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HomeMy WebLinkAbout12-79 .�` + CITY OF DIAMOND BAR " � I • I ;} UEPARTMENT OF COn�I1�lUN1T�'S DEVELOPI��IENT SERVICES �-� q,��,�,�5 21825 Copley Dri�•e,Diamond Bar,CA 9176� � ��� (909)839-7020 Fax(909)861-3117 Building Inspection HoUine(909)839-7027 PRESS � �'^"'� BUILDING PERI�IIT APPLICATIOI�T FIRMLV � JOBSITE ,t� /�� APPLICATION PERMIT p/C o ADDRESS ZZX'S u� �I I.�� �n UI LI �k� DATE NUMBER/�.-�9 � `-� APN LOT TRACT ISSUE / TYPE OCC t� q DATE / �� CONST. GROUP p OWNER ��.1C'1h1�Q� �"�,I!�lfS nPril� q d �fT p ADDRESS • ZONING ETBACKS z CITY Z�P TE�. FRONT qyy � � APPLICANT TEL REAR � z SIDE/SIDE STREET RW O ¢ CONTRACTO SIDE � ADDRESS o CITY �" ZIP TEL �- PROPOSED USE ��-��F t�.�ti�ll�' �� /�UQii �l�A�(� wo ARCH/ENG/ z DESIGNER w NO_DWEL. NO. � ADDRESS UNITS NO. � CITY ZIP TEL. STORIES BEDROOMS � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER•BUILDER DECLARATION p SFR/ADDlFtEM p I HER�Y AFFIRM UNOER PENALTY OF PEH.IURY THAT I AM EXEtdPT GROM THE CANTRACTORS LI� G3fe9B/COfpOA W CENSEUWFORTHEFOLLOWINGREASON(SEC.7071.SBUSWESSANOPROFESSIONSCO�EANYCITYOR (n ZCOUNTYYMICHREOUIHESAPEAMITTOCOVSiAUCT,ALTEiLPAVROVE.DEl10U5H2ORREPAlAANYSTRUG W PafiO/DBCk w TURE,PRIOR TO I75 ISSUANCE.AL50 REOUTAES THE APPLICAIJf FOR SUCH PERMIT TO FILE A SIGNED w STATEMEtJT hIFT HE Oq SHE IS IJCENSEO PUiiSUANT 70 TME PROVISIQ45 OF THE C0.YTRACTORS U• � CENSE UY!(CHAPTER B(COIAMENCINO YJITH SECTION�000)OF DIVISION 3 OF THE'oU51NE55 A40 PRO- � POOUSPB � FESSIONS CADE)OR THAT HE OR SHE IS EXEMPTTIEREFROMAND THE B/SIS FOR THE ALLEGE�E%EIAP� C7 TION.ANVVIOLATIqYOFSECTION70.l�.5BVANYAPPLICA7TFORAPERMRSU9JECT5TNcAPPUCAflTTO Z Re-Rool �, A CIV1L PENALiY OF NOT MORE TNAH FIVE NUNDRED DOLLARS(SSoo).): � ❑I,ASOYlNEROFTHEPROPERTY,OrIMYEMPLOYEES\VITHLVAGESASTHEIRSOLELOMPc'NSATION, COfflfilBfCldl z WILL DO THE YlORK,RNO THE STRUCTURE IS NOT INTENDED OR OFFERc�FOR SALE(SEG 7aas,BU56 � � NESS ANO PROFESSIONS CODE THE GQ4TRACTORS UCENSE UW DOES NOi APPLV TO AN OWNER OF � PROPEATY W/10 0U1LDS OR W PFOVES 7NEREQ4,AND WF70 DOES SUCH wOAK HIIASELF OR HERSELF OR Q THROUGH NIS OR HER OWN EMPLOYEES,7ROVIDED THAT SUCH IIAPqOVEMEMS ARE NOT IMENDED OR LO w OFFEAEOFORSfLE1F,HOWcVER717E8UdDWGORUAPROVERIENTI550LDWfiHwONEVEAROFCOMPL6 � TION.TME OWNER-BUIIDER WILL MAVE TNE BURDEN OF PROVINO THAT HE OR SHE�I�NOT 9UILD OR Z IMPROVE FOH TNE PURGOSE OF SALEI. _ �1,lSOWNEROFTHEPFOPEHTY,AA1EXq.USNEIYCANiRALTINGYrtTHLICENSEDCOHTRACTORS W (t TO CONSTRUCT THE PRQIECT(SEC.TON,BUSINE55 AND PROFESSIONS CO�E TNE COMMCTORS U� ValUB[IOfI ADJAREA = CENSEUWDOESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUROSOqIMPROVESTHEREON,ANp , � MM1IOCONTRACTSFORSUCHPRQ/ECTSWITHACONTRACiOR�9)LICENSEDPURSUAMTOh1ECONfRAG (]UANTITY DESCRIPTION FEE Y TORS LICENSE LAW.�. ¢ ❑I AM EXEMPT U�DEH SEC. J Q B.d P.C.FOR T/IS REASON � U � DATE OYJtJER � � LICENSED CONTRACTORS DECLARATION W � 1 MEREBY AFFlRM UNDER PENALTY OF VER1uRY THAi l A!A LICENSE�UNDER PROVISIONS OF CHAP7ER � � e(COMMENCW/3 VJITH SECTION 7000J OF DIVI510N 3 0F THE BU51NE55 AND PqOFES5YJN5 CA�E,N:D z X AIY LICENSE IS 4V FULL FORCE AND EF�ECT. LLI m � LfCENSE CLASS � �—G�� LIC.NO. _���I � � V DATE I 7_— �'�—�I 7 _ CONTRACTOq d W � WORKERS'COMPENSATION DECLARATION ¢ - � I HE Y AFFIN.i t1NDER PENALTY OF PEAIURY ONE OF TNc FOLIOVANG�ECIARAT10N5: U C/J Z � IHAVE.WD�NLl1.WNiA1NACEqTIFICATeOFCONSEMTOSELF�iNSUREFORY/OfiK'cR5' a Z = ¢ GOMPENSATION,AS 7ROVIDED 8Y$ECTION 3700 OF THE LABOR COOE,FOR THE PERFORl1ANCE U OF THE WORK FOR YhtIGH THIS PERMIT IS ISSUED. W � � w _I NAVE N:D 1'fILL MAtMAPJ V10RHER5'CA!APEKSATION INSUNJ:CE.AS REOUTAED BY SECTIO�t Q �70o OF TH'c LAfi0.7 COO'c,FOR THE PERFORMM;CE OF THE Y/ORK FpR Y/HICH THIS PERMIT IS //'./�Q ISSl/E0.lAY V:ORKERS'CA/.IPENSATION WSURANCE CAHq1ER AND POLICY NUM9Ei7ME: CONSTRUCTION ���' j CARRIER �'EII � C ��O l!(7��I�f('� pLAN REVIEW � 70UCY NVMBER � �� �1�,� I I z � --'-�—v-T�I-r� ELECTRIC ¢ � (rassecra�necorx�ra=_oa.!�.ErEooFn�aEa�.rrr,wacrL�rlR�R�pp1�Rs�5,cplp��E55} PLUMBING Z I CERTIFI'7YAT Ut TME P�RFORI1lJfCE OF TH=\'lOqK FOR iVHtCH THIS PERIAIT IS ISSUED,I MECHANICAL CJ SMALI�OT E1A?f,OY ANY PERSON IN ANY 1.1 R SOAS TO BECA!AE SUBJECT TO THc U� WORKERS'COMPENSATION LAYlS Of O �Il.ANDAGREETNAT IF I SHOl1lD BECOIAE INSPECTION FEE � SU3IECT TO THE Y/OPo(ERS'COIAPENSg .! AO`/ISIQ4S OF SECTIO:7]7000F THE LA80R O CADE,I SFUly FOHTHWITH COMP�Y iN r aaow wNs ISSUANCE i� 'p DATE: ��-��APPLICANT: SMIP r� 'J VlARNING:FAI�URE i0 SECURE 1'JORKERS C �NSATION COVEFAGE IS UNLAY�L,AND SHALL BE ENERGY P/C J � SU7JcCTAt1EMPLOYERTOCRI!AWALPENA�TIESMDGVILFu:ESUPTOON�HUNpREDTHOUSAND ENERGYPERMIT DOLLARS�5100.oM�,IN ADDITION TO THE COST OF COI.IPEt�5AT10N,DAh1AGE5 AS PROVIDED FOA IN J SECTION 7708 OF THE LABOR CADE,INTEREST NF1D ATTOAI7EV'S FEES. ��`� w REfENTION FEE: � CONSTRUCTION LENDING AGENCY o�_A�� _ � I HEREBY AFFIRIA UNOER PENALTY OF PeRNRY THAT TH'cRc�5 ACANSTRUCTIDY�ENDW6 AGENCY � � fOR THE PERFOF!AANCE OF THE YlORK FOR 1'Mlb/THIS PERMIT IS ISSUED(SEC.]097,pV.CJ. � Z W � IENDER'S NA1.1' F-- LENDER'9AO�RE55 � � ^� w ICERTIFYTHqTIHAVEqcADTHISAPPUWTIONANDSTATETHATTHE0.90VEWFORA1ATpNI5C00.RECL TOTAL FEES � 7 � 1 AGREE TO COldPLY\•lITH ALL CITY AND CAUNiY ORDWANCES AND STATE UWS REUTW6 TO 9llILDINC � CONST.iUCTION,ANDHEREBYAUTHORREREPRFSEMA71VE50FiMISCWNTYTOEMERUPONTHE Z ABOVE-MENTIONEA PROPERiY FOF INSPECT10.4 PURPOSES. �p ' � COIAMENTS � :7 CD pERMI EE N E(PRINn `� -1 -/2 �� � 516N TUR� E fTTEE A7E .Z��'. 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