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HomeMy WebLinkAbout11161 --��`'`---- C1TY OF DIAMOND BAR I I COMMUNI7'Y DEVGLOPMENT DEPARTMENT � -�.W 21G60 E_Cupiey Dnve Suite 190 PRESS \""'.Y�y,,.,' (909)8G0-3195 Fax(909)861-3117 BUTLDING PERMiT APPLICATION FI RM LY �' JOBSITE � ,��p� l� ; APPLICATIDN PERMIT � P/C o' ADDRESS �-�."f�� l..-1�I/Q�W�Y �I�7 7 �_�� � ' DATE NUMBER # � ISSUE TYPE OCC APN� LOT—�— TRA T �� DATE__ CONST. GROUP ___ p OWNER Y�(�i�4,iQ �-��E1�1��� ��t-CL' -- o. ADDRES�(y � - � Si �i�i✓. ���"_T. ZONING SETBACKS Z CITY ��. ZIP fS� rTEL._____ FRONT .. _.__ RW ❑ ___ o j APPLICANT TEL.� _ REAR ❑_,..____ Z SIDE/SIDE STREET_____. RW___ ❑ _ <' -y-- � SIDE �'-....__._.._ — m CONTRACTOR � 1 � - --- � A�DRES� I.S I . �'1 kfc(J.�� � 'g:�FA _.,. � CITY . ��'"tn1 F� ZIP��F,;;TEL. PROPOSED USE__„ _ � w ARCH/ENG/ W. DESIGNER __ ' — a ADDRESS - " NO.DWEL. NO. NO. UNITS STORIES BEDROOMS � CITY --.--, ZIP------ TEL. _ �-- -cn- N DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION .pC OWNER-BCILD[R DECLARATION SPR/ADD/REM O p�. I HERE�Y AFFWM UNDER AENAIN OF PERJUHV THAT I AM EXEMPT FROM TIIE CONTRACTORS LI- G8l8gB/C2f�70f[ W' CENSELAWFORTHEfOLLOWINGNLA50N(SEC.703f.5BUSINESSANDPHDFFSSiOYSCOOE:ANVCITYOH (n U COUNTYWHICHREQUIFl[SAVEFMITTOCONSTHUGT,�LTER,IMPROYE,DEMOLISH,OfiREPAIRANYSTRUC� `W Patio/Deck 'Z' TURE,PHIOR TO IT�ISSUANCE,A150 NE(IUIRES THE APPLICANT FON SUCH PGfiMIT TO FILE A SIGNE[) w� STATEMENT THAT ME OR SHF lu UCENSED PURSUANT TO THF.PHOVISIONS OF THE CONTRPCTORS U� �W �� CENSE�AW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION J OF TH[BlI51NE5S AND PRO� ��' POOUSPa �. FFSSIONSCOCE)ORTHATHEO(i5HEI5EXEMPTTHEREFFOMAN�THE�A5ISFOHTHEALLEGE�EXEMP� C7 V TION.ANYVIOLATIONOFSECTION7031.SBVANYAPPLIGANTFORAPERMITSU&1F.CTSTHEAPPLICANTTO Z Re-Roof A CIVIL PENALTV OF NOT MORE THAN FIVE NUN�REU DOLLARS($500).7: �; ❑I,ASOWN[ROFTHEPROPEflTY,ORMVEMPI..0YEE5YATHWAGE5A5THEIR50LECOMPEh5�T10N, . � CORIfI10fC18I Z� WILL DO THF WORK,ANO THE STRUCfURE IS NOT INTENOED OR OFFEREU F'OR SALF:(SEC.7044,BUSI� J � NE55 AND PROFESSIONS CODF.:THE CONTRACTORS LIC[NS[LAN'OOf:S NOT APPLY TO AN OWNER OF � PROPC:qTY WHO BUILDS OR IMPPOVES TH[HEON,AND WHO DOES SUCH WOflH HIMSLLF OH HERSF.LF OR � 711ROUGHHISOqHEROWNEMPI.OYEF.S,PROVIDEDTHATSUCHIMPROVEMENTSAR[�OTINTENDED�R m Q.;; OFFEFE�FORSALE.IF,HOWEVEftTHE6UILDINGO(iIMPROVEMENTI550LDWITHINONEYEAROFCAMPLE� Z TION,THG OWNLR-�UILOER WiLL HAVE THF.BUHUEN OF PHOVING THAT HE OR SHL UID NOT�UIIA OR � IMPROVEFORTHEPURPOSEOFSA:E). W (iI,A50WNEROFTH[PROPERTY,AMEXCLl15NF.4VCONTtiAGTINGWITHLICENSEDCONTHACTORS �� TO CONSTfiUCT THE PROJECT(S[C.70d6,AUSINE55 AND PROFESSIONS CO�E:TME CONTHACTOHS LI- V8IU3I1011__,,, ..,,,_,_ADJ.AREA W� CEN9ELAWDO[SNOTAFPIYTOANOWNEROFAPflOPEfiTYWl10[7UILDSOqIMPROVESTHEREON,AND --' -- ��� WHOCONTRACTSFONSUCHPR0.IECTSWITHACONiRACTOR�S�LICENSEDPURSUANTT07HECONI'H/!G �UANTITY DESCRIPTION FEE � lONS UCENSE LAW.�. � ..___9.8 P.C.FOH THIS REASON U _ ��- � '���(�;1 �G.��_ �,r� � � ❑IAMEXEMPTUNDLRSEC.___... --. � �. �......"-_"__ '_'...__-_..... ._ -'_..."_' LL DA7'[ '__...._. 04VNER.___._.._. ___...__ U Z W �� LICENSED CONTRACTORS DECLARATION W �� 1 HF:REDYAFFIRM UYDER PfNALTY OF PENUfiV THAT I AM UCENSED U��ER Pf10VISIONS UF CtIAPTEH � - d' 9(COMMFNCING WITH SECTION i0oo)OF OIVISION 30F TH[BUSINESS ANO PHOFESSIONS CA�E,ANU Z W MY LIGF'NSE IS IN FULL FORCE ANU EFFEGT. m o � � E� ������ � � LIGENSE CLASS.__......__...._ LIC.NO.__......_..—___ . . J VDATE ... CONTRACTOH _"..___"'� a W __.._...'___--...._._ �� WORKERS'COMPENSATION DECLARATION �� � � -� Q y U N IHEHEBVAFFlfiMUNOF:RPENALTVOFPERJURVONEOFTHEFOLLOWMGDECLARATIONS: Z A 0 IHAVEqNDWILLMAIYTAINACERTIFICATEOFCONSENTTOSF.LF-INSl1R�FORWORKEflS' _ � fAMPENSATION,A9PROVIDEDBYSECTION3]aoOFTHELA(i0liCODE,FORTHEPEFFORMANGF. U ¢ UF 7HE WORK FOR WHICH THIS PERMIT IS ISSULD. � � W __I HAVE AND WILL MAINTAIN WOFlK[f13'COMVENSATION INSURANCE,AS REOUIflED BY SECTIOh Q37C0 OF THE LAROR CODE,FOR TH[PfRFONMANCG OF 1)IE N'ORK FOR YJHICH THIS PEHMIT IS _ ISSUE�.MV RKERS'COMPENSA'fIONINSURANC!E�CAqRIERANDPOLICYNIJMBERA �� CONSTRUCTION j cnHRiEa !c: �6��r �CyJ'£�y� �� . L`9 ..�;� . PLANREVIEW _._'.---��- -- -- _..-.-...---- c' ,. . 0 POLICY NUM9ER���_�_�'�' ? ,�k��- _ • �1 '- ¢ -�'- —�}�;"�- �._.��" -...._.._...-- --�_—_ • Q �}{�,55[C7pN�EFDNOTBECOMf'LE�EOOFhIEPEMMTI3fOROIJ[HUNUHLDDOUJFi57�too)oat�ss), PLUMBING ...__-�"' ` ��. _...."__ U .�,:{',.�% ,y., Z i CEH7IFY THAT IN THE PERFORMANCE OF THE WDRK FOR Wf IICH 7HI5 7ENMIT IS ISSUED,I MECHANICAL __�_ ._. _______ (� SHALL NOT EMPLOYANY Pf:HSON IN ANY MANNtH SOAS TO BECOME SUBJECT TO 7HE � Uj WURK[fl5'COMPENSATION LAWS OF CALIFORNIA.ANDAGPEE THqT IF I VIOULD�ECOME �NSPECTION FEE ,______.,,, ,_.__„_ ,_ � SU&IECTTOTHEWOFlKFflS'COMP[NSATIONPROVISIONiDF5ECT1 N3 OOFTHf:I.ABOR � GO�E,I SHALL FOflTH TH COMPLY WIT S[PROVISIo . ISSUANCG . ' � �_ g��}� __.__.. - � `���� , .. SMIP .e.7,F"a1�u__ .. s�........---- -�----��---- -- p DATE:�_._.... APPLICANT: ..._ '_' _ _"-- � ENERGY P/C J WARNIN(`i.FAILURET05[CUREWOHKEHS'COMP[NSATIONCOV[Fl�GEISUNLAWFUL,ANDSHAL4P[ ---"--"-'�--- ---- -'- "'_"_'_' LL SU[LECTANEMVLOYERTOCHIMINALPENALTIESANDCIVILFINESUPTOONEHIIN�H[DThI0U5AN0 ENERGYPERMIT DOLLARS�St00,ttq),INADDITIONTOTH[COS70FCOMI�F:NSATION,UAPAAGF.S�SPROVIDEDFOflIN -------- --- ------ --- --� --- J SECTION 3708 OF THE LABOR CODE,INTEREST,ANDATTOFiNEV'S FCES. RETENTION FEE: ______ � ...._ _..-...._ -""-" dCONSTRUC710NLEN�INGAGENCY PRE-ALTFEE: __,.,,...—._.... _.__.._.._ _.._._.__.... - O � IH[R[flVAFFIfIMUN�ffiV[NALTYUl�PEfiJURYTIIA'f'fNEHEISACONSTRUCTIONLENDWGAGCNCY � �OHThIEP67FOf1MANGEOFTHCWORKFORW111GHTHISPEflMITISISSUED(SEC.309I,CIVC.�. "" ��� � "' ������ '� ' �"' Z W .. __..__..._._...-__....._ _.-. _'.- - = L[ND[fl'SNAME _._.-..___.._._... ... --._.__ � -- ..._....-...__ '.-__ ___;, _- F- LENDER'SADORE95_ ...._-.- . � ICEF1'IIFVIIIATIHAVEREAU711ISAVVLICAfIONAhDSTATETHAiTHEAUOVEM�OFiMATIONISCORRECT. TOTAL FEES I W IAGREETOGOMPLYWRHALLCIIl'ANDCOUNTYORDINANGLShNUSTATELAWSRELA71NGT00UiLDING � CON3TRUCTION,ANDIIEHLI3YAU7��OH�Zf:H(:pqESENTATNESOFTHISCUUNTYTOENTf:IIUPONiHE � AOOVE�MENTIONEDPqOPER1Y(ORINSVECIIONPURPOS[S. ? GOMMENTS __..._...._---...-.. _ ..----... '.-"--...__ � � ...._-. .------. ..-.._ ...---' -._ � -.._..—.. .—.......—_..' . _...---...._..._..... ..- ¢ PEH ... AME(PHINT) y __' "'_'____ _ ryp (�^( _. _ � ��.�.Lr"�s_ •.� -__.-.._.. ^��' RECPT.N����__._..... PAID BY -- ,--.VALIDATI�.".--_ _ - ----- -------- - __ _ l� �---- � SIGNATU OFPERM,ITTEE DATE �J 2 � WHITE-�epartment Copy,YELLOW-Finance Copy,PINK-Assessor Copy,GOLDENROD-Fiie Copy.GREEN-Applicant's Copy . __ ._ _. __.. w � -� ,. ; � , _ � ... _.,_. �. ._- - ; - , _ ---- - - � i � i , � i .� �. � I ( � ' ; � � � I .i �_ _ 1 � � ; , ; � ii ;, ' � � � ! � ' i j i � I i , , i � ; � ,� � � : I � � f � � : � � � , � � ��>� ; , ' ' � ' ( ; � ' ( � � � , � I � � I �. i i � I I I � � �� ' I ' ' ' 1 j I I I : � I I j , I � i ',_. ' ! ` � � R � �� i .i ; i ' I � ( 1 ,; , I ' � � � 1 � , ��� _ � j i_.. � __� �._ �_. ; _1... � ' � - ' I ; ' �' ; ! � ��� i —� ' � � - — ( ' I ' � ' � ��� � , �� � , � � � � ' � � � �) � ,,,� � . ( � � � ' I i � � ;; � �� � � � i � � � ` j � I i � � { ! ' I I � � ! , � ��� i � I ' , � ; � � � I � ' '� � ; i � , ���'— �-- � � .; ' .' � ! �-- ' — ' � ' f � - i � f � - _ , ���� I ' i 7 ' 4 I_ 1 ' t f,� i � ; i � � E I , �� i I , j E . _ ��� i ! ...i � ,. 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