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HomeMy WebLinkAbout10782 (5) i _ . . -- - - - � CITY OF DIAMOND BAR �' ' COMMUNITY DEVELOPMENT DEPARTMENT :,. ' 2I660E.Coplcy Drive Suitc 190 . ' PRESS (909)86Q3195 Fax(909)86I-3117 �'^" BUILDING PERMIT APPLICATION FI R M LY �o DDRESS� �� I_�/�./l�t'f �[� APPUCATION �(�� � PERMR � P!C DATE 1 NUMBER M � ISSUE _ TYPE OCC APN LOT T ACT DATE CONST. GflOUP p OWNE�.I/3-E�� l�1.L17�'� _. I�-[�/ "" ADDRES ZONING SETBACKS � CfTY ZIP TEL d FRONT RW p APPLICANT TEL REAR ❑ � —� SIDE/SIDE STAEET RW ❑ CONTRACTpR ' � - SIDE ❑ � C�D�DRES z�P 0 TEL — � PROPOSED USE � ' o ARCH/ENG/ _. - , � � DESIGNER � � NO.DWEL NO. •NO. . . ADDRESS UNITS STORIES BEDROOMS � CfTY ZIP TEL � DESCRIPTION S�.Ff. FACTOR PSF AW.AREANALUATION . � Q OWNER-BI:ILDER DECUTAATION SFRIADO/REM O p I NEREBY AFFIRY WOER VEWLLTY Of PERAIRY THAT I AA1 EXEMPi FR0117NE tOHTMCTO0.S l4 GeflQ9�CeIpOR � W CENSEUWFORiHEFq10WINOREASON(SEG70.11.6BUSINESSAN�VROFE5510NSCOOE:ANYCRYOR (n U COUMYyM1p/RE0URE5APERMITTOCONSTRUCT,ALTERaPROVE,DE1/OUSH,ORRE7AIRANVSTi1UG W Patio,+Deck � il1RE.PNIOR TO RS ISSUANCE.ALSO REWiRES ME APVLICMff FOR SUCH VERMIT TO F0.E 11 SiGNED W , � STATEMEHT 7HAT ME OR SNE IS LIGENSED VUHSU�NT TO T„E Pf10V1510N5 OF TME CONTRACTORS LE , . � CEN6E UW(CHAVTEN 0(C0IAAIENCN�WITM SECTqN 7000)OF DIVISION 7 OF THE BUSINE55 N10 VRO� LL' P�� FESSIONS CO�E)OR TW1T ME OR SHE IS E%EYPT iHEREFR0A1 MlD TME BA515 FOR THE ALLEOED EXELIP• r TION.ANYVIOLATIONOFSECTION707f.6BVANYAPPIICFNTfORAPERMITSUBJECT4THEAPiIICArITiO f�q-F1pp1 � A GVIL VENALTY OF NOT MORE TMMI FNE MUNDRED DOLLARS(fR�ol)' � OtASCNNEROFTMEPROPEFTV,ORMvf�PIOYFESNATHWA0ESA5TMEIRSOLECOAIPEN5AT10N, 0 COrt1m6fGi8I - YVILL 00 THE YIONK AND THE STRUCTURE IS NOT WTENDED OR OFfEAED FOq SALE(SEG 70u.BUSI- J � NE55 M7�PROFESSIONS COOE:THE CONTMLTORS UCENSE Uw DOES NOTAPPLY i0 AN OVMER OF ? 7f10iERTY YMO BUlDB OR IMPRDVES hIEREON,AND N7�0 DOES SUCl1 NOFK HIMSELF OR NERSELF OR [L TNAOVQHNISOqHEHONTIEYPLOYEES.PROV10EDTHATSUCMWPROVEYENTSMENOTMENDEDOR m WQ OCFEHEDfORSAtE1F,F10N�EVER7ME8ULDp1GORMVROVEMEM650lDWfiMNONEYEAROfLOMPLE- Z T10N,iME OWNERbUILDER W1LL HAVE TME BURDEN OF VROV7J0 THAT NE OR SME 00 NOT BURD OR = WPiqVE FOR TME PURPOSE OF BALE� O l�+��ER OF THE PiqVERTY.N.�E%CLUSNELY CONTMCTNO WRIi LICENSED CONTMCTORS ¢ TO CONSiRIKT THE VRO.IEGT�SEG.7W�,BUSINESS AND Pi10FE5510N4 CODE:iHE CONTRACiORS U• V91UiI10�1 ADJ.AREA W CENSEUWDDESNO7APPLYTOIWOvmEROFAVROVERTYW/10BUILD50NIMPROYESTMEREON,ANO � 1MqCONTMCTSFORSUCHVR0.IECTSYATHACONTRAGTOR(S�L�CENSEDVURSVIMTOTMECONTMG OUANTITY DESCRIPTION FEE � iD0.S LICENSE UW.). � OIAAIF%EAIPTUNDERSEC. B.10.GiORTHISAEASON U '� ¢ u" OATE OM�NER f' + • ... � W • . . F LICENSED CONTRACTORS DECLARATION w � IMEREBY�FFIHMUNDERPENALNOFOE0.NRYTUTI+IMUCENSEOUNDERPROVISIONSOFGIAPTER � � Y(COI,M�ENpNO WITX SEGTION 7ooD)OF OMSION 70F THE BUSME59 AND Pfi0FE55qN5 COUE,AND Z lL ��NSE IS N ML i RCE AND G�T.j m � UCENSE CU � • • IIC.NO. � V DATE CONTMCTOR W � WORKERS'COMPENSATION OECLAAATION . � = U � 1 NCREBV hFFIRM UNDER PEN/LLTV Oi PEfWRV ONE OF TNE FOUAVANG�ECURATIONS: [A Q � _IHAVEANDWILLMAMTAINACERTIFlCATEOFCONSEHiTOSELFiN5Uf1EFORNVRNERS' _ GDMPENSATION.A9GROVIOEDBYSECTIONI7000FTHELIBORCODE.FOHTIEGEH�ONANICE w OF TME MlOR1(FOR MMICII TMIS PEIIMIT IS ISSUfD. � C / � ,�1 HAVE AND WILL NAPlTA1N WORKERS COMVENSATION w5URA1lLE,IS REOIARED BY SEGTION Q 77000FTHELABORCOOE.FOR EVERFORYANCEOFTHEM/ORKWR C�I7MISVEfWR15 2 'J � ISSUED.W NORKERS COMPEI T�� 10E CARRiER AND OOL� NUi iBER ARE: CONSTRUCTION il" " Y L S� . � CARRIER PLAN REVIEW. . 0 GOIICYNU.�OER ELECTRIC p (nass[cna+r��r+oreEoor.a¢rmocnfrEwarsxaor+eH.►a�n0n�uu6+aqaa�rs51 PLUMBING Z IGERTIFYTHATNTMEPERFOfiMNlCEOfTMEMpAKFORWH�dITH�SPEPA11TI5155UE0.1 MECHANICAL (� SNALLNO7EMPLOYANYPERSONWANYMANNERSOASTOBECOMESUBJECTTOT}1E , , uj WOPo(ERS'COAAPENS�TqNLAW50FCALIFORNI�ANDA6REET1UiIFISHOULOBECOUE INSPECTIONFEE S SU61ECT70THEWC%INERS'COMPENS�TIONGROVISIONSOF C �7000f71/EIABOH cooE,i v �c�rwi sevaovis ISSWWCE � r � SMIP � _/ p WTE: � A �CMJf: ,. ,� �._t�� w ENERCaY P/C �� �'! w J� � WMMNO A0.URE TO CURE WORKERS'COYPENSA7qN COVERAGE IS AND S/ULLBE �"� 6UBlERANEMPLOYERTOCR4NALPENKTIESANOCMLfINESUPTOONE ED7HWSAND ENERGYPERMIT DOLURS�i100,000),N AODITIOH TO iHE C0.5TOF COMPENSA7qN,DAMAOES AS PROVDFA FOiI p1 ¢ 9ECTON77WOFTMEUBORCOOE,NTEREST,ANDATTORNEYSFEES. � R�7ENTIONFEE: a CONSTRUCTION LEND�NG AGENCY PRE-AlT FEE: O v . , ,. � 111EHEBYhFFIRMUfDERVENALTVOFYERIURYiMATMEREISACONSTRUGT10NlFNDINOAGENCY Z iOH iHE iERW RMANGE�F 1HE WORK W R MnnCN 7MiS PERMI7151SSUED(SEG]oa7,CIV.Gj. W � � IENDERSWWE � LENDER'SADORESS � ICERTIFYTFIATINAVENEADTWSMVLICATqNANDSTA7ET1UTiHEABOVEHFORM�TpNISCDRAECT. TOTAL FEES , � W IAOREETOCOYGLYNnTNALLCRVANOCOUMYORDwANCFSMIDSTATElAWSREUTIN�TOBULDINO � � CONSTRUCTqN,ANOMENEBYAUT110RIZEREPRESEHi�TNESOFTH15COUNTYTOENTERUPONiNE � S�. �BWE�MEMIDNEOCROOERiYFOi11N5PEC�ONPURPOSES. COAAMENTS � a��`4--� S � O° v¢ e C /'� Cn � n/ � TUR CERM F O�iE � ��` RECPT.NO. � P.+JD BY VALIDA � ,� WHITE—Oapartment Copy,YELLOW—Finana Copy.PINK—Astesaor Copy.GOLDENROD—Flk Copy,GREEN—AppllanCs Copy .. '•f� .. _ •.�,..w�.Ty'M)'f .�St'�JJ:�t��y4�c•�e�4..t...:�. ..► �:v..�+, 1�. .rl��••�.I�JI'.� �t.i"� ��r�r)'��:•" � �f 'N-. 'l.`.'v ^y: •{. r,. �1'.�o- f�}.`i :-r/.ti'.f'I ^�!'� :r . . - , lS'�".").�,.w.i.�y .iR� . ,. '+•. '•�.i'i.."��•,��' . �.5`. . . . 1...,. . . �l�'e.(:''. 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