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HomeMy WebLinkAbout13224 (17) � � .r ��_ CITY OF DIAMOND BAR �` DEPARTMENT,OF COMMUNITY&DEVELOPMENT SERVICES �� . ,,,�� 21660 E.Copley Drive Suite 190 � (909)860-3195 Fax(909)861-3117 PRESS � "9N' BUILDING PERMIT APPLICATION FIRMLY < DDRIESS�"-�"l�'�' �-`'r r�c`�;.�l�].�"- 12T�, APPLICATION L,,4 T� PERMIT L °��, -/C , p � ! DATE � � NUMBER # � ISSUE TYPE OCC APN LOT ��-' TRACT ��'�-'��7 DATE CONST. GROUP p OWNER G:�.�"iN%/�•%i ,;',y�;'.�I " ADDRESS "��•'I-(c: -�'��r. -E'!,t_' 'i:%� ZONING SETBACKS o - • z CITY '�l/-k�/c>,i�» j�/.�a'� ZIP i�G �� TEL. I �' FRONT RW ❑ __ �QQQ APPLICANT ..�Y�7%>u�� �'5���� TEL.��� REAR [J ' SIDE/SIDE STREET RW Cl CONTRACTOR Ci%M'vI� ?"S t=�L-� Ls.»e'� SIDE ❑_, �. ADDRESS r`' >. l;,��.'' 4"z^'a-.."�__�;�.�._ ppOPOSEDUSE ,�•tl. r � p CITY JsY,iis�ni�^E�7-S ZIP��S^TEL.,� F — o ARCFUENG/ — Z DESIGNER a: ADDRESS -- NO.DWEL. NO. T NO. �--'� �. CITY ZIP TEL. 11NITS 4 STORIES __=__ BEDROOMS _ �. cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATfON .. t � OWNER-9UILbEA DECLARATION SFR/ADD/REM O 0 I HEREBY AFFlRM UNDER PENALN OF PERJURY THAT I AM EXEMPT FROM THE CONiHACTORS LI� GefeJ�/C2fpOff W CENSEUIM1FORhIEFDLLOWIN6REA50N�SEGT031.59U51NE55ANDPROFE:SSIONSCADE�.ANYCITYOR (n C,�; COUNIYWHICF1flEWIRESAPERMITTOCAN3THUCT,ALTER,IMPROYE,DEMOLISH,ORREPAIRANYSTRUC- W P2IIOIDBCI( L� TURE,PRIOq TO ITS ISSUANCE.ALSO RE�UIRES THE AOPLICANT FOR SL1CH PEflMIT TO FILE A SIGNED '-,� W• SiATEMENT THAT NE OR SHE IS LICENSED PURSUAN7 70 7HE PPCVISIONS OF TMF CON7RACTORS LI� � �� CENSE LAW(CHAPTER 9(COMMC-NCIN6 WI7H SECTION�000)OF DIVISiON 3 OF THE BUSINESS AND PflO= � POOVSPB ' �' FESSpNSCOOE)OflTHATHEOR5ME15E%EMPTTiEREFROMANDTHF:BA515FORTNEALLEGEDEXEMP� (� � V TKKJ.ANYVIOLATIONOiSECTiON7o37.5BVANYpPPLICANTFOR�IPERMITSU&1F.CiSTHF-APPLICANTTO � Re-Roof � ACNLL PENALTY OF NOT MOqE TNAN FIVF HUNURED DOI.LAqS�3500))� �� ❑I,ASOHT1EflOFTHEPROPERT(,ORMYEMPLOYEESWITHWAGEYAS7HEIflSOLECOMPENSATION, C� Commercial � �` VYILL DO TNE WOHIC,MJD THL STRUC'(URF_IS NOT INTEN�ED OR OFFERED FOR SAL[(SfC 704a,9U51- J __ _ � y' NE55 AND PAOFESSIONS CODE:iNE fANTRACTORS LICENSE LAW UO:S YOT APPL'/TO AN OYlNER OF = • PfiOPERTYVh108URDSORIMPHOVESTHEREON,ANDWHObOE55UCHWORKHIMSELFOFiHER6ELFOR �.� TNfiOUfiHH�,SORHEROWNEMPLDYEES.PflOV10E�TMATSUCHIMPROVEMERTSAHENOTINiEN0E00R m Q: OFFERED FORSAIE IF,HOWEVER 7HE BUIL�ING OR IMPROVEMENT IS SOLD W ITHINONEYFAH OF COMPLE- , TION,TME OWNER�9UIL�EFl WILL HAVE TXE 9lIR�EN OF PROVING 1HA1 HE OR SNE DID NOT BUIID OR �: IMDROVE FOqTHE PUflPOSE OF SM.F.j. (� W ❑I,NS OWNEROF THE PROPERTY,AM EXCIUSIVELY CON7RACTING YATH LICENSE�OONTPACTOHS � �' TO CONSTRUCTTHE PROJECT(SEC.70M,BUSINESSAND PROFE5510Y5 CAUE:Th1E CONTRACTOFlS ll- ValU2fIU11 .,_.,__.,,_ ADJ.AREA ,__._____,...____, �: CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTVWFiOBUIlD50R1A7PfiOVESTHF.HFDN,AND .. - N7pCOPoiqAGTSFORSUG1PR0.1ECTSWIiHACR1TflAC70F�51LiCENSEDPURSUANT707MECOMTR0.G �UANTITY DESCRIPTION FEE � TORS IJCENSE IAW.). �� � ❑I AM EXEMPI UNDEfl SEC. �_'_'__B.6 P.C.FOH Ttl!5 REASON Q I�+�Z-�.�'I`�l� �%C%"O. ' ..�}j'� � �� U � LL — "'__ — CC� �?f 4.i Y.'.f?_ �'i L, ' f _ O�7E__ OwNER______ U � Q UCENSED CONTRACTORS DECLARATION ~ W '�'� 'e. /"s-�: � IHEREBYAFFIHMl1NDEHPENALTYOFVERJJRVTNATIAMIICENSEOUNUEfiPROVISIONSO�CHAPTEF � � e(COMMENCINOWITHSECTION7000)OFDIVIulON30FTliEBIISINESSAN�PROFE5510NSCODE,AND Z �� MY LICENSE IS IN FULL FORCEAND EFFECT m � LICENSE C1A55 � ,r.�' ___LIC No. I� 7 .S �{ '�` _ ,� _Z_.�1--._"__-- � � -- J �ATE^ '��"' '�� .. �'�I CONTRAGiOH[1:,-'sa.1'. �h=�.�aa !_•x,_('� d W . --� � � WORKERS'COMPENSAT�UN DFCLAKiAT10N ��•i`�� � I N IHERE9YAFFIRMUNDERPENAI,TYOFPERJUF'/DNEOFTHEWLLOWINGPECLARATIO '"�� Z � �IHAVEANDWILlMA1NTAINACERTIFlCATEOFCONSFNTTOSEIF�INSUR[FOpWOF1KLftS' _ , ( COMPENSATION,ASPNOVIDEDBV9ECT1(Nl3rooOFTHELABORCWE,FORTHEPtFlFOqMANCE W � OF T1E WORK FOR WHICH THIS PERMIT IS ISSUED. � � W .�I HAVE AND WILI.MAINTAIN WORKERS'CAMPEM1SATION MSUFiANCE,AS REOUIHED BY SECTIDti I Q 37000FTHELR90RCODE,FORTHEPEqFORMANCEOFTH�WORKFOiiWI{�CHiH�SPEqMIT15 154L167.MYWORKERS'CAMPENSATIONINSUfiANCECARiiIERANDVDLICYNUMU[RARL CONSTRUCTION __ _________ _ � CRRRIEti ���'�_�_�'•" � ��1ff{� PLAN REVI.�W - __ _ _ ..,,�.,•;:,.� -��-..__... --------� . - , --���. -....------- ---. ZPOLICYNUMBER�.tf� . � ��.�' �� � Q C��+�--------��-G-- _....- ---- ---....----- --� - �--- i n (iHSSECiqNNE�NDTBECiNv9lF.TIDOFTHEPLFWII'SfG'IONEMJI�DREDDOLLAHS(S1WIOf1lF:SS�. PLUMBING i;__(l._'����__ ___ i '-�----'—'— ! Z ICEPTIFYhiATIN1HEPERFCRMANCEOF7HEWORKFORWHICHTHISPEHMITI515iUE:U.I MECHANIC:AL •:'� • i3 (} SNALlN01'EMPLDYANYPERSONINANYMANNERSOASTnB[CCMESUBJECTTOTHE ���•�-`� �I ' -•- � WORKERS'COMFF:NSATIONLAWSOFCALIFORNIA,ANDAGREEiHPTIFiSHUlJL�BECOME �NSPECTIONFEE ___�y_�_____��' ' '� ' SUgJECTTOTHEWORKERS'COMPENSqTICNPROVISIONSOFSECTION37000FiHElABO(i '1J'i"�3r��,:'�, , _ . ~ CA�E,ISHALLFORiMWItt1COMPLYWITFITHO E�ROV S. ISSUANCE��•1.4 �?' - ' �J 1 � � = r„ va3':' _""_'_'___ _".. ..__ _ -__ ' O DATE: ��" t� APPLlCATJT."..._ �iJ-����� 1� SM1P f.�4�J�.'�.," � I p -.�._�� l; . ,�.. _. _ . ,r __ '. .'__-_'._ _- � WARNING:FAILURE TO SECURE WURKERS'COIAPFNSATI��COVERAG��.��Eis uNia�n'""�"uL�' nct�eE----� ENERGY P/C =___..,.. ___.__ _._,-____ i �y SU&IECTqNEMPLOYERTOCRIM!NALPENALTIESAN7CIYILFINESl1Pi00NEHUNUN THO allo ENERGYPERMIT DOLLARS(51a0.000),INADUITIONTOTHECUSTOFCOMPENSATION,DAMAGESASPqOVlZlp9� NIN J SECTION 3708 OF THE LP.BOR CO�E,INTEAEST,AND ATTORNf:Y'S FEES. RETENTION FEE: � __—__ i __ , __'"____-_'_ "__'_'�_ � � CONSTRUCTIONLENDINGAGENCY PRE-ALTFEE: ______ ' p -�------ ---- - � I MEREBY AFFIRM UNOEH PENALTY OF PERJUf1Y THAT 7fIERE IS A CONSTf1UCTION IENDING AGf:NCY �� FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISGEPMITISISSUED(SEC.30B'I.CIVC.�. �--"-- -"-- -'---"--�-- � '_ --""__""'_ -_""-' '__--'_ i � } LEN�ER'SNA.ME____._. .._. ..—" I y "'____.......'-_.____ _...._'____ '. j F- LENDER'S W�PESS , ____. -. _____ _ �O � � — TOTALFEES � � ICERTIVI'TH�TIHAVEREADTI1iSAPPLICATIONAN[)STATETHATTHEAdOVEINFORMATIONISCORRECT. W IAGREETOCOMOLVWITHPILCINANDCOUNTYORDINANCESANDSTATELAWSHELATINGTO&JILDING � � CONSTRUCTION,qN0 HEREBV AUTHOFlIZE HF.PHESENTATIVES OF I IaS CAUNTYTO EMER UPON THE ZABOVE�MEMIONEDPROPEFlTYFORINSPECTIONPUqPOS[S. COMMENTS O ,_'-'_ -__-'"' _"_"_ J :.i• L/�� A��../�-- � -_"_ - 'S/=! G1d '" __"'_ "_ m _-__��1L_____"" ""_'_' . _.__._ - � ¢ PERMIT�EE NNAE i�RINT) ; _, '___ ______""_ ___ _` ' .: � � _ � ' • I � --......__ .,.. .�_. -�-��-x.. � �: �'f_-.�- Y � SIONATORE9 {FGE�--..._.�....::::+�:._ ,..._. .. - DATE "_- —"_'-_ I '�� RECPT.NO� _PAID BY �'VALIDATION � � WHITE-De a`t ent Copy,YELLOW-Finance Copy,PINK-Assassor Gopy.GOLDENROD-File Copy,GREEN-Applicant's Copy _ ---___ -`�-�_�:'_ - - -_ �� __. �. _. _. . . .. _.. .... � - - _ _ _ - - - . _. I ' _ , ..�_. � � � � � � ( � i � i � . �, <. , , � � ' � � � � I I ` � � � i � � i E � , 1 3 � � . . i ' . ' , � � ' . . . I ( t .. ' . ' . . � .. . � � � . . , . , i , . ,. Gt'� 1 . . '� - . i . ' � . , � ,. ' . , i. . � � � , . Ik Y ! . � � , ' . � ' . _ � � � { . . . ' i , i i I � � . � _ {� , , ' ' � . � . ,y. . . . �� . . . � y _ .J.._ _ .�.._ . : �." 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