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HomeMy WebLinkAbout10349 (5) CITY OF DIAMOND BAR COMMUNiTY DEVELOPMENT DEPARTMENT �; 21660 E.Copley Drive Suite 190 (909)86D-3195 Fax(909)86t-3117 PREaSs """ BUILDING PERMIT APPLICATION FIRMLY � JOBSITE �` /��; o ADDRESS g Q�� ��S c-t=,�A-.C�S DATEiCATION /� PERMIT . P/C S�2-�; j� NUMBER # � ISSUE T— TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER �}+'�'Y�u�i2-S�i� L�L "' ADDRESS 1�[��.��+S ��t"slj°�RC�.� ZONING SETBACKS � z. CITY � (J �1� ZIP TEL. FRONT RW n �� � PPLICANT .YTd�//�l�,.J/L�dYFyad.S�� TEL,�'.�S" "� REAR p z " ��'�� SIDE/SIDE STREET RW ❑ � CONTRACTOR `^=SJe"wc .� SIDE ❑ �. ADDRESS�J���.� i��Ja-�ct9C3c"�,� j}df� ' CITY,�I,(,t/ZHY�<�+��/!lLL�`� ZIP /�SS� TEL.`�(�I S.��/�S�/J�' PROPOSED USE w ARCH/ENG/ '� z DESIGNER w. NO.DWEL. NO.«- °r...�M'°' NO. a ADDRESS � CI7Y ZIP TEL. UNITS STORIES BEDROOMS �` DESCRIPTION SQ.FT. FACT R;�?�F ADJ.ARE ..ALUATION p�: OWNER-BULDERDECLARA710N SFR/ADDlREM ' ;' �"` O,` p�, i HEREBV AiFIRM UNDEP PENRL7Y OF PERJURY THAT I AM IXEMPi FqOM TME fqNTRACTORS L4 ,e"� W, CENSELAWFORTNEFOLLOWINGREASON(SEC.7a31.58U51NE5SANDPFOFES5KKJ5CODE:ANYCIriOR - � Gef898/CefPOtl �}- . C..)' COUNTYWHICHpC-0UIpESAVERAl1T7000NSTFUCT,ALTER,iMPflOVE,DEA/OLISH,OHHEPAIRANYSTRUG W �; NRE,PPIOR TO ITS ISSUMlCE,ALSO REIX11RE5 THE APPLICAN7 FOR SUCH PERM�T TO FILEA SIGNEO W Patio/Deck ��;.� � .�; STATEMENT THAY HE OH SHE IS LICENSED PURSUANT TO THE PqOVI510N5 OF THE CONTflACTORS LI• . . . - �„ CENSELAW(CHAPTEH9(CO�IMENCINOWI7HSECilON700�)OFDIVI5bN30FTHEBUSINESSANDPRO� - �'1' POOUSp9 00 �: FESSIONSCODE)OFTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORiHEALLEGEDEXEMV- (� V; TWN.ANYVIOLATIONOfSECT10N703L5BYANYAPPLIGANTFORAPERMITSUBJECi57HEAPPLICANTTO � Z Ra-Raof � -- � ACIVILPENALTYOFNOTMORETHANFIVEHUNOREDOOI.I.ARS(55eD).): ? ���- ❑I,ASOYMEROFTHEPFOPERTv,ORMVEMPLOVEESWITHWAOESASTHEIRSOLECOMPENSATION, . � Commercial ' "sd'--� �� - Z; Wilt DO THE WORK,ANO THE SipUCiURE i5 NOi INTENDE�OR OFFERED FOR SAIE(SEC.7044.BUSI� �� J •�� �e -NESS AND PqOFE5510N5 GOOE:THE COMNACTORS LICENSE UW OOES NOT APPLV 70 AN OWNEH OF !. .� ,,}„ � �;� ' PROPERTVWHOBUILDSOR�MPROVESTHEREON,ANDWHODOESSUCHWORKHIMSEIFOqNERSELFOR ' �� - Q-� THflOUCiHHI30qNEROWNEMPIOYEES,PqOVIDEDTHATSUCHIMPROVEMENTSAfiENOTIMEN�EDOH � m - W� OFFEREDWRSALEIF,HOWEVERiHEBWl01NGORIMPflOVEMENTISSOLDWITHINONEYEAROFCOMPLE� - d�, '{ .. �q� . TION,hIE OWNER•BUILOER WILL HAVE THE BURDEN OF PROVINCi THA7 HE OR SHE DID NOT BUIID OR �� IMPqOYEWRTHEPURPOSEOF5AI.E�. �� � . ❑I,ASOYMEFOFTHEPHOPEHTY,AMEXCLUSNEIYCANTRACTYJOWITHLICENSEDCONTRACTORS' ' � ��:' TD CONSTRUCT THE VHQIEC7(SEC.7odd,BUSINE55 AND PPOFESSIONS CODE:TNE CONTRACTORS LI� �- V81U8II0(1 �'�� �J.AREA W: CEN6ElAW00E5NOTAPPLYTOANOWNEROFAPROPEHNWHOBUIlDSOflIMPROVESTNEREON,AIVO ? � �'_� N71000NTRACTSFORSUCHPRQIECTSWITHACONTflAGTOR�S�LICENSEDPURSUANTTOTHECAliTMG ". QUANTITY DESCRIPTION FEE ~3 � TOflS LICENSE LAW.). . - �5.. J 0,. ❑I AM EXEMPT UNDER SEC. B.8 P.G FOR THIS REASON � Q ��: V u''��'DATE �WNER - - H Zi U pf ' W Q��, LICENSED CONTRACTORS DECI.ARATION W fLp lHEREBYAFFIRMUNDEAPEN?LTVOFPERJUqVTNATIFMLICENSEDUNDEflPROViSIONSOFCHAPTER d'-. s(CO!1.lAE4CINGWITHSEC7lON70C0)OfCN�910N30�THE8UStNESSAhDPROFESSfCN5C6DE,AN� z r�,.i.v� � �I�r`L'= cjiY„ ��'��' O - �'- MY LIGENSE IS IN FULL FORCE M7�EFFECT. . m �� IICENSE CIASS �-y '-���L�C.N0. '�L�` � �. j : �j^ DATE '7 CONTRACTOA- 6-�%�I.�✓aL7� � CJ. � W~ h y- �i WORKERS'COMPENSATION DECLARA170N '�Vi--� Q . -(- �j IHEREBYAFFIRAIl1NUERPENAINOFPEii1t1RYONEOFTHEFOLLOWINGDECLARA710NS: \� z . i Y ={�� �_�.. _IHAVEANDWILIMAINTAMACEFTIFICATEOFCON5ENTTOSPIF•INSUREFORYJORKERS' . I ¢, COMPENSATION.ASPROVIDEDBYSECTION97ooOF7HELABORCOD[,FOPT4IEPERFORMANCE U - Q,_ �OP 7T1E WORK FOR WHICH THIS PERMIT IS ISSUED. � y`., i'. ' �' _I XnVEAND WILL MAINTAIN WORKERS'COMPENS0.TION INSURANCE,AS HEQUIRE�6Y SEC7KKJ � Q� 3700 OF THE LA90R CODE,FOfl THE PERFORMANCE OF THE WORK FOR WHIqi THIS PERMIT IS ' � ISSUED.MYWORKER9'COMPEN9ATIONiNSURANCECAqR1ERANDPOLICYNUMBERARE: CONSTRUCTION ` �J.- j_ j� CARRIER �LlF�t rJ `jsdF /C7 a: PL4NREVIEW .. z�.` voucvNUMeea � Gs�Jc'���,.S cI � ELECTRIC ¢ , ��� 0; (f}USS[CTpNNE�N0TBE0C�LE7WOFTtiEPERA4�I3FORONEMX�OfiED (Siao)oRlE55F P � W Z- I CEFITIFV THAT IN THE PERFORMANCE OF 7NE WORK FOR WHICH THIS PERMIT IS ISSUED,1 MECHANICAL -� . CS_: 5HALLNOTEMPLOVANYPERSONINANVMANNERSOAS708EGOMESUBJECTTOTHE. . (n'-. WORKERS'CAMPENSATIONIAWSOFCALIFOflNIA,ANDAGREETH ISHOULDBECOME INSPECTIONFEE �- SUBJECT TO THE WORKERS'COMPENSAT PROVI NSOF N�7ooOF THE LABOR �� , � � CODE.ISHALLFORTHWITHCOMPLYWITH H S I N. ISSUANCE ��� - p�- DATE: � � % APPLIGANP. . � SMIP � �-��� ENERGY P/C - � .WARN�N6:FAILURETOSECUqEWORKERS'COMPENSATIONCOVERAGEISUNUWFUL,ANDSHAILBE q '- �'�SUBIECTANEMPIOYERTOCRIMINALPENALTIESANDCIYILFINE5UP700NEHUFIDqEDTHOUSAND ENERGYPERMIT ��b �� � L. ��k% � JDOLLARS(5100,000),IN ADDIT�ON TO THE COSTOF COMPENSATION,UAM0.GES AS PqWIDEO WR M '. BECilON97080FTHELABORCODE,INTERE9T,ANDATTORNEY$FEES. - . , OC. RETENTION FEE: QCONSTRUCTION LENDINO ACiENCY pREALT FEE: dC1 HEREBV AFfIRM UN�ER PENALN OF PERIURY THAT THERE IS A CONSTRUCTION LENDWG AGENCY _ 7 FOR THE PERFORMANCE OF TME WORK f-0R WMICtI THIS PERMIT IS ISSUED(SEC.3087,qV.C.�, _ � Z W � LENDEH'3 NAME � � t 1—=' LENDER'SADORESS � � ICEHTIFYTHATIHAVEREADTHISAPPUCATIONANDSTATETHATTHEABOVEINFORMATIONISCARRECT. TOTAL FEES �-� IAGREE7000MPLYWITHALLCYTYANDCOIIN7YOflDINANCE5AND5TATELAWSRELATIN6706UILDING ' � � �� � �. CONSTHUCTION,AND HEREBY AU F REPNESENTATIVES Of THIS COUNTY TO EN7ER UPON THE Z ABOV T D PE F I ECTIONPURPOSES. CQMMENTS - � 3 � � � m PERM EENAME(PRINn - � � �4��1� �- l:t��'��/e����l .�12�'�J � SIQNATUREOFPERMITTEE DATE —�— � - F RECPT.N0. PAID BY VA(,IDATIO � WHI7E—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applirant's Copy � -� -_. 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