
� cirv r'A'�'�'��+��-� ZIP�j�_I TEL. �cl S 9 3 PROPOSED USE +
o ARCH/ENG/ � `�n11 � _
W DESIGNER NO.DWEL. NO. NO.
a ADDRESS UNRS STORIES BEDROOMS
� CfTY ZIP TEL.
N
N DESCRIPTION Sa.FT. FACTOR PSF ADJ.AREANALUATION
¢ _ OVYNER�BUIIDER DECLARATION SFR/ADOrAEM
O
� 1 MEREBv AFFIqM UNDEF PENILLTY OF oE0.1URr TMAT t AA1 E%FMpT FRdI TwE CONTMCTpf15 U- G2f8y91�'.81flOR
W CEHSEUWFORTHEFOLLdMNOREA50N(SEC.7o]1.6BVSiHE55AnDPROiE55WN5CO0E:IWYCITYOR (n
U CqUHTI'N71IpIpEOU�RESAiERM�TTOCONSTRUCT,ALTE0.IMPROVE,OEMOUSM.ORREPIIRAN�57NUG• W Patio/Dack
Z TURE,iRqR TO RS ISSU�fICE.II.50 REWIRES TME APPLI�AHT fOR SUGN PEFMIT TO FILE 11 SIGNED
W ST�TE4EM T}uT NE OR SME�S UCENSED VURSU+W7 TO TME VROVIS�ONS OF TNE CONTMCTORS U� W
� CENSE LAW ICMAOTER�IL01d,AENCING Yn7M SECTION 7000)OF DIViS�ON]OF TME Bu5iNE55 AMJ VRO• u' POCUSpd
iE55iON5CO0E10RT�uTMEORSHEiSExE�oTTNEREFpOUAN'JTHEB4Si5�OHTHELLLECEDEMEuv. (�
VTION.ANYVIOUITqNOFSEC110N7071.6BVANYAPPLICANIFORAOERMITSU&IEC?STHE�PPLIGVITTO Z Re-Rocf .
� A GVIL vEHALTY OF NOT AbRE TM/W irvE HUNDRED OOlURS�fS0o1.)'
ZOI.ASOvmEROFTHECROPERTY.ORMVEun�0YEE4wiTHw�GESASTHEiRSO�FCOuvENSATqr1, � COrt1TlfCtal
MLL DO TME WORK,AN�TME STRUCTURE IS NOT INTENOED OR OFFERED fOR S�IE ISEC 7W�.BU56 J
y NESS AN'J iROFESSWNS C00E.7NE CONTRACTONS UCENSE UW DOES NOT�VC�Y TO AN OWNER OF j
iROPERTY MMO BUILDS OR IUPROYES T1E REON,AND MMO OOES SUCM WORK NIUSELF OR MERSELF OR
� TMROUGMMISORNFROM?IEUPLOVEES.OROYI�E�T1UTSl1UlYAPROVEIAE!(iSARENOTMEN'JEDOH m
OOFiEAEDFOR4ILEIF,IqWEVE0.7NEBU'LDiNGORYPRpVEMEM.I55dDWITMNONEYEAAOFC04v�E•
Z TION.TME OwNfR�DURDEN WILL MAVE T+E BURDEN OF PqOVING TNAT ME OR SNE DiD NOT BUI{D OR
= WPiqVEfO�iTHEPURPOSEOFS/�LE).
W OIA+OMMEHOFTMEPROOER7Y.AA1E%CLUSrvELYCANTRACTWGVATMIILENSEDCONTRACTORS
Q TO CONSTRUCT TrE VRO.IEGT ISEG.tw�.BUSiNE551wD PROFESSiOdS CODE.TNE CON7MCTORS U- VBIU8Si0f1 ADJ.AREA
W CENSEUWDOESNOTAPPLYTOANOVMEROFAVROVER7vVnqBURDSORMVROVESTNEREON.AMJ
� VnqCONTMCTSiORSUCMiROJECTSWiTMACONTRACTORIS)LICENSEDVURSUANTTOTNECONTML- QUANTITY DESCRIPTION FEE
Y TORSl10EN5EUw1.
� C 1 nM EXE�P7 UNDER SEC. B t PC.iOA THI$RE�SOH a
� U
u. �
DATf ONMER U
� W
� LICENSED CONTRACTORS DECLARATION W
IHE0.EBYAFFIRYUNOERGENALTYOFGfR1VRYiHAT1AAIUCENSEDUNOERCROVISION50FCMAPiER �
Y(Cd�MENCwG Iv�TM SELTqr+70ao1 OF DIVISqN J O(�TME BUSiNESS An0 PROFESSqNS CODE.Iw� Z
�X M�LIGENSE IS N fUll iORCE�ND EFFE '. �� m
� UCENSE^CU55 � �� � LIG.NC, ✓ G � �
V DATE I� �I COtdTFUCTOR � C G.
W -
� WORKERS'COMPENSATION DECLARATION 1 � ��1 a �,� �.(. Pd pOiJ ^
� � � U .
� I MEpEBV IIFFIiU1 UN�ER DEHAL7Y OF VE0.n1HY ONE OF THE FOLLOW:NC OEMRAT S. " /1�y � h
G
G �I IUVE AN9 W:LL 4AINTAIN A CERTIFICATE OF CONSEM TD SELFdMSUFE FOi1 WORKERS' _
Z LOu�ENSATqN,A5 VROVIDE'J BY SECT�ON 77000F TME LABOR WpE.FOR THE 7ERW RMNICE U
Q OF THE M/ORK iOR WMICN iN15 OERMIT IS ISSUEO. �
�
w �INAVEIWDWI��M�MTAIHWORKERS'COMFENSATIONINSUPANCE.ASREWIREDBYSECTqN
4 7100 OF TME 1A90R COOE.FOR TME OERFpRMANCE O�iHE WORK FOR WMiLM TMIS 7EN�IT IS
0 ISSUED.MYVYORKERS'COMPENSATIONINSURANCECARRIERANDPOII�YNUIJ9ENARE CONSTRUCTION
�
� GFRIEH PLANREVIEW
Z DOLICYNUUBEN ELECTRIC
¢
0 (iHSSECiIONNE�NOTBEW�LE'fmOF7�EPE�i.►f6iaROnEW�OREDRJU�iS6+aC1ORlE55) PLUMBING
Z 1 CERTIFV TwAT W 7ME oEAFOiWu+CE OC TME WOAN FOF wMICN iMiS CE�iT IS ISSUEO,1 MECHANICAL
(J SHk�lqTEUP�OY1WVPERSONNWVM�wHERSOASTOBFCOUESVBJEC7TOTwE
�j 1MpRKERS'CO4PENSATqNU'MSOF�IFOANiA�M.7AGHEETNATIi15NOl1LDBECOME INSPECTIONFEE
� SU&JECT707MEwORNER2'CddvENS�7iONP.OY1510N50�3EC710N]�OOOFiMEUBOR
w^.�swu.�►}o�nnm'in+couc�ry�p{���fta vno� s ISSUANCE � '� )
� D�TE: •���,"V` AV7LIWNT. �f�� � � SMIP _"... . .. _ . .
W ENERGYP/C �
� W�RNING:fALVRETOSECUREWOAKEAS'COM�ENSATpNCOVERAGEISUNUwFUL,I�N�SNKIlE
� SUBJECTANEMVIOYERTOLRIMP1�LiENALTIESM'OCm�fNESUpTOONEMUNDREDTMOUS�ND ENERGYPERMIT
DOLLAR$17�o0.0001.N ADOI710NT0 TME COSTOF COM�ENSATqN.DAMAGES AS iROVIDED Fqi IN (�
� SECTqN]70�OFTHEUBORCODF.NTERESLANDARORNEY'SFEFS RETEN710NFEE: ��II •�I11I
d CONSTRUCT�ON LENDING AGENCY pqE•ALT FEE:
O
CC INEREB�AFiIiUAUNDERVENALTVOFGER1UfrvTN�T7NENE15�CONSTRUCTIONLENJiNGAGENCv
0- fORTMEDERFORUANCEOFTMEWOARFORYMiCN7HiSiENMii15t55UEDI5EC.7ov7,CIVG1.
Z
W
�Z LEKOER'S NAME
�
f— tENDER'SA7DRE55 �
� TOTAL FEES
¢ I CERT6Y TMAT 1 NAVE REA'J THIS AOVlKAT10N AND SlATE THATTNE 1180VE PlFONM�TqN�S fARRECT.
W IAGREETOCOV�LVWITM.i1LLCITVANDCOUNTYORD!NudCES�N'�ST�TEUWSREIATINGTOBULL➢IHG
� Cd+STRVCTiON.ANDHEREBYMJTi+OR13EREPRESEMTATNE50�TMISCOIMTYTOENTFAUpONTME
� ABOVE�M �IONED iROPERTY FOR INSPECTION PURPOSES.
COMMENTS
� � {,.P�{ �GZLi
� •
¢ PEA/+iT7E E vT)
�, � .el.�,• 1—1,� —o (
y S�GNA'UREOFGERMI EE O�rE
� RECPT.�O. PAID BY VAUDATION
WHITE—Depanment Copy.YELLOW—Fv+enee Copy,PINK—Assessor Copy,GOLDENRO�FJe Copy.GREEN—Appl�canCs Copy
. � � � �
� ��� ��
�/ G�
�
�D
1
��_