HomeMy WebLinkAbout107 (8) �, !'�. � �� '
'"� CITY OF DIAMOND BAR PRESS
. ��.,, `�" ' DEPARTMENT OF 8UILDING AND SAFETY
�� BUILDING PERMl7 FIRMLY - -
JOBSITE � !: DATE CATION ^-� �BER I G� OS E---.--
ADDRESS �-�� ��� �_ �����_ �SSUE TYPE OCC.
� APN __ LQT���RACT DATE ,� �CONST. GROl1P
� CROSS ST ET
o SETBACKS �'"s
O° OWNER � � ZONIlJG FRONT, ----�/��— ❑
O ADDRESS_ �L �� ��._�-� REAR ❑
��CITY�' N IP a.�� TEL.���!�v—�i3L � S DE STRE T RW ❑
O APPUCANT - TE�.��� �-- SIDE� ❑
4 CONTRACTO � � C ��' �Z��.L�.. SEWAGE
o I ADDR ❑ PUBUC PMT�
� �-r DISPOSAL ❑ pRIVATE SQ.FT./100 GAL
��CITY_���� ZfP �TE�t'
� LlC.NUMBER ��� '1 (3RADING C� CU.Y�S.EXC. CU YDS FILL
y ARCH/ENG! —�T �i T1�pE ^��I_�T F1#CTC)R PS ADJ. ARERNALUATi
`—' DE5IGNER ��_�� �
o ADDRESS fy 2 �I� ��
2 CITY ZIP TEL.. � _3 j -
� —1
� PROPOSED USE C��2- — �:I t-'�Z--- 4 -.--�
� � GARAGE '�
z NO.DWEL. NO. ��� � PORCH
�,�UNITS STORIES BEDROOMS�._,
� LOT DIMENSIONS � VALUATION ADJ.AREA_
o No oF�t_�cs How " ouA�,Tr,�v DESCF�I ! N �EE
W ON LOT USED Q c �� • U
� U
w
N �
❑C E'��ON7F.4CTf:NS OEC(ARATI�N�I herehy afliriri ihat I am licrosed�nder pmarsions ol Ciiapler 9(cammenciig M�- �
� �nnP Seceun'000;ol Oimsmn 3 nf t�e Busmass ane Professions LoAe an�my hcense a in full lorce and eHecl �
3
❑ �
W �VNC-.9 3JIl�EF.�fCLABdTION I heiehV alfirm�hat I am e�mp!from rhe Lontrano�'s Lic¢nse I.aw la�me Po!lewing .
rr.esm��,Ser. 7f131 5,Business antl Professions Code Any ciry or conntY which requires a permrt m r.onsvucl, �`j �
o�ahr,im,•o�e r.r,molsh,ar repau any struc!ure,pnor;n its issuence,alsa reCmies Ihe apphcant lor sw:h permit Z
Q I!a 6!c a signed s;atement ihat he•s Imensrd pursiiam to the pmvisions ol the Cnnba�lm's Liceitse taw IChapter p�y
� 9�a�ue?ncnig m�ilh Seclion 70001�f 2misinn 3 of the 6us�ness and Pmlessons Code)ar that hr.a eaemG�Iheiafrnm ,� -
d�antl;hr�asii icr!hr allegeA exemptior am v;a,uon or s�cnon 1037 5 ey aatl aOP���ar.t fm a perm�sud�ens J
K hr.app6can;:n n r.ai�pene.ry n'ro:ma�e;har f��ve hundred dollars 155001 I -.1;
W I �
����I ex crvrer o!the�mpeny ar mv empluyezs wrt!i wa,es es iher.sole compensabon wlil An the work,aM
'he slmc��re is nm in!rntled or ollereo lar sale(Sec 7044,8usiness and Fmfessions CnJe The Cortractor's lmense
�,~j iaw 9ues^,1 aCA�Y�c an pwner pt pioCeRy who huildS or imCroVeS Ihereon.dnd wha Ere5 Suf.h warY hxnsell (.)
' �� th:rur,h nis awr er..ployees p�a.iJed tha;such impravemen•s are nm m�endM or ofhad for sak 1`however z
m ih,���ii:�,r���r impro��r.ment;s sold wnhm one Year al campienan,fie mvnx-bnilder�,�dl haee ihe 6�rdcn nf praving ad'
� �het he diJ nu:L•urtl cr;mpmve for the purpose o!salx j T�
h 1�.�I as�.unei r.l ihe proFer!y an xrcl��sively rentractiny rnh;;r.ensed cont�actors lo[ons!ruct Ihe nra�ect�Sec uI --
Z( 04G 3nvnesa antl Piofessions CoUe The Cor[rocmYs ticense law�aes not auO�Y�o an mvnei of pmD@rry who �
hi,ilds n�.mp�m�es ihr.�ea�.,antl whv:omraus loi such prolecis wtth a[onttactoqsi hcensed purswm ro the Cortraclar's
'¢;�"�"�`a" � CONSTRUCTION _
o -
'y ❑I em erempf enr.er Ser ,8 fi PC IAttxh f.e�uficatel ,PLAN REVIEW
H
o Oaie Owner i ELECTRIC
? WOflNEfiS'f.BMVENSAiION�ELLARATION I here0y alhrm[nat I have a atnlicate ul consem m xeil-insure.ar'
a cern�:cn;r.n�VJo�6ers'Cemper.sanan Ir.sma�e,or a cr.rtified�opy thaeat ISxc 3800.La6.C.I ��PLUMBlNG
G
Q C�-;�c���;��•a�ooY�s��e«nr nK�,�snea `� MECHANICAL
o 'LY Ceruhen copy u ftle0 wuh ehe Buddmg Ins�ectmn Oepatlmem ar Ilepaz�mem � GRADING
W
� f.EP.TiFI�AiE 0'E%EMPTION FRDM lYORKERS'COMPENSATION INSURANCE This seUion need nm hz wmpkte1l � �SSUANCE ."S;_.(�
��d me perma is ior one huMreJ 151001 ar lass I cenify tha�m i De�lormance of the wmM lor w�Kh mis
pennu a issued, snall, 1 employ any pnson�n any manner so a ome su6�ec�to Ihe kers'Conpensttion SM��
� ta�na or y�rfor ' ,. i/ � -'
� � W PARK FEE
p On!e� � ^po�a"� � SCHOOL FEE3 � �n
� NOTICE i0 APPLICANT If,af�er making ihis Cernhcate ol xemplion,you should come su6;ttt m Ihe Worker's __
Cumpensauan Drovisions ol the LaLror Code.you mu51 fonAwith tamply with srh piouispns a tAis peimrt shall
'i he deemeA revaked �
T
� pYISION OF INDU.STflIAt SAFETY PEflMIT CEHTIFICATION
"' Alftl�Q � o
d ❑I P�ere�y�endy mat na e�cavaum five(51 a��ere leet m tlepth inro whrth a persan is requirai m descene. ����
� wdl he made m cemrec[iun w�th work aumoraed by this permn.and that no huildinp sta�ctwe.scalfoldmg.tAsewark.
m Ae^�nntim or drsmant6rg;herr.ol will he mme ihan thrtry sn 136)feei h�gh (CAap 32.Gry 2.An Y,Se.c _
W 341 T�11e8,CACI
S p
3 Gar awne�hudJer I will no�emphy a�ryone ta da work whtth would mqmre a permrt hom Me pvisian af ' �� Df��
� Indrslna�Safety as nmeJ a6ore,unless su[A per5on Aas a permit to da su[h umh fran Ihe drvision. v
�
W ❑a��s�o�.�,�,�����,a�s�e„���„�Na TOTAL FEES �� . t J
0.
�I COP'STFIICTION LEN[11NG ASENCY�I herc6y atfi�m Mat the�e is a�onshuctian�enAing agenCy for Ihe pnMrmw�e
Z nf tlre wmk lor wmch this permn is rssued(Sea 3097.Civ.L.1. .
� lender's Namr. COMMENTS
� Lender's Add�ess
"� CFKnFIfATE fIF C067PLIANCE AN�AUTIqpiZd710N OF EN�FV.1 certify I qAre rQfd Mis opplintwn aM snle i
y fia�IM inlormanon qiven is cnrect 1 ag�ee m compN wn�al suie laws a�M t�ry orAiiurces rdemp to Auitlinp
y �onslrucnon,and autho�e a re0�eumaUve at ihe pepar[meni N&iMmO�ntl Sa�ety tu m upm IMe qoperry
� fo�which I have upp M�th�s pemrt for 1he purpose al Innp inspecibns, i,
X�`�,' �' � ' �
/ � - RECPT NO.._�_ PAl�BY VAUDATIOM
Signature af Apglc t r Agei Oete
WHITE—Department opy,YELLOW—Finance Copy,PlNK—Assessor Copy,GOIDElVROD—File Copy,GREEN—Applicants Copy
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