HomeMy WebLinkAbout17219 CITY OF DIAMOND BAR �
�---J�`— DEPARTMENT OF COMMUNTTY&DEVELOPIv1ENT SERVICES r
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117 PRESS
�'��� BUILDING PERMIT APPLICATION FIRMLY
� JOBSITE �^nc�� C7� APPLICATION � NU B R., P/
o ADDRESS y�+c�.� l� DATE ( �� g���-�
� ISSUE ` ,.,Q � TYPE OCC
APN LOT TRACT DATE �
�— CONST. GROUP
p OWNER ROgErL�"L•� �]d4kN5p�l
o ADDRESS �1� GQ-E.�l�'R�'N� �b ZONING SETBACKS I
gCITY Q lA. �2 ZI�TEL� ��-S7 FRONT Ryy p
APPLICANT TEL. REAR �
zd SIDE/SIDE STREET RW ❑
� CONTRACTOR C� SIDE p
� CITY EV�I�LtJt7T ZI�� EL.��y^�I� PROPOSED USE O V C lZ
w ARCH/ENG/
z DESIGNER
a ADDRESS NO.DWEL. NO. • NO.
� CITY ZIP TEL. UNITS STORIES BEDROOMS
�
� DESCRIPTION S�.FT. FACTOR PSF ADJ.AREANALUATION
O OWNER-BUILDER DECLAFATION . SFR/ADD/FiEM � I
p I HEREBY AFFlRM UNDEF PEN4ITV OF PERIURV THAT 1 MI EXEMPT FROM THE CONTRACTORS LI- GflfBgB/C9fpOfl
W CENSELAWFORTHEFOLLOWINGREASON(SEC.7031.6BUSINESSMIDPROFESSIONSCODE:ANVCITVOR (n
C-� COUNTVWHICHREWIRESAPEqMITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANVSTRUG w
w NRE,PRIOR TO ITS ISSUANCE.ALSO REOUIFES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W P8f10/DBCk
� STATEAIENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTMCTORS LI-
�I CENSE LAW(CHAPTER B(COMMENCINO WITH SECTqN 7000)OF DIVISION 3 OF THE BUSINE55 AND PRO� � PooUSpa
� FESSIONSCODE)ORTHATHEORSHEISE%EMPTTHEREFROMANDTHEBASISFORTHEALLEOEDE%EMP- �
V TION.ANV VIOLATKKJ OF SECTION 7071.6 BV ANV APPLICANT FOR A PERMIT SU&lECTS THE APPUCANT T0 Z Re-Roof
A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLURS(f500).):
� �I.ASOWNEROFTHEPROPERTV,ORMVEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, � CpmmBfCldl
Z WILL DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.70M,BUSI� J ' �
N NESS AND PROFESSIONS CODE THE CONTFiACTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF �
PROPEHTY NM1iO BUILAS OR IMPROVES THEREON,AND VhiO DOES SUCH WORK HIMSELF OR HERSELF OR
Q THROUGH MIS OR HER OMM EMPLOYEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR m
� OFFEREDFORS�LEIF,FIOWEVERTMEBUILDINOOHIMPROVEMEMISSOLDWITHINONEVEAROFCAMPLE-
Z TION,7HE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILA OR
� IMPROVE FOR THE PURP0.SE OF SALE).
�y,� ❑I,AS OWNEF OF 7HE PROPERTY,AM EXCLUSIVELV CONTRACTING WITH UCENSED CONTRACTORS
� TO CONSTRUCT h7E PR0.IECT(SEC.70/1,BUSINE55 AND PROFESSIONS CODE:THE CANTRACTORS LI� VeIU0�I0l1 � ADJ.AREA
W CENSEUWDOESNOTAPPLVTOANOWNEROFAPROPEFTVWFIOBUILDSORIMPROVE57HEREON.AND
= WFiOCANTRACTSFORSUCHPRQIECTSWITHACONTRACTOR(S)LICENSEDPURSUANTTOTHECANTRAG FEE
� roasuceNSEuw.�. OUANTITY ' DESCRIPTION
Y
� ❑I AM EXEMPT UNDER SEC. B.a P.C.FOR THIS REASON �
� U
� DATE OYMER H
Z U
� LICENSED CONTRACTORS DECLARATION w
� I HEREBV AFFIRAI UNDER PENALTY OF VERIURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER �
� Y(COAIMENCINO Wlhl SECTION 7000)OF DIVISqN�OF THE BUSINESS AND PFOFESSKKJS CODE,AND Z
��� MV LICENSE IS IN FULL FORCE AND EFFECT.
`` J m
� LICENSECUISS �\C LIC.NO. � 1�• �
wDATE CONTRACTOR T ��L a
� WORKERS'COMPENSATIONDECLARATI�� `�" Q
� I HEREBV AFFlRM UNDER PENALTV OF PEFLIURV ONE OF THE FOLLOWING DECLARATIONS: V
� Z
� �Z _I HAVE AND WILL MAWTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS' a
Q
COMPENSATION,AS PROVIDED BY SECTION 37000F THE LABOR CODE.FOR THE PERFORMANCE U
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. w .
W �
I HAVE AND WILL MAINTAIN WORICERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTION ��
Q 370o OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHlpi THIS PERMIT IS
J ISSUED.MY WO ERS'COMPENSAT�ION-INSURANCE CARRIER AND POLICY NUMBER ARE: CONSTRUCTION
j CARRIER �TE rU N.� PLAN REVIEW
� POLICY NUMBER '�'�'��—
z¢ 0 ELECTRIC �"?""'�7 .�Q� �T �
J �
� (n+ssEcianr+E�raoraEa�IJaFiEooFn-IEa�aMiswaorlErur�n(imoau�asR�ro�alLEss} PLUMBING '
W ^h
Z I CERTIFYTHAT IN TME PERFORMANCE OF THE WOqK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL �11 T � Q �O O�
C'3 SHALL NOT EMPLOV ANY PERSON IN ANV MANNER 50 AS TO BECOME SU&IECT TO THE ����
(/J WORKERS'COMPENSATION LAWS OF CALIFORN10.AND AGPEE THAT IF I SHOULD BECOME INSPECTION FEE1 �,
S SU&IECT TO THE WORKERS'COAIPEN ATION Pi70VIS NS OF S TqN 3700 0F THE R
CODE I SH FOR7HWITH COMPLY THOSE PR 5 5. ISSUANCE I � �� �
O DATE: � b ��~�. � "
� p APPLICAN SMIP �,`.- i���
W
J WARNINO:FAILURE TO SECURE WORKERS'COMPENSATION CAVERAGE IS UNLAWFUL,AND SMA BE ENERGY P/C
J
� SU&IECTANEMPLOVERTOCRIMINPIPENALTIESANDCIVILFWESUPTOONEHUNDREDTHOU o ENERGYPERMIT
DOLLAHS(5100,000),W ApDITION TO THE COS70F COMPENSATION,DAAIAGES AS PROVIDED F R IN
J SECTION 37oe OF THE LABOR CODE,INTEREST,M1D ATTORNEV'S FEES.
OC � ENTION FEE:
w
O CONSTRUCTION LENDING AGENCY - PRE-ALT FEE:
� I HEREBV AFFIqM UNDER PENALTV OF PERIURY THAT THERE IS A CONSTRUCTION LENDING AGENCY �
n- FOR iNE PERFORAIANCE OF THE WOFK FOR WHICH TMIS PERA/1T IS ISSUED(SEC.30G7,CIV.C.).
Z
W
� LENDER'S NAME
� LENDER'SADDRE55
w ICERTIFYTHATIHAVEREADTHISAPPLICATIONAtJDSTATETIiATTHEABOVEINFORMATIONISCARRECT. TOTAL FEES O � I �����
� I AGREE TO COMPLV WITH ALL CITV AND CWNTV ORDINANCES AND STA7E UWS REUTINO TO BUILDING � 0
� CONSTRUCTION,ANDHEREBYAUTHORIZEREPRESENTATNESOFTHISCWNTYTOENTERUPONTHE
Z VE-MENTIONED PR PE TV FOR INSPECTION PURPOSES. COMMENTS
�
J
�
m PE M EE NAME( IIfT) '
� �O
N 51 UR OFPERMITT DA -
� RECPT.NO. PAID BY VALIDATION
WHITE—Dep ment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENRO�File Copy,GREEN—ApplicanYs Copy
1'
(CD�f�Y (�� �B��iI�G�1� �1�1(�
�(�l�[�[�c�ii"0�� (f�f�t��I��
° 0�� D�� ��3 D[n�l�� DGJ4� O��p
SET BACK FLOOR JOIST �
FTGS/FORMS/STEEL � FHA REQMTS '
ELEC7RIC GROUND � UtUDEFi FLOOR DUC'T
GROUND PI.UMBING � UNDER FLOOR CU�IDUIT
SLAB GRADE FIREPLACE FOUNDATION
TEMP POWER FIREPLACE BOND BEAM
WATER SERVICE MID HT. BOND BEAM
ROOF SHEATHING 8 FT. BOND BEAM
FRAMING/VENTIL(AT(ON FINAL BOND BEAM
ROOF COVER PRE-GRADING
ROUGH HEATlNG BENCHING
ROUGH ELECTRIC ROUGH GRADING
ROUGH PLUNIBING FiNISH uRADING
SHOWERITUB TEST POOL ELECTRIC
EXT. LATH/SIDING POOL FENCING
WALL INSULATIOt�! POOL FINAL
CEILING INSULATION OFF SITE IMPS.
DRYWALL NAILIIVG DEDICATIONS
SEWFR FiNAL ENG. �
SEPTIC TANK LANDSCAPE/IRRIG.
SEEP PIT/L.L. ON SITE lMPS.
GAS AIR TEST FINAL ZONING
FINAL CONST. . FiRE DEPT. FINA!
FINAL HEATING HEALTH dEPT. FINAL
FINAL ELECTRIC dEV. FEES PAID
FIhIAL PLUMBING ENERGY
F��:�i.��;� _���• � /1--�� -- -
c r► o�oc�o
CO�iiVIIENTS
,
SEPTIC TANK SlZE �
SEEP PIT/U SIZE
�
� . . � � �
� �