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HomeMy WebLinkAbout15501 (23) YT�I'� \ CITY OF DIAMOND BAR �i ---��— DEPARTMENT OF COMMUNITY 8c DEVELOPMENT SERVICES � c �, �:;��; I 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRES$ y*^.. BULLDING PERMIT APPLICATI(ON . ;iN . ,, , FIRAI�LY , . o ADDRIESS ��a 4� S. I-7'tJ�� C N I�L �' _ APPLICATION ``-� PERMIT ��� P1C DATE `"Z� NUMBER # c� ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER /-T/`S '- �O-*a � ADDRESS '"� ZONING SETBACKS �W CITY ZIP TEL. - C) REORT RW L� APPLICANT �.�� IC_f�`a TEL.�y�y���'�1��,�-�j'"�^ SIDE/SIQE STREET RW ❑ � CONTRACTOR �I t41-1�'Nv "��s�'�t f��� SIDE ❑ ADDRESS r �.'����K �,r�.-� � .��� I NST�-� ` f,c.� +� PROP�SEp USE 6 o CITY `—C� l 6�,�_ ZIP TEL. N -> � — � wo ARCHlENG/ —.�jl--� �-�a s � f� c'" . t.,. � ADDRESS NO.DWEL. ` -- NO. NO. UNITS S'fORIES ' BEDROOMS y CI1Y 21P TEL. __� uy DESCRIPTION SQ.Ff: FACTOR PSF ADJ.AREANALUATION OOWNER-BUILDER DECLARATION SFR/ADD/REM � 1 HEREBY AFFIRM UNDER PENALTV OG PEFl.IURY THAT I AM FXEMPT FPOM TNE CONTRACTORS LI- CaefaJB/CflfP01'I Ly3 CENSEUWF�7TNEFOLLOWNGREASON(SEC.7031.SBUSINESSANOPROFESSpNSCODE:ANYCITYOR ((� V COUMYVh11CHREQUIRESAPERMITTOCONSTRUC7,AI,TER,IMPROVE,OEMOLISH,ORREPA1RqNY57RUC- W pdi10/DeCk �V TURE,PRIOR TO RS ISSUANCE,ALSO REQUIHES THE APPLICANT FOR SUCH PEFMI7 TO FILE A SIC'NED � STATEAAENT THAi HE OR SHE IS LICENSED PURSUANT TO THE PHOVISIONS OF THE C�N7RACTORS ll- ! CENSE LAW(CHnPTER B(COMMENCINO WITH SECTION 7tl0o)OF PIVISION 3 0F THE BUSWESSANb PR0- LL' POOUSpa � FESSqNSCODqOflTHATHEOR5ME15ExEMFfTHEREFAOMANOTHEBA5ISFOR7HE0.LlEGEOEXEMP- (� V TION,MlYVIOLA710NOFSECTION708t.6BVANYAPR,ICANTFORAPERMITSU8JEC75THEAPPI.ICAN7T0 Z RB-ROOf �.�-� � AGIVIIPENAL7YOFNOTMpRETHANFIYEHUNDflE�DOLLAPS(56Jo).�: �.�: . � ❑I,ASOWNEROFTHEPROPERTV,ORMYEMPLOYEESWITHWAGESAS7HEIR50lECOMPENSATION, � COttlmefC181 � WILL 00 THE WORK,ANb?HE STRUC7URE IS NOT INTB.IDED OR OFFERED fOR SALE(SEC.7o4a;BUSI- J NESS AND PHOFESSIONS CODE:hIE CONTRACTORS LICENSE LAW DOES NOT APPLV TO A�OWNER OF � PROPEe7YWtiOBUILD30RIMPROVESTHEREON,ANDWHObOESSUCNWORKHIkSELFORHERSELFOR = � THti'JUGHNISORHERONMEMPLOYEES,PROVIDWTHATSUCHIMPROVEMENrSARENOTINTENQmOR � 6 ,OFFEAEDF-0H&PLEtF,HOWEVERTNEBUILDINGORIMPROVEMEN'fISSOtDWITHINONEVEAqDFCOMPLE- � 'TION.THE OWNER-BUI{AER VfILL HAYE THE BUPDEN OF PROVING THAT HE OR SHE DI�NOT BUILD OR � IMPHOVEFOHTHEPURPOSEOFSILE). � W ❑I,ASOWNEROFTHEPF�PERTY,AMEXCLUSIYELYCONTRACTINGWITHLICENSEPCONTRACTOPS {�� WTO CONSTRUCT THE PRQIECT(SEG 7044,BUSINESS ANb PROFESSIONS CDOE:THE'CANTRAC74R5 LI- V8N31iOn � � 11 ADJ.AREA GENSEUWDOESNOTAPP�YTOANON7JEf10FAVROPER7YWHOBUILD30RIMPROVESTHEPEON,RND - � WFI0CAN7FUCTSFORSUCHPPOJECTSWIhiACbNTRACTOR(S)LICENSEDPURSUAMTTOTHECONTRAG QUANTITY DESCRIPIION FEE x TORSLJCpJSEUW.j. � ❑I AAf EXEMPT UNDEP SEC._ 8.6 P.C,FOp THiS REASCN J Q � , U � a OATE OWNEA U 41J �+V[ LICENSED CONTFACTORS DEClARATION W C[ 1 HEHEBY AFFIRM UNDER PENRITV OF PERIURV TNAT I AA1 LICENSFD UNDER PROVISIONS OF CHAPTER � � s(COMMENCINOWITHSECTVOh170o0�OFDIY1510N30F7NEDUSINESSANOPROFESSIONSCD�[,ANO Z X MY UCENSE IS IN FULL FORCE AND EFFECT. � LLJ C� Gj� � UCENSE C S C � P LIC.NO,�J,��� � ~ -�(�,.�� � J V DA7E �� d�� COP1TqA�Tc�R_._�_�--.,{_l� a- LiJ � WORKER3'COMP[NSATiON DECLARATICN Q � IHEREBVAFFIRMUNDELIOEWLLTYOFPERIURYONEOFTHEfOLLOWINGDECLARAT10N5: U � Q ' C] �t HAVE AND WILLMAINYAIN ACERTIFICA7E OF CONSENT't0 SELF-INSURE FOR WORKERS' Y � C0/APENSATIOk,ASPROVIOEDBYSEC'IOiM37000FTHELABORCODE.FOP7HEPERFOHMANCE 'U OF THE WORK FOR NMICH THIS PERMIT IS USUED. � O W _I HAV£AND WIl1 MAINI"ABd WOAKEAS'CCMPENSATfON INSURANCE,AS AEQVIRE�9Y SEf.TION � 37000FTHELABORCOLE,FOR7HEPEqFORMRNCEOFTHEWORKFORWhIICHTHISPERMfT15 �/(� /�'�1 ISSUED.MY WORKERS'P7MPENSATION IP4:UftANCE GARi11Efl AND POUCY NUMBEFARE: CONSTRUCTION �� �"'✓ " �'�✓ � CARqIE9 �� ���_✓_�� -� PLAN REVIEW � _ � POLICV NUMBER�� � C�_n�'"`�� I ELECTRIC Q Q (fHI5SEC11QNNE�NO7BEpQ\A£'I.£ZEDOFhFPEFB.4TtSFOROfJEI-IUPAIIFD ;5700)ORLESSA i PLUMBING W �c,. Z I CERTIFV 7HAT IN THE PERFOFMANCE tlF THE WORK FOR WHICN 7NI5 PEFMIT IS ISSUEU,l MECHANICAL ���� �1 � SHAL4 NOT EMPIOV ANY PERSON IN ANV NANNER SO AS TO BECOMe SUBJECT TO THE � -�� • � 1YORKERS'COMPENSATtONLAW50FCAL�FORNIA,ANDA6REETHATIFISHOUlOBcCOME I INSPECTEONFEE � SU&IECT TO THE WbAKERS'COMPeNSATlO�PROVI51(1NS OF SECTION 3700 OF THE LABOP �.r�J CODE 1 SHALL FOR7HWITH COMPLY W ITH THOSE PROVISIC)NS. { �SSUANCE . o �- , A4�� � � p DATE: �'� APPL!CANT: � t� / SMIP C .. � ENERGY ppp/G, �y„1-�a"� q � WAflNINGFA7LURETOSEGUREINORKERS'COMPENSATIONCOVER GEISUNLAWFUL.ANDSHALIBE ��+gw;;r p�o� ����.T�s� #�z`'3�. �y SUBJECTANEMPLOVERTOCRIMINALPENALTIE9ANOCIVILFINESUPTOONEHUNOAEDTHOUSANO J����-"lJ DDLLAfl5�51o0.000),INAbD1T10NTOTNEC0570FCOMPENSATION,�AMAGESASPROVIDE�FORIN ENERGY` ttM�1 J SECTION37oBOf1HELA00RCODE,INTEREST,ANDATTOflNEV'SFEES. �gY��� :�v S � � ftETENTIi�g _ ____�— a CONS?RUCTION IENDING AGEPdCY PRE-ALT FEE: O � I HEPEBY AFFIRM UNDER PENALTV OF PERJUFlYTHATh1ERE 16 ACONSTRUCTION 4EN�MG AGENCY FOR TNE PERFORMANCE OF TNE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3o9T,CIV.C.). . . . Z LLl �Z LEN�ER'SNAME y F`- LENOER'SADDAESS . .. W I CERTIFY THAT 1 HAVE READ THIS APpLICAT70N ANO STATETHAT7HEABOVE INFORMATION IS CARRE 1 OTAL FC ES . � . � I AGflEETO COMPIY WITH ALL GTY AND COUN7Y ORDINANCES AND STATE LAWu REUTING TO BUILDING � CONSTRUCTION,ANDHEREBYAUTHOR2EREGRESENTATIVESOFTHISCOUNTYTOENTERUPONTHE . Z ABOYE-MENTIONED PROPERN FOR INSPECTION PURPOSES. 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