HomeMy WebLinkAbout103 �'�.' �.w,�
''�` CITY OF DIAMOND BAR
� � ` " ` DEPARTMENT OF 9UILDING AND SAFETY PRESS
BUILDING PERMIT FIRMLY
JOBSITE �f��� APPLICATION PERMIT USE
ADDRESS _1'J �-� ���'�� �r�.-• DATE ..Ll..����L_NUMBER �d CODE
lSSUE TYPE OCC
� APN �OT TRACT :� DATE �s��.�CONST. \�� GROUP�
O CROSS ST ET SET�ACK.S "�'o�'"E°"5
°� OWNER �, ZONINC'a FRONT ---A'9� ❑
� ADDRESS�r�_ ����! REAR—._ � ❑
W CITY _ '� Z ��.�T�LG�,.�:�s-3 � SIDE/ REET RW ❑❑
i
o APPLIi^,ANT TEL.��' E�
4 CONTRACTO �`�/ " �- -'` �—�-���' �- SEWAGE
❑ PUBLiC PMT#�
o ADDR�,,S,S -�''., �? �'O�� . r�g��� DPSPOSAL ❑ PRIVATE SQ.FT/100 GAL
W CITY�-�7���4 ZIP ���"�TEL�. •'
z STATE [f���� GRADING ❑ CU.YDS.EXC. CU YDS FILL
� LIC.NUMBER I /
y ARCHlENG! � �''P� SQ F1` FA�7OR PS ADJ. AREANAi. TION
� DESIGN�R _ � ? ____, '
' o ADDRESS �,�. 2
z CITY ZIP �T�L. +� 3
� PRO?OSED USE_���C- ""�Ex„�__ � 4
� � GARAGE
z NO DWEL. NO. NO. � P� —�
y UNITS. STORIES BEDROOMS._–__. m ---�•
� LOT DIMENSIONS VALUATiON ADJ.AREA_
o NO.OF BLDGS HOW � QUANTItY CtESC,RIPTI N FEE
w ON LOT USCD � �
w u ,- ,� � �
�� � --
ICE .:�C9'�?flACTORS OECLAF0.TION I herehy aHinr ihai 1 am ficensed!maer provisions uf ChaD�ei 9 1[ommencmg }'� --
� wirh Sar.m•��7;7f10i��'D,vrsion"s oi ihe Business ar.d Prulessions Cnde and my Lcense is m full}orca and¢ffect W
3 ❑ w
=I CVJ�tiF'�5UII OFH CEf.LARl.TION I hereLV alfrtm:hat 1 am eeempt Irom the Contracror's L¢ense Law!or the!ollowing , �.� -
rea:un ISr.r. �G315 Business nnd Professions Catle Any ciry m tounry which requiies a permn to construcL i,� ';��u�
oaha- impra.e,Cr.inclixh,or iepau any svueturr. pnar In its issuance.,also reQmres the apphr.ant fm such permit �'
F- to hle e s�on�v!s;atement that he�s Iicensr0 oursuant to 4,e pmvisans nt ihe Cnntracim's ticense Law IChapter �
� 9lconmencmq w�Ih Senina 700CI ol Di�aion 3 of!ne Busine.as ard Piolessons f,ode�a�hat Fe is eKempt therefmm �
d and ih�•Lasis:�r f e.allegeA r.cnnDOm•� Airy viala[ion at Secipr 7�31 F by any appli[anl to�a pr.rmit sullecn �
u Cx apWream to a c:nl penahy a�not more ihan Lve hmdreC daflars iS50Q1� —�
.., a
� _�I,,is�,wner ol the pruper�� o�niy employres with wa5es as tneir snle compensaUon w�ll rio Ih;work,aM � --
nre s;�icune,s cot:�tenar.d:.r effere0 for sale i5ec 7044,Bnmiess and?mfessians CrAe T�:e Cnmracicr's ticense e[
� w Ares nnt xpp��c an nwnr.r of praperty whc tuilds c �mpra•es th�xaon and who Aces sucM1 wmk himsell (,� --.
' or;lirau[F hs ms�i=^�oloYees pr0aideA tl`at 5uch impr0vement5 ate noi�n1P.nAeA or afferen!or Sale If,howevef, �
m ri=budd�ni or:mprnvement is sold withm one year of compleli�n,the owner6wide�w�5 have Ih•burEer n!proving � _
�I riai iie mtl nm burd nr�mprovz for the pur0ese a'sale j 2
y G
�s i�:.�I,as r,�nner 1'�1�'�E FiU(�Cf1Y Tm PMCIUSIVCH(cort�actm�with I•ce.nSN.^.onvactow!0 C01151111C1 IhQ�fp�PCi IS¢C � ��
Q ?C44.B:s�•ieas a�n Prafess�ons Lone The Cuntrac�oi�s hcense law doPs nol apD�Y Io 2n nwn�i of pref•erty w�o g
�I::u M;�r imprnvr.s�I�rr=or and whg convar.:s for such pro�rcts with a contractor�sl licensed pursuarl!n the Cont�a�tor's "
Q'�irr-s'c faw� CONSTRUCTION I
c
"'��L�a�n exvmp�unCer Sec ,B.6 PC 1Attxh Crnifitatel PLAN AEVIEW �
p�Datr. Ov+ne� i
ELECTRIC
3 VrURKEPS C�MYENSnTILW�JECLARAl10N i he2cr alfirm tAai I ha�e a certAicate of rnnsent m s¢N-mcwe.o�
a certibratr ul Workns'Cnmpensaunr Insurance,nr a certilied copy Ihereof ISec 3900,la6 C 1 P�.UMB��G
¢I�.�Geinfie0 r.aay s herehv fwnisheU � MECHANICAL �
d� �Ct�nlieA coOY is ftletl wrtA:he Bmltlmg Inspecnon DeDartmert or xnd��m���.� � GRADING
W — • ,��y
Z CEATIFICATE OF E%EMPTION FHOM 1NORKERS'COMPENSA710N INSUflANCE This eection need not he cnmpkted I o ISSUANCE �,.�t(TC.!
� •.f V�r permrt:s!ar cne hunereA i5100)or less I cerirfy�ha�in ihe erlarman[e of the work for which ihis
y ;emni s�ssu^d, shall not em la art pe�son m an marnei so as w nme subecl to Ihe Wor
P Y 4 Y I J�rs'Compensalion g�iP
.aws cl[,�lar.a .F ^I
� I �, -'� �,�{� �,��.�,�' f W PARK FEE
p iatr �� ADOlicanl �'�„�_ �
� NOTICE TO[�PPLICANi If,aNn r^•aking ffi�s Certilicate al aemD�on,you slwuN hepame sn6�ec1 ro�he Nbrke�'s I SCHOOL FEES
_+ Cempensauon;rm�aions of the La6or Code you must forlM1with comply eunh such prwrsans a M¢permrt sh�ll
LL he der.med mroked � --.—
�
� �IVISIUN OF INCUSTHIAL SAFETY PEBMIT CERTIFICATION
W S
� CI Iie�r.Ay cerlAy thal ro e�[avatior.In�e(51 nr ma�e leet m depth inic whith 7 person is repuired�o de5cend.!!
� wdl�e matle m connecuon wnh work authaaed hy thu permn.end that r.o huAding stru[Ime,sulkldinp,felsework,`�
a- ;r darnolmon cr dismanllinp theieo}.will he mare.Ihan ihirty�siM(36)ire�hph (Chap.31.Grp 2.Art 7.Sec Ij
Z aa�.T����a.r,nc; I� --- _�.ITY t7F D1AI�1dNU
_ — — ---
3 ❑Ac owner�hwi4r I wili noi employ a,ryor.e to Go woik whrth wwl9 require a permn hom me pnsm of I g����{(y� A�1D SA�E'1'
�—. IniM,slna!Salety,as nmed above,unless such persan Fas a DMmn ta do such wwk Iroo the diuieion. I � -
�
w ❑Unswn ul InEusa�al Sahry Pe�mrt No. TOTAL FEES ' , `�1�
a.
� CUJSfRUCfION LENOING AGENCY I herehy aflirm Mat therz is a conshatinn lendi�apency 1a ihe pertormence
Z nf the wa�k lor wh¢h�hrs permn rs rssced ISec J091,(]v C.1
� Lender s Name
= ie�n��,aeare,� CCMMENTS
m
4 CER7IFICATE OF COMPIIANCE ANd AUTfI0R17ATI0N OF ENTHY I catily 1 haw aad Mis applintian and sbte (
rn that fie mlormat�an�iven is correct I agree ro mmply wnh all state laws and nry orM�uMns rela�ing to Miildiip
�y onstmaion,and ihori e a repasentative of the Department of BuiNinp a�SafMy m mhr tlie p�dperry
_ !ar whirh I ha pl�ed for tAis permit forrN�'d ose ot mak'��ay nspectans- / �
f- \ !? � ��f��.y��Q I
/d' �� WJ �
X�.- r �L, I RECPT NO. PAID BY VALJDATIOW
SM�naWre a Applitan r Ayem Deie
WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—AppGcants Copy
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