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HomeMy WebLinkAbout17568 (35) i J� CTTY OF DIAMOND BAR � ,i DEPARTMENT OF COIvIIvIiTNITY&DEVELOPMENT SERVICES 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 PRESS "%.�' BUILDING PERMIT APPLICATION FIRMLY N JOBSITE �tlr� ���� �A�/� l/�� Q� APPUCATI9 PERMIT �7 l PIC o ADDRESS �� ' I ��" DATE / �� dZ NUMBER lSI�J � O�. � I c� ISSUE TYPE OCC APN LOT� TRACT �_�/2?� DATE I '��" ��CONST. GROUP °C OWNER 0 p ADDRESS ZONING SETBACKS Z CITY ZIP ' TE C� FRONT RW O g APPLICANT TE REAR ❑ SIDE/SIDE STREEf RW O � CONTRACTOR ��P SIDE p Q ADDRESS PROPOSEDUSE /"DOG /'.[1/� �S�l� � CIN ZIP TEL w ARCH/ENG! iz DESIGNER SQ/� NO.DWEL NO. NO. n. ADDRESS UNITS STORIES BEDROOMS = CITY ZIP TEL y DESCRIPT�ON SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER•BUILDER DECLARATION SFR/ADDlREM O p 1 HEREBV AFFlRM UNDER PENALTV OF VEiWRV THAT 1 AM E%EMPT FROY THE CONTMCTORS l4 Garege/Carport W CENSELAWFORTNEFOLLOWINaRFA50N15EC.10.11.S8USWESSANDPflOFESS�ONSCODE:ANYCITYOR (n C� COUNTYVIHICHREOUIRESAPERAARTOCONSTRUCT.ALTER�PNOVE.DEMOL151i0RREPAIRANYSTRUC• W Patio/Deck �L TURE,VRIOF TO RS ISSUANCE,ALSO REOUIRES THE APOLICAM FOR SUCH 7ERM�T TO FILE A SICNED w �, STATEGEM THAT ME OR SHE IS LICENSEO PURSUPNT TO iHE PROVISIONS OF TME CONTMCTORS U� � CENSE UW I��ER9(COMMENCW6 WITH SECTqN 10001�01VISION 7 0F THE BU51NES5 AND VPO� LL" POOVSQB FESSIONSCOOE�ORTHATHEORSHEISEXEMPTTHENEFRdAAN�TME8A5ISFOPTHEALLEGEDE%EMP- (!f TION.ANYVKKAiIONOFSECTION70.71.6BYANYAPPUCANTFORAPERMITSUBJECTSTHEMPIICANTTO Z Ra-Rool � AQVILp�AL7Y OF NOT AIORE iHAN fIVE HUNORED DOLURS(f5oo).j: 0 �T,ASONTJEROFTHEPROPERTY,ORMYEMPLOYEESWITHWACE511STHEIRSOLECOMPENSATION, � COrtlme�tl81 �- Z WILL DO THE WORK AND THE STRUCNRE IS NOT INTENDED OR OFFERED FOH SALE(SEG 7W1,BU51� J NESS AND 7ROFESSIONS COOE�T11E CONTRACTORS LICENSE UW DOES NOT APPI'/TO AN OWNER OF � OiL�VERTVVAIOBURDSORMPROVESTHEREON,ANOW1/ODOESSU(Y/WORKHIMSEIFORHERSELFOR � (L' 711ROUCHHISORHEROriRlEMPLOYEES,PPAVIDEDTHATSUp/11APaOVEUENTSARENOTWTENDEDOR CO QOFFEREDFORSILEIF.FIOWEVERTMEW0.DINGORMPROVEMENTISSOlDYN7MINONEVEAFIOFCOMPLE� Z 710N.THE OWNER�BUILDER WILL HAVE THE BUROEN OF PflWINC TMAT HE OR SHE DID NOT BURD OR = MVROVE FOR TNE VURPOSE OF SALEG �� ❑l AS OWNER OF ME VHOPERTY,lUI E%GLUSNELY COMHACTPlO YATM LICENSEO WNTMCTORS � TO CONSTRUCT TME�R0.1ECT(SEG 70l1,BUSINESS/WO FqOfE5510NS CO�E:TME CONTMC70RS LI• V21U8l1011 I ADJ.AREA W CENSEUWOOESNOTAPPLYTOMIOWNEROF�7ROPERTYWHOBUILD50RIA1PROVESTHEREON.AND � W/1000NiMCfSFORSUCHGRQIECTSNATHACONTMCTOR(5)LICENSEDPURSUANTTOTHECONTRAG QUANTiN ESCRIPTION FEE Y TORS LICENSE LAW). ¢ ❑I MA EXEMPT UNDER SEC. B.t V.G FOR THIS REASOl1 U � U.. � DATE OWNER V �4 UCENSED CONTRACTORS DECLARATION W 2 IHERE9YAfFIRMUNDENPENALttOF7E0.)URYTMATI/JAUCENSEDUNOERDROVISIONSOFLHAPTER � v � i�CqAMENCWOWtTNSECT10N7000)OFDMSION70FTHEBl151NESSANDVROFES510NSCODE,�ND Z �� YYLICENSEt51NiUUFORCEANDEFFECT. m 0 UCENSE CLASS LIC.NO. J _ , V DATE CONTRACTOR d W � WORKEFiS'COMPENSATION DECLARATION Q . N IHEREBYAFFIRMUNDERPENAITYOFPERNRYONEOFh1EFOLLOWMCDEQARATIONS: U U] Q � _IHAVEANDWILLMAIMAINACEHTIFlCATEOFCONSENTTOSELF•iNSUREFORwoRKERS'� _ � � � COMPENS�TION.ASPROVIOEDBVSECTION7)ODOFTHEIABORCODEFOHTHEGERFORMANCE �U OF 1HE WORK FOR NMiCH THIS iERM1T IS ISSUED. � � w �IMAVEANDWILIMAINTAINWORKEFS'COMPENSATqNINSUMNCE.ASREOU�REDBVSECTqN - O 77000FTME UBOR CODE,FOfiTHE PERFORMMICE OFTHE WORK FOR WMIp11NIS PERMIT 15 �Q� � ISSUED.MYWORKERSCOMPENS�TqNINSURANCECARRIERANDPOIICYNUMBERME: CONSTRUCTION� - /(. � � CARRIER PLAN REVIEW IU a�-- � POLICVNUMBEH ELECTRIC 5 1_ 0 (f}q55EGi10NNEmN0T8E07�.plETE00FTEPEW.�TI'+iORONEM.f�DRED00lWiSRi00)IX1LEu4 PLUMBING � W ` Z I CERTIFV THAT W THE VERFOfUAANCE 0F THE YYORK FOR HRfid1 iHIS PERAIIT IS ISSUED,l MECHANICAL •J � (,') SNALL NOT EMPLOV ANY PERSON IN ANY MANNER SOAS TO BECOME SUBJECTTO THE � WORNERS'COYPENSATIONUWSOiCALIFOHNIA,ANDAGREETXATIFISHOULD9ECOME INSPECTIONFEE S 6V&1ECTTOTHEWORI(ERS'CdA7EN5ATbNiRONSION50FSECTION7T000FTHEU80R CAOE,1 S11ALl iORTMMM COMPLY WITM TlqSE PRONSiONS. ISSUANCE � p DATE: APPLICANT: SMIP •J D � ENERGY P!C WARNIN(i:FAILURE TO SECURE WORKERS'C0IAPENSATION COVEMGE IS UNUWFIA,AND SHALL BE � SIAJECTANEMPLOYERTOCRIMINALVENPLTIESANDCMLFINESUPTOONENUNDRED7/1IX15AND ENERGYPERMIT DOlLAR3(f100,000),IN ADDITION TO THE CAST OF COMPENSATION,OAMACES AS PROYIOED FOF IN J SECTIDN 77oe OF TME UBOR CODE,INTEREST.AND ATTORNEYS FEES. RETENTION FEE: � � . a CONSTRUCTION LENDING AGENCY pRE-ALT FEE: � IHEREOV��FlFM�OERPENA�,TYOFPEFLURYTNATTHEREISACONSTRUCTIONLENOWOAGENCV d FOR THE PERFORMANCE OF TME WORK FOR WHICH iN15 PERMiT IS ISSUED(SEC.]09�,dV.C.). Z W � LENDERS NNAE � LENOERSADDRE55 �^( ¢ ICERTIFYTMATIMAVEREADTHISAPDL1CA7qNANOSTAlETMATTHEl�80VEWFORAAAT10NI5CORREC2 TOTAL FEES ��� " Oa2 '/� w IAGREETOCOMPLVWITHALLCRYANDCOUNT'ORDINANCESANDSTATEUWSREUTWGTOBUILDIN6 .�/� � CONSTRUCTION.�NONEREBYAUi/10R1ZEREPRESENtATIVESOFIHISCWMYTOENTERUDONTNE � N•l,•�J QABOVE�MENTIONEOPROPERTYFORINSGECTIONPUftPOSES. COMMENTS���`7' / ��� -' �v/'f✓. cS /S fr',t�-#'�¢ _ � VERMI ua¢�vw � dz � SI NATUR i EE ��T � RECPT.NO. PND BY VALIDATION WHITE—Department Copy.YELLOW—Finance Copy.PINK—Assessa Copy,GOLDENROD—File Copy,GREEN—ApplicanCs Copy • . .' ��'.�.r . . .. .. ! ,���T . �r .1. ., �t'1 . .r ..• A1. . , . ... . ♦ `�h.!':V t. Y�'• . . •• w ... .''1 i . . . . '1r..Y � .. ... ( ,r '�—�ar-..• ,r.!' .. �.L_ _ 'S.:. . . . � . , . .. � . 1 ce-r:�� a�= r���-:r��oz�� Br�e� � . If�:SF=�C"s"90��! F;ECQi�D _ �_______��.._._. __�____�.�_ ._ .. , . _ - '�)►��1.��-,�,161���p '�`�� �:�'.-. 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DRYWALL PJAILING DE�ICATIOPJS SEWER FINAL ENG. SEPTIC TAWK LANDSCAPE/IRRIG. SEEP PIT/L.L. � . _. ON SITE IMPS. GAS AIR TEST r' '�� FINAL ZONING ��l Li FWAL CONST. � , F!RE DEPT. FINAL FINAL HEATING HEALTH DEPT. FINAL FINAL ELECTRIC � � DEV. FEES PAID FINAL PLUMBING � EP�ERGY ` '_._:.w.__.�� , . .. - : ____. � � t._ ;; '':r`_.._�. I -=---- COMMENTS_��NG�; 5 C?/�'1�S �G_t� C�IL � �Jc�.r I�����1'�'I I;111.e d:'.���i�;�.����r/�'__�.G�v,�'_L��Rr_���r-�T:,��1s%2,:s-�—i�'U .��-���G���C���_�������'`_.__ -?.o z�±��—G�4ss_.s�u�w_�.:_�v�._6fL� SEPTIC TANK SIZE SEEP PIT/U SIZE '"�� I I , �+`� s � — !i � � — J ' _. . _. .___ ._______._.I