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HomeMy WebLinkAbout12452 (14) :''�-�, ! ^ �� 1 CITY OF DIAMOND BAR �°/�I .�� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES / r 21660 E.Copley Drive Suite 190 �� (909)860-3195 Fax(909)861-31F7 PRESS `��^��°� BUII.DING PERMIT APP�.ICATION � FIRMLY N . "E:,v+.:•r.�.v. �. . . � JOBSITE APPLICATiON ,,� )�� PERMIT 1/� /�.. .�P/C '2 � 0 ADDRESS �s � �.i.+/" cy 'p , ��r'. DATE NUMBERLv' I # � APN LOT TRACT_ DA EE ���� � �j� CpNST. GROUP p: OWNE�GII'f�/�i/' o. A�DRESS�t'�✓►� d'• • _ ZONING SETBACKS Zi CITY�'� vrr L4c� _ ZIP �d�-`!s� TEL. 17ci � '�U223 REOART RW rl g` APPLICANT �'C'�' :3� TEL. F�r". ' �'�_�3 �� ` SIDEJSIQE STREET RW CI � CONTRACTOA ` �_� SIDE ___ C; Q ADDRESS ROPOSED USE � ��'� ���,�� Cy`1.,,,,�r--(i}� �..,/�� o CITY ZIP TEL.__ ' �- ' w ARCH/ENG/ � — �z DESIGNER — NO.DWEL. NO. NO. a. ADDRESS — UNITS STORIES BEDROOMS � CITY ZIP TEL.__ — � v� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFRIADD/REiU O Q I HEREBY AFFlRM UNDER PENAL7Y OF PERIURY THAT�AM EXEMPT FROM TIiE CONTRACTORS Lb Gafage/CflrPOrt Ld3 CENSELAWFONTHEFOLLOWINGREASON�SEC7031.SBUSINESSAPAPROFESSIONSCODE:ANVCIiYOR (n U COIINfYWHICHREOUIRESAPEqMITTOCONSTFUCT,AITERIMPR[TJE�EMOLISH,ORREPAIRANVSTqUC- �,f,J pg[IO/�BCk w TURE,VRIOR TO 1T4 ISSUMICE.RL50 itEOUIRES THE APPUCANT FOR SUCH PERMIT TO FILE A SIGNED w �?:.I STATEMENT lHAT HE OR SHE IS LICENSED PURSUNJT TO THE PROVISIONS OF THE CONTMCTORS LI- � � CENSE LAW(CHAPTER e(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- V' PooUSpa FESSIONSCODE)ORiHATMEORSHEISE%EMPTTHEREFPOMRNOTHEBASISFORTHEALLEGE�D(EMP- � TION.ANYVIOUTIONOFSECTION7031.SBYANYAPPLICANTFORAPERMITSU&IECTSTH�0.PPLICANiTp Z Re-Root � ACML PENALTY OF NOT MORE THAN FNE HUNDREO�OLIARS(S5o0�.�� � ❑I,ASONMEROFTHEPR09EHTY,ORMVEMPLOYEESWI7HWAGESASTHEIFlSCLECAMPENSAT:ON. � CommerCial WILL DO THE WORK,AN�THE STRl1CTURE IS NOT INTENDED OR OFFERED FOR SALE(SEG 7otd,BU56 J � NESE AN6 PROFESSIONS CODE:THE CONTPACTORS LICENSE LRW OOES NOT APPLV'O AN OWNER OF � PROPERTY WFIO BUKDSOA IAIPROVESTHEFEON,ANDNMO DOEP SUCk WORN HIh15F_IFOR HERSELFOR � hlfqUGHMi50RHERONMEMPLOYEES,PROVIOEDTiAT&UCHIMPROVEMENT3nRENOTINTENDEDOft m QOFFEREDPDP.SALEIF,FIOWEVERTMEBUIIAPIGORIMPROVEMENTIS50!DSYITHIN04EVEAROFCAMPIE- Z TION,THE OWNER�UItAER WILL HAVE THE BURDEN GF PROVIhG 7HAT HE OFi SFiE DI�NOT EUIL�OR � IMPROVE FOR THE PURPOSE OF SALE� ' " '. . ❑I,AS OWNEq OF THE PROPEHfY.AM E%CWSIVELV CONTRACTING N11TH L'CENSED CONTP.ACTORS � TO CONSTRUCT THE PqO.1ECT�(SEC.7DM,BUSINESS AND PROFESSIONS COOE;?HE CON?AACTOpS LI� VelU0ti0n �___ � ADJ.AREA_ LL1 CENSELAWDOESNOTAPPIVTOANONJNEROFAPROPERTVWHoBUILDSORIMPROVESTiEREON,ANO �-------- '— � NAiOCONTtUCTSFORSUCHPHOJECTSWI7HACONTRACTOR�S)I.ICENSF�PIIRSUANTTOTNECONTFlhC- QUANT�TY � DESCflIPTION FEE Y 70fl5�N5EL�WJ. �, _ � J /^� � IAMEXEAIPTUNDERSEC.___.___,_,_______B 6P.C.FOR7HISREASOK Q _� G.� � U ` r � Q Z 1 DATE ���' —OWNER_ �n^:T.a[+!'�— iRp-_—_"__— F- ��_�_""""_— U W � �,"�' LICENSED CONTfiACTORS DECLARATION W I --}I � I HEREBYAFFIRAI UN�ER PENALN OF PERIURY THA71 MA IICENSED UNDEfl PROViSIDYS CF Cn.APTER � I � � B(COMMENCINCi NATH SECTAN 70ooj OF 01VI510N 30F THE BUSINESS AN�PROFE5510M1S CCDC,AN� Z X 41Y LICENSE IS IN FULL FORCFAND EFFECL � LLJ o I LICFNSE CLASS_____ LIC.ND. • '_�j F � J � E DATE_ __ CONTRACTOR___________.________ �1- 4i.1 � � 1NORKERS'COMPENSATlON DECLARATION a _ � � IHF.REBYAFFIRMUR'DE9PENALNOFPERJURYONEOFTHEF011_OWINGCECLARRT:ONS: Z L] � IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSEiF-INSUREf-ORWORKERS' S � COAIPENSATION.ASPHOVIDE�BYSECTION37ooOFTHE:.ABORIXN�EFORTNEPERFORMANCE 'U OFTHE WORK FOR WHICH THIS PF.RMIT IS ISSUED. g � _ L__ _I HAVE AND YVILL MAIRRAIN WORKEFiS'COM7ENSATi�N IM1SURANCE,AS flE�UIREO BY SF.CTION G 370o OF THE LABGR COOE.FOR THE PERFORMAM10E Of PHF WORK FOR WIiICH Th{IS 7ER7AIT IS ' ��Y �� ISSUED.MYWOP,KERS'COEiPENSATIONINSURANCECAFRIERAN�00LICYNUM9ERARE� CONSTRUCTION T L (___ — - �' � ,,�� ? CARRIER—__ f� � � `r . �_"�'-(—s�`� ---------'---'-----�—'--"--� . PLAN REVIEW a _ zPd_ICY NUMBER__ ____ ___.___.____ _.._ ELECTFIC ____,___, , � Q ---�---- ---e--�— 0 (fYUSSECTIDNNE�NO'6ECOAdPLEfEDOFhiEPERA4TSFGWIXJEHL4�UREDDOLLAAS(f1W10RLESSI PLJPABiNG � I CERTIFV THAT IN T}IL PERFORMANCE OF THE WORK FOfl WHICH THIS PER�AIT�S IFSUED,I MECHANICAL � -_'__""_"____ '___ {} SHALL NOT EMPLOY ANY PER30N IN ANY MANNER SOAS TO 9ECOME SUBJECT i0 THF � WOFKERS'COMPENSATION UWSOF CALIFOflNIA,AN�AGREE THrtT IF 1'SHOULD BCCO'dE INSPECTI�N FEE _ _ SU9JECT TO THE WORKERS'COMPENSATION PftOVI510N5 OF SECTION 37oi1 OF Tlic 1A60R �' /�'g � ' COOE.i SHALLFORTHWITH COMPLY WITNTFiQSe PROVI�IONS. ISSUANCE _____ _____ � L/ o SM1P � CATE: APPLICAkT: __'______._______ � '-- — �� � � ENERGY P/C J WARNINC FAILURE 705ECURE WORKERS'COMPENSA7ION COYsAAGE IS UNU1WFliL,AND SHALL BE --��-- - — � SU&IECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFINESUP700NF.HUNOREOTkOUSRND ENERGYPER�J!IT DOLURS(Stm,doo),INAD�ITION iOTHECOSTOFCOMPENSATK7N.DANAGESASPROVIDEDFORIN --------- -------- —�� � SECTION 37ae OF THE LA90R CODE,IN7ERE5T,AND pTTORNEY'S FEES� __ RETEN?ION FEE: _ _. X r Cf V d CONSTRUCTION LENDING AGENCY PR�-ALT FE�: p -------'-"-" -- � IHEREBYAFFIRMUNDERPENALNOFPERJLIRYTHATTH'eREISACONSTRUCTIONLENDINGACENCY FORTNEPERFORMANCEOFTHEWORKFORWHICH?HiSPEF1AITI5ISSUED(SEC.�097.CIVC.�. --� Z W � LEN�ER'SNAME_____,_.__ — —_ .. � LF.NDER'S.IDDRE55___ ______ }y/�/� /] � I CERTIFV THA71 HAVE REA�THIS APPLICATION AN�STATE THAT THE A60VE INFORMATION IS CORRECT � TOTAL FE�vv�/� V b ��o /���! � /'�, � I AGAEE TO CAMPLV WITH ALL CITY PNO COUNTY ORDINANCES A,�'�STATE LAWS RELATING TO BUILDMG /1 / y 1 CONSTRUCTION,AND HEREBV AUTHOFIZE PEPRESENTATIVES O:THIS COUNT'TO ENTEF UTON T4E � / 1 ZABOVE-MENTIONE�PROPERNFORINSPECTqNPURPOSES. '�� V p ., � CO?NMENTS _' t,�:) I �d�--�1'�r �"'t �.,'i�.��_. � •��i _— ------- m PERMITTEE N.UAE(PRIM) ¢ � —;�_,.. 2 r�.� ---�-- -------- �' �'�,�'=-�-�'.� -�--�"'-�-�'- ---- � � S�G A F PERMITT E"� GATE 7'� = pECPL NO.��N .__ PAID BY � ' . 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