HomeMy WebLinkAbout14970 (20)- CITY OF DIAMOND BAR `
COMMUNITY DEVELOPMENT DEPAtt'iMi+l'1'
21660 E Copley Drive Suite 190
(909) $6D3195 Fax (909) $61-3117- -.' . { PRESS
BUILDINGPERMITAPPLICATiON I FIRMI V
ADDRESS AS GC CL> F? A- 4L
ADDRES
APN---�- LOT TRACT _
OWNER ._ I/
ADDRESS C f u-- 4ah P_
CRY Dh Gtr ' ZIP !r'176TE(f:� 9 (•-S�
APPLICANT TEL
CONTRACTOR_
ADDRESS
CITY ZIP TEL
ARCKENGI
DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION
1 HERESY AFFI W UNDER PENALTY OF PERA M THAT I AM EXEMPT FROM THE CCNTMC',ORA LL
CENSE LAW FOR THEFOLLOWNO REASON (SEC. Mils INAIM SANO►AOFE3SIONSooOE:AMYC(T►OR
CCVrT' VAMCHAEOCVLESA PEAWTOCONstRUCt ALTER NFROYE DEMICUSKORAEPANANYSTF AC.
TORE ►A)OR TO ITS ISSUANCE ALSO REOUILES THE APALCANT FOA V-01 PERMIT TO FILE A SIGNED
STATENEPR THAT NE OR SHE M UCENSED PURSUANT TO THE PROVISIONS OF THE CC•RTRACT00.4 4A
CENSE LAW {OU►TER r (COMM ENCwG VAT" -SECTION 7-M) OF ONISCN 3C4: SAG Ei14adES5 AMO lRO
FESSONS COOE)OR THAT HE OR SNE IS EXEMPT THERErACUANO THE SALS FOR THEALLEGEOEXEMA.
TION. ANY VYYATICNOF SEGTON 7O3tJ BYANYAPPLK:ANT FOA A PERMIT SUBJECTS TE APPLICANT to
A CN'L fENA.LTY OF NOT MORE THAN FNE HUNDRED DOLLARS (Sun))
0 L ASOWNEAOFTHEPAOPERIY, OR MYGMPLOYEEs WITH WAGES AS THOR SUE COWPENSATIDN.
WLL DO THE WORK IND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SHE (SEG lou, BUS
NESS AND PROFESSIONS COOS: ME CONTRACTORS UCEM.SE LAW COE$ NOT APfLY TO AN OWNER OF
PROPERTY VMO BUILDS OR IMPROVES TNFAEOK INC WHOOOCS SUCH WORK RMSELFOA HERSELFOR
THROUGH HOS OR NEA OWN EMPLOYEES. PROVIDED THAT SUD1 SIPRCIYEMENTS ARE NOT INTENDED OR
OFFERGD FOR SALE 6. HOWEVER. THE BULONO OR aMMDYEMEW IS SOLDWRTHBNN/E YF AA OFCOMPE[.
TO", THE OWNFAdUELEA WRI. HAVE THE BURDEN OF ►ROUWO THAT HE OR SHE DD NOT M" OR
NPAC}VE FOR THE PURPOSE OF SAIF}
O LAS OVIIFAOF THE PAOPERTY AM EXCLUSIVELY CONrRACTNO WITH LICENSED C ONTRACTOAS
TO OONSTFUCT THE Phalt= (SEG 70N, BUSINESS AND PROFESSIONS CODE' 7ME CONTRACTORi Ll
CENSE LAW DOES)IOTAPPLY TO AN OWNER OF A PROPERTY WrO WILDS OR W PROVES THERECH. AND
VMOOONTMCTS FOR SUC H980.1ECTS WITHACONTRACTOR(S) LICENSED PURSUAW710THE OONTRAC.
TORS LICENSE LAW J
0 1 AM EXEMPT UNOER SEC. B. S P,C. FOR THIS RFASCXF
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HERESY AFFIRM LMER PENALTY OF PERJURY TROT IAM LICENSED UNDER PROVISIONS OFCNAFTEa
I (COMMENCWC WTTIi SECTK7N )COO) OF OMSION i OF M£ BUSINESS ANO IROFFSS10N5 CDDE AIA
MT LICENSE LS N FILLFOACE ANO EFFECL
LICENSE CLASS LJC. NO.
DATE----- CONTRACTOR
WORKERS COMPENSATION DECLARATION
1 HEREBY AFFIRM FACER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
`_I HAVE AND WB1 MAINTAIN CERTIFICATE OF CONSENT TO SELFiNSUM FOR WORKERS
COUREHSAT)ON.AS PIWI D90 SYSECTION 3tOo OFTHELABOR CODE FORTMCPERP60.1 tE
OF THE WORK FOR WNKH TILS PERT M 13SUED.
_„_ I NAVE ANO WDLL L(AWTAN WORKERS COMPEHSAT?ON WSVRANCE AS PEOUIRED BT SECTION
3703 OF THE LABOR CODE FOR THE PERFORMANCE OF WORK FOR WHICH THIS PERMIT LS
ISSUED. MY WGIU(ERS COMPENSATION INSURANCE CARRIER AND POLICY "SER ARC;
C.LVRIGI ..
POLICY CUMBER
M43 SECTUI.'CEDNOT BE UJ-FLETEOCFTE PEPNTT S FORCPEHLPORED 031/RS C51cq CRLESSL
I CERTIFY THAT N THE PERAJAC
FORME OF THE WORK FOR WHICH TMS PERMIT IS ISSUED.I
SH
UNOT EMPLOY ANY PERSCN a ANY MANNER$OAS TO BECOME SUNECT TO THE
7VORIERT CCAIPENSATION LAWS OF CALIFOAMA. AMO AGREETHAT IFI SHOULD BECOME
SUBJECT TO TH.E WORKERS COMPENSATION PAOVISCN3 OF SECTION 37m OF THE LABOR
CDDEI SHALL FORTHWITH COMPLY WIRY THOSE PACv134NSI
DATE: APPLICAP7T:
WMWtNG: FALVRF TO 3ECURE YNRKEAT COMPERSATON COVERAGE IS UNLAWFUL ANO SMALL BE
SUBJECT AH £MPLOY''ER TO CAVA WL PENALTIES ANO ChIL FINES UP TO ONE KINDRED TNOUSANO
DOLLARS (IIOO,oOOi N ADDIMN TO ME COST OF COMPENSATION, DAMAGES AS FROMOEO Ft)R N
SECTION 373A OF THE LIBOR COOS NTEREST. MID ATTOANM FEE&
CONSTRUCTION LENDING AGENCY
1 HEREBY AFAPM LSOERPENALTY OF PERA/M TNATTHERE tS AOONSTRUCTION WM04 AGENCY
FOR THE ►EAFORMUICE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEG 3OP7, CN, G).
LENDERS NAME
LENDERS ADDRESS
1 CEATIFY TNAT 1 HAVE READ MISAPPLICATION ANO STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 AGREE TO COMPLY WTTA1 ALL CITY ANO COUNTY ORO WJJICFS ANO STATE LAMS AELAYNO To OLID WC
CONSTRUCTION. AND HEREBY AUTHORIZE AEPRESENTLTNES OF MIS COUNTY TO ENTER UPON ME
ABOOVF•MENTICMED PROPERTY FOR INSPECTION PURPOSE
40lro'_/ /1 e 'Je_
PE E NNAMEL(P,wrl, p- /
GNA RE OF PEAMrTTEE TE
WHITE--4:)6Partmm1 COPY. YELLOW --Finance Copy, PINI
APPLIOATI014 �%
DATE [
PERMIT J►
0 Pi
NUMBER'`
V t
ISSUE I
TYPE
OCC
DATE
CONST. _
GROUP
ZONING SETBACKS
FRONT
RW
Q
REAR
O
SIDE/SIOE STREET
RW
0 -
SIDE
PROPOSED USE
NO. DWEL NO.
0.
UNITS STORIES
BEDR S
DESCRIPTION SO. FC
FACTOR PSF
` ADJ. AREAIV ATION
SFRlADD IREM
�
GarapaJCq
W
Palid0adl
U-
PDDY$pa
`�
Z
0
Commercial
in
Va)uNion
ADJAREA
QUANTITY DESCRIPTION
FEE
J
L)
U
2
L)
UiF-
W
0
z
ib
g
CL
CL
U
z
Q
S
U
W
CONSTRUCTION
PLAN REVIEW,
._.
-__:-..:..�. .. ...-._.. _..
ELECTRIC
PLUMBING
MECHANICAL
114SPECTION FEE
ISSUANCE
SMTP
ENERGY PIC
ENERGY PERMIT
RETENTION FEE.,
PRE -ALT FEE
TOTAL FEES
COMMENTS
�RECPTNO. PAID BY
VALIDATION
VI3654" -QF7. GOLDENHtna-t•IIB COW. GREEN—Apot nC$ Cvy