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HomeMy WebLinkAbout17681 (23) �� CITY OF DIAMOND BAR DEPARTMENT OF CONII�tUNITY&DEVELOPMENT SERVICES EX P I R E D � ,�N� 21825 E.Copley Drive ,,.-- (909)860-3195 Fax(909)861-3117 PRESS �»- BUILDINGPERMITAPPLICATION JUN 181002 F�RMLY } JOBSITE �i ����,/�I L t,� /, / APPLICATION O�PERMIT 1�! C1' P/C o ADDRESS ✓ U �-�V. DATE NUMBER� �0 '� N � APN--�LOT TRACT DA EE �"-CONST. GROUP o OWNEfl �l/L lE'���)A,✓ U/.fI p ADDRES ZONING SETBACKS . gCITY�• !)�. ZIP /7��TEL � ~./� 3�1 FRONT RW O APPUCANT TEL. � REAR p zd SIDE/SIDE STREEi RW p � CONTRACTO � / ( SIDE p ADDRESS /. � CITY ZIP TE .{/- (� PROPOSED USE o ARCFUENG/ a DESIGNER a ADDRESS NO.DWEL. N0. NO. � C�7Y ZIP TEL. UNITS STORIES E3EDROOMS � N DESCRIPTION SO.Ff: FACTOR PSF ADJ.AREANALUATION p� OWNER•BUILOER DECLARATION SFFUADD/REM O 1 HEREBV AFFlRM UNDER PENALTY OF PE0.IURY THAT I AM EXEMPT fROM 7HE CONTMCTORS lF Garage/Carport W CEN3EUWFORTHEFqlOWINGREA50N�5EC.70.71.68U51NE55AN�iROFE5510N5CODE:MlYCITYOR (f) � C� COUNTVWHIpiREWIRES�PERMRTOCONSTRUCT,ALTEILMPROVE,OEMOLIAI,ORREVNRANYSTRUG W PalI0/DOCI( � 7URE,PRqR TO I75 ISSUANCE,ILL50 REQUIRES THE APPLICANT FOR SUqi PERMIT TO FIIE A SIGNE� W � S7A7EMENT 1HAT HE OR SHE IS UCENSED PUHSUANT TO TME PHOVISIONS OF 7HE CONTMCTOHS LI• � CENSE UW(�M�TER Y(CdAMENCWO WITH SECTION 7000)OF DIVISION J OF TME BUSINE55AND OqO. �- PooVSpa � FESSpN5C00E)ORTHATHEOHSMEISEXEIAPTTMEREFROA,1u10THE8A515FORTHEALIEGEDE%EUP• C7 TION.ANYVqLATIONOFSECT10N70J1.SBYANV�OPUCANTFORAGERA/ITSUBJECTSTMEl1PPLICANTTO Z Re-Rocf ACMLpENI1TV OF WOT MORE THAN FIVE MUNOREO OOLURS(SSDO�): 0 OI.ASOWNEROFTHEPROVERTV,OHMVEMPLOYEESWI7HWAGESASTHEIRSOLECOMPENSATION, 0 �,pmm8(LIBI Z 1Mll DO iNE WORK,AND THE STRUCiURE IS NOT IN7ENOED OR OFFERED FOR SALE(SEG 70u,BU51• J � N NE33 AND PROFESSIpNS OODE:THE CONTMLTORS LICENSE UW DOES NOi APP�Y TO AN DY/NER Oi = PROPERiYMMO BVIIDg OR IMPROVES 7MEREON.AND WMO DOES SUp/WORN HIA15ElF OR HFRSELf OR � 7HROUGMHISOHMENOVYNEAAPLOYEES,VROVIOEDTHATSUq11MPROVEMENTSARENOTNTENOEDOR m � OFFEREOFORShLE1F,MON'EVEqiHEBUILDINGORUAPROVEIAENTISSOIDWITMINONEYEAAOFCOMPLE� Z 710N,THE OWNEREUIIDEfl WILL HAVE iHE BURDEN OF PRONNO THAT HE OR SHE DID HOT BUILD OFl � MPROYEFORTHEWRPOSEOFSALEI W 041150WNEROFTHEFROPER7Y,A1AE7(CLUSIVELYCOMMCTwGY11THlICENSEDCONTMCTOqS [C TO GONSTRUCT TNE PR0.IECT(SEC.70�t,BUSINESS AND PROFESSIqJS CAOE:THE CONTflACTORS U� VdIU0110f1 ADJ.AREA W CENSEUWDOESNOTAPPLYTOANOKTIEROFAVAOPERTYN7108UItDSORMPflOVESiHEREON,/JIO � VAIOCONTMCTSiORSUd1GRO.JECTSWITNACONTMCTOR(3)LICENSEDPURSUANTTOTMEGONTMG OUANTITY DESCRIPTION Y Tons ucense uw.�. FEE 0 ❑I AA1 EXEYPT UNOER SEG B.t P.C.FORTHIS REASON Q ?y U LL � DATE OWNEN F- p W � LICENSED CONTRACTORS DECUIRATION w � IHEREBYAFFIRMUNDERPENALiVOFPERJUMTMAilAA1LICENSEDUNDERPROV1510NSOFCMAPTER � p., 9(COMMENCINOWITHSECTION70o010FDIVIS10N70FiMEBU5�NE55AN0VRDFE55iON5CODE,AND Z _ `X MYLICENSE61NiULLFORCEANDEFFECL m 0 UCENSE CLASS�(_ ,� /� LIC.N0. � f+r I � W OATE 7,���1l�/�� CONTRACTOR �✓ �S GJ. / � WORKERS'COMPENSATION DECLARATION 4 � IHEREBYAFFIfUAUNDERVENALTYOFPERJURVONEOFTNEiOLLON7NGDECUMTI0N5: Z � �IHAVEANDWILLAUINiAINACERTIFICATEOFCONSENTTOSELF-INSUREFOqWORKERS' a COMPENSATION.ASFROVIOEDBVSEC710N77ooOFTMEUBORCOOE,FORTMEVEFFORMANCE �U Q OF iHE WORK FOR NTtlp1 TMIS VEFMIi SISSUED. � � �IHAVEANDWILLMAINTAINWORNERS'COAIPENSATIONINSUMNCE,ASREOUIREDBYSECTpN � J7000FTHELABORCODE RTHEPERFORMANCEOFTHEWORNFORWHid/THISPERMITIS J ISSUE�.MYWORKERS' ENSATIONWSURANGECARRIER/AN�DPOLICYNUMBERAAE: CONSTRUCTION j CARRIER � , ��� r �'/. PLAN REVIEW Z POIICY NUMBER��'��. /I � � ELECTRIC Q 0 (iNSSEcnorar+�taoTSEon.w�imoFnEVEautswnon.Ew�n+moouu�s6+oo�a+�Es51 PLUMBING - � :. Z ICEHTIFYTl/�TMMEPERFORMANCEOFTMEWORKFORWMICMTHISPERMITISISSUED,I MECHANICAL U' SnALL NOT EMPLOY ANY VER50N N�f1v MANNER 50 A5 TO B E SU&I i0 E (/� WORKEHS'COMPENSATqNUW50FCALIFORNIR DAGR TNATIFI O lD8 IAE INSPECTIONFEE S SU&IECTTOTHEW'ORKERS'COM�ENSATIONPR SIONS SECTq 700 FT UBON � . CODE,1 F HT/NATHCOMPLYWIiHT ROVI ISSUANCE � p DATE: APPLICANT: . SMIP J WARNING:FAILURE O SEWRE WORKERS' NSAT COVERAGE IS UNUy UL,ANO SWLLL BE ENERGY P/C � SUBJECTANEMPLOYERTOCPIMINALVENALTIESANOpVILiINESUP700NE11l1NDHEDTFIOUSAND ENERGYPERMIT DOLURS(f 100,0001.IN ADDITION TO THE CASi OF COMPENSA7qN.OMAAGES AS VROVIDED FOR IN � SECTIDN370!OF THE LABOR CODE,INTEREST,AND ATfORNEYS FEES. RETENTION FEE: oCONSTRUCTION LENDING AGENCY PRE•ALT FEE: � IHEREBYAFFIRMUNOERGENALNOFPERNRYTHA7TMEREISACONSTRUCTIQVLENDIN6AGENCY FOR THE VERFOfiMANCE OF TNE WORK FOR WHlpt iH15 PERAl1T IS ISSUED ISEG 7097,CIY.C.). Z w � IENDER'S NAME � IENDER'SAODRESS � TOTAL FEES (D7�S O � ICERTIFYiFUTIHAVEREADTHISAPCLN:ATqNANOSTATETHATTNEABOVEWFORMATION15fARRECT. W IAGREETOCOAIPLYWITH�LLLITYAN�COIMTYORDiNANCE5ANO5T�TEUWSRELATINGTOBUtIDINC � CONS7RUCTION.ANDHEREBYAUTFqRIZEREPRESENTAT1YE50FTH15COUNTYTOENfERUPONTHE ZABOVE�ME TICNE07ROPERTYFORINSPE PURPOSES. , o � COMMENTS J 2 ,-� �. _ m DER ITfEENAUE n � � � � � 9iaw�TUPE F � OATE � RECPT.k0. � PAID BY VALI�ATION WHITE—Departmen[Copy,YELLOW—Finance Copy,PINK—Assessa Copy,GOLDENROD—File Copy,GREEN—ApplicanfS Copy , , ,�r . .. ,.., . i:. :�'� . , ',aC , , • .. . �r'..'x�rl '7-. 'rv' . � :�x�r,.:'. .,. ,Y,_;__ -. ...���.'�4��� � • .if.�•.'r:.... .,. ` . . 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SEEP PIT/LL. ON SITE IF.9P5. GAS AIR TEST FINAL ZONING FINAL CONST. � . �IRE DEPT. FINA! FINAL HEATING � HEALTH DEPT. FINAL FINAL ELECTRIC DEV. FEES PAID FINAL PLUMBING ENERGY , t-.,.,...-r.-,.-•�-----�-----, r���.,�f1 t'�1�,Clr.l�:, .s,..___„_ -._..�__._.__.,��._,_.._ cor,nnnEr�Ts SEPTIC TANK SIZE SEEP PIT/U SIZE i�G � r��� i�I � I ; `� ' , .