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HomeMy WebLinkAbout12895 (13) i ` C1TY OF DIAMOND BAR ,t.-- ' '- ��"� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICE 21660 E.Copley Drive Suite 190 �,,� � (909)860-3195 Pax(909)861-3117 �--� PRESS I �����° BUILDING PERMIT APPLICATION FIRMLY � � JOBSITE p� �y J y� , APPLICATION �-C_ PERMIT �, P/C � A ADDRESS�(y I� ,�� �U(Z h?'L. � �! �.. DATE � NUMBER�_ # c� ; ISSUE TYPE OCC APN LOT TR T__ DATE CONST. GROUP p OWNER i � ` LL A�DRES L ZONING SETBACKS � CITY ' 21P I TEL._S - FRONT ' RW f_l_ APPLIC NT TEL. REAR ❑_._._____ z SIDEISIDE STREET RW ❑_ � CONTRACTOR f� SIDE _ ❑_._._ o A�DRESS 3 ' PROPOSEDUSE ���J CITY ZIP TEL � ! oARCH/ENG/ — � dDESIGNER NO.DWEL. NO. NO. i ADDRESS� UNITS STORIES BEDROOMS ! � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION I O OWNER•BUILDER DECLARATION SFR/ADD/REM I � I HEREBV AFFIMI UNDER PENAL7V OF PERJUFlV THAT I AM E%EMPT GROM THE COMRACTOqS LI- � � Garage/Carport I GENSE U1W FOR iHE FOLLOWING REASON(SEC.7031.5 BUSINESS ANO GROFESSIONS COOE:ANY CITY OH COUNTV WHICH REW IPESA PERMITTO CONSTRUCT,ALTER,IMPROVE,UEASOLISH,OR RE7AIqANY STRUC- � w 111RE.PRIOfl TO IT9 ISSUMICE,ALSO RE-0UIRES 7ME NPPLICpNT FOFl SUGH PEFMIT TO FILE A SIGNED ; W PdtI0/DBCk � STATEMENT THAY HE OR SHE IS LICENSEU DURSUM7T TO THE PROVISIONS OF THE CANTRACTORS LI� � � CENSE UW(L7IAPTEH B(COMMENCINO WITH SECTION 700�OF DIVISION 30F THE 6USINF.SSAND PRO� ' LL' POOVSPB � FESStONSCODE)ORTWRHEOHSHEIS[XEMP7THEFEFHOMANOTHEBASISKORTHEALIEGEDE%EMP- �. (� TION.ANYVIOUTIONOFSECTION7031.58YANYAPPLICANTFORNPERMITSU&IECTSTHF.APPLICANTTO Re-Raaf � ACIViI PENAITY OFNOT MORE THAN FNE HUNDREO DOLLARS(3500).)' Z � ❑I.ASOWNEqOFTHEPROPERTY,ORMVEMPLOYEESWITVIWAGE5A5THEIF50l.fCAMPENSATION, � Commercial � z YI�LLpO THE WOHIC,AND iNE STflUCTURE IS NOT INTENDED OR OFFERFD FOa SALE(SEC.7aas,BUSI� . _1 NE55 AND PflOFES510N5 COOE:THE CONTflqCTOFS LIGENSE UW DOES NCT APPLY TO pN OWNEfl OF , � PROPERTYWF100UILUSORIMPROVE57HEREON,PNDWFtO[bESSUCHWORKHIMSELFOPHERSELFOR � �� � Q THqOUGH HISOR HEH OWN EMPLOYEES,PROVIOE�IHAT SUCH IMPqOVEMENTS ARE NOT INTEN�ED OA m W OFFEREDFORSALE.IF,HOWEYERiHEBUILDINGORIMPROVEMENTISSOIDWRH14C4EVFAROFOJMPLE- �� z TION,THE OWNER�BUILOER WILL HAYE THE BUHDEN OF PROVING THAT XE OR SHE DID NOT 9UII.�OR � IMPROVEFORTHEPURPOSEOFSALE). I f7 1,AS OWNEROF THE PqOPERIY.AM EXCLUSNEIY CONTRACTM6 WITH LIGENSED CONTRFCTORS ; � TO CANSTRUCT 1TIE PflOJECT(SEC.70tA.BUSINE6S AND PROFESSIONS CODE'.THF.CONTRACTORS LI- ._�� V8IU0110f1 ___.___„_. _.___ADJ.AREA_,,,__ _._._._ I W CENSEUWOOESNOTAPPLYTOANONMEROFAPROPERTYWHOBUILOSORIMPROVESTHEflEON,AND � �� KHOCOMRACTSFORSUCHPROJECTSWITMACONTRACTOR�3)�ICENSEDPURSUANTTOTHECONTRAC- __ QUANTITY DESCRIPTION FEE Y TOqS LICENSE UW.�. � J �.... 0 L'J I AM E%EMPT UNDEFl SEC._ ___8.&P.C.FOR THIS PEA50Y �; U � '_'_ _'_ ""_' �[ � Z �ATE _OYMER_'__ _..—_ '� W /'J C � � LICENSED CONTRACTORS OCCLARATION ,: �j � I HEREBY AFFIRIJ UNUEF PENALTY OF PFRIl1pY THA71 AA1 LICENSED UNDER PHOVISIONS 0F GHAPiER .�' � � '' � B(COMM6NqNOWITX5ECT10N7o00)OFDIVIStON30FYHE�U5INESSAhDPROfLSSIONSCADE.AN[7 Z —�`� Y MY LICENSE IS IN KULL FORCE AND EFFECi ° LAJ � i 0 LICENSE ClASS LIG.N0..___ ____ _—. _� � � �i V DATE CONTRACTOR__."_ _'___"_ d � W , � WORKERS'COMPENSATION DECLARATION a � � IHEREBYAFFIHMUNDEHPENALrYOFPF_RIIIHYONEOFTHEFOLLOWING�ECLARATI0Y5: � � � Z O _IHAVEANDWIILMAINTAINACERTIFICATEOFCANSENTTOSELF-INSUREFORWOFK[RS' � I Z COMPENSATION,ASPROVI�E�9YSECT10N37000FTHElAWRCAOE,FORTHF,PERWRMANCE U Q OF THE M�ORK FOR WHICM THIS PF.RMIT IS ISSUEO. � � W 1 HAVE AND WIIL MAINTAIN YlORKER5'COMPENSATI04 INSU7iANG[,AS REOUIRF,D OY SECTION Q 3700 OF TME LABOR CODE.FOR7HE PERFORMPNCE OF THE WOHK fOR WHICH THIS PERMIT IS � �SSUED.MYWORKEPS' P NSATIONIN ECA RANDPOLICYNUMBERPRE: CONSTRUCTION �_.._,,._ ,_„__._. ___.__ '_—" � ' � ` ry -. • ..---- PLAN REVIEW � CARPIER --"--'- '_—'... _....__.. ..__ 5 � POLICY NUMBER � � .—. --- EI.ECTfI�C.`� (y�����. � ' _"—"'_ .____. ._._...._ r � (fH166EC110NNEmNJTBECOqiPLEiEDOFlHfPERAN7ISFOIiONEHUNN�LU�OLLARfiISIm?ORLESS} ,PLUiU161NG __- __. U � ��, 'r _._.-__. ..—_. '__.-_.— Z ICLRTIFYTHATINIHEPEflFORMANCEOF7HFW�RKFORWHICHTk11SPERMITI5ISSUF.U,I ANICAL ______ _.___.. ... ._.—. (} SHALINOT EMPLOYANY VERSON IN ANY MANNEft 50 AS TO BECOMG SUBJF.CTTO TIIE '' � WORKEflS'COMPENSATIONLA'NSOFCALiFORNIA,ANDAGRE[THATIFISHOUL00[COME INSPECTIONFEE _...... ...—.—_ - _ — - SUBJECTTOTHEWORKERS'COM7ENSATIDNPFlOVISIONSOFSLCTION37000FTHF.LAEIOH ' . � � . � 5 LLF RTMWITNCOMPIYWITHTN O�ISIO 5. ISSUANCE . . �.,� � O / � � ��-��� SMIP �� -'- -� —� —�— i: p DA7E:�_�_. APPLICANT: d _.._'_ _._'_ .._—.... '__ : -.__'.__ J ENERGY P!C J WARNING:FAILURETO SECURE WORKERS'COMPENSATION CAVERAGE IS UNLAWFUL.AND SHALLOE —'—" ' "'--"'-/yry -"""—"' "'—"—�— � LL SU&IECT AN EMPLOYER TO CRIMINAL PENFlTIE3 MID CIYIL FINES UP TO ONE HUNDRED THOUSANU ENERGY PERMIT 1�yy �' OOLIARS(5100.0OO�.INADDITIONTDTHECOSTOFCOMPENSAT�ON,DAMAGESASPf70VI�EUFORIN —"""' 747'a'm�---"""'—' '-'—'— � J SECTION370BOFTHELA80RC��E.INTEREST,ANDATTORNFY'SFEES. ' FETENTIONFEE: � � _ ' ,._.. "'-_. _.._..—.. .—.—. y O CONSTFIUCTION LENDING AGENCY PRE-ALT FEE: �.��+���� .__. _ '� ����-�' �y''��[�p5;'�' �: �- FORTEHEPEflIFOFMANCE FNp[W RKFOJqWHIGHTHSPRIMITS�ISSUED(SCN3o97oCIV.C�ENCY ___�yyg�YA�� 1a1`U[4.�DYSL�1.��� _____„ ___ M� St' �. Z _— .._—' —' '_' '— t: LLI —_' n � IENOER'SNAAIE..__"'__—_ _'___ _-' '-'-- .-- ---- -- ----- --�- ------- i� 1— LENOFp'SA�ORE55_. -- --..--._—... ..--- ,/J����. `�] � I CERTIFV THAT I HAVE HEA�TMIS APPLIGATION AND STATE THAT THE ABOVE INFORMATION IS CARRECT. TOTAL FEE� /��,�,�]/J '�' w IAOREETOCOMPIYWITHALLGTVANDCOUNTVORDINANCESAN�STATEIAWSRELATINGTONUILDING t../C.�' /(�' 4�•: � CONSTRLICTION,ANDMEREBYAUTHOFIZEREPR[SENTATIVESOFTHISCAUNTYTOENTERUPONTHE 6 ZABOVE•MENTIONED PflOPERTY FOq INSPECTION PURPOSES. COMMENTS_. ___ _—.. — --- �% � �,p J ' (//'/ "__ __ � PEHMITTEE' wNT�^ '—"— '— ,i —.'_ . "— _'___ � . . / ..�� — r _._ � ,-• Uj SIGNAT R OF PERM EE a E -;'�i�— � � � RECPT.N0._ � PAID 8Y ., __,VALI�ATION._, _. � WHITE—Department Copy.YELLOW--Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicanl's Copy �S S . �....�.. ... � ....... � � ... ..,� ..�,.,. ..� .., � � i I ' , i � — — � —� ` I �. � �� � � ' � I I � ' : i ' � I i �� � � i � i ( , � � i � j ; I � � ' � ' � z� , � i � ( ' I' � � ' ' � i � 1 � 1 � � � � � i i � ' �?�"� ': i .; ' I : ' I � ' � ;' I - ' i � � �. i i � � ; ; � k � �i I �� ; I j � � � I . � i ; ! � j � � § � ���; ,,' � � � ' 1 � I � I � 1 I � � ' � . ' �� ' �� ��. j � � i � j � 7 � ' � � � � ! 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