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HomeMy WebLinkAbout12-188 �.�_ CITY OF DIAMOND BAR � � DEPARTMENT OF COMMLJNITY&DEVELOPMENT SERVICES � 21810 Copley Drive,Diamond Bar,CA 91765 � � (909)839-7020 Fax(909)861-3117 Building Inspection Hotline(909)839-7 �Q PRESS `��9���w BUILDING PERNIIT APPLICATION !L- : FIRMLY � JOBSITE �� L{� ��( DATE CAn�I V�l�- NUMB A.�� �t/C o ADDRESS � $ ISSUE TYPE ��,1�_/� C1CC APN OT TRACT DATE m�- CONST. � v�� GROUP °C OWNER � � ZONING SETBACKS o ADD SS m FRONT RW ❑ Z CITY� � ZIP TE �U REAR ❑ o APPLICANT TE SIDE/SIDE STREET RW O � CON AGTQR K (,t_ 1�) SIDE � O ADD SS�� � PROPOSED USE ci ��F _� .i ziP o2`� r �310) w ARCHlENG/ z DESIGNER NO.DWEL NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANAIUATION � ¢ OWNEii-BUILDER DECLARATION SFR/ADD/REM � O 1 HEREBY AFFlRM UNDER�PEN►LTY OF PERRIRY TFU7 I AN EXEMPT FROM 7HE CANTRACTORS LL G��g���h W CENSE UW FOR THE FULLOW WO REASON(SEC.7o31.6 BUSMESSAND PROFESSIONS OODE:ANV CfTV OR (n U COl1NTl'WHIpIREOUIRE3APERMfTTOCON9TAUCT.ALTERIAIPROVE.DEA10115H.ORREPNR.WVSTHUG IW Patlo/Deck . . 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Z TION.THE�OWNER-BUIIDER WILL HAVE 7HE BURDEN OF PROVWd THA7 HE OR SHE DID NOT BUILD OR � IMPROVEfORTHEPURPO5EOF5AlE} . .. , w ❑I.A30NMEROFTHEPROPEHTV.AAIE%CLUS�VELVCANTRACTINOWf11�lICENSEDCONTRAGTORS � ro corrsrpucr niE aqwECT�sEc.�au.euswEss um aaocEssroHs cooe:n+e oorrrru�croRs u- Valuatbn ADJ.AREA CENSE UW DOES ND7 APVI.V TO AN OWNER OF A PAOPERTY WHO BUd0.5 OR IMPHOVES THEREON,AND � WHOCONTRAGT6iOR3UGHPRQ1ECfSWrtHACONTRACTOR�S)LICENSEDPURSUANTTOTHECOHiMG 7Y �pESGRIPTION FEE � � TOiIS 110ENSE IAW.�. _ O ❑I AM EXEMPT UNDER SEC. B.d V.C.FOR THN3 REASON � U �i ¢ � DATE OWNER . V � Z W � UCENSED CONTRACTORS DECLARATION � oC W I HEREB�AFFIRAI UNDER PENALTV OF VERJURV TMAT IAM LICENSEO UNDEA PROVISIONS OF CHAPTER � � Y(COMNENGN(1 WITM SECTION 7Um)OF DNISION 1 OF THE&15ME5S M1D PPOFHSSIONS COOE,ANO Z. � LCENSEC�SS�L`' J6ECT. LIC.NO. � / . � 7 . � � J � pp � CON7RACTOR . a . . ' .. � � WORKERS'COMPENSATION DECLARATION Q � ��� � � U � I HERFBY AFFIiU1 UNDER PENALTV OF VERfURV ONE OF THE FOLLOW WG DEClAM710N4: ZQ � _IHAVE'ANDWILIMAINTNNACfATIFICATEOFCON9ENTTOSE'LF-WSUREFORWORICERS' Z Q CplAppdSA71pH,/�9 PROVIDED BV SECTION 3100 af THE LABOR CODE,FOA Tl4E PERFORM/JICE w' OF 7HE WOPo(FOR WM�CH THIS PERMIT IS ISSUED. � ' � 1 HAVE AND WILL MAWTAIN WONNERS'COMPENSATION INSURANCE,AS RE�UIRED BV SECTION Q 770o OF�THE LABOR CODE,FOFl THE GERFORAIANCE OF THE WOR)c FOR WHICN'fF1lS PERMIT IS, ISSU£0.MV�'dORKEA5 COMP TtON IN RlJJCE GnRRIER AN�POL�CY Nl7MBER ARE: CONSTRUCTION� � CARRIER � �� ` PLAN REVIEW � ro�xr r�iMeEa ELECTRIG 0 (nussEcnonr+FIDwreE�iE�oF sroaar+E�ro�oouaasR �ssl PIUMBING _ ��`e�-d4 w I CERTIFY TMAT IN 7ME 7ERF IWCE OF THE.WORK FOR CN 7H14 9ERMIT IS ED,I MECHANICAL Z (,r} SFIA��NOT EM7LOV ANY P �N W ANY IAANNER SO AS T ECOME SU&IECT T E� � WORKE S'COM7ENSA LAWS OF CALIFORNIA/NO EE TNAT IF I 51KK11D coMe �INSPECTION FEE� q SU&IE TO EWOAI( RS'COAIFENSATIONPRO SOFSEC710N97000F EUBOR ISSUANCE s E 5 FO 7HCOAIPLYWITHT VIS S. . . . . �7/•-- O � SMIP � � A ' w ENERGY PIC � WARNIIN3: AWRETOSEGUREWOHICERSCAMPENSATIDNCOVERAGEISUNUWFUL.ANDSHALLBE - � � SU&IECT AN EMPLOYER TO CRININAL VENALTIES M!D CML FWES UP TOONE HUNDRED THOUSAND ENERGY PEFMIT . ppLLhp$(t10o,000),W ADDITON TO THE COST OF COMPENSATION,DAMAGES AS PROVIDE�FOR IN �7�u J SECTION 37oe OF THE LABpFi CODE,WTEREST.AND ATTORNEv'S FEES. ' RETENTION FEE: �` : � w CONSTRUCTION LENDING AGENCY PRE-ALT FEE: a � 1 HEREBY AFFlRM UNDER PENALlV OF PERAIRY 7HAT 7NERE IS A CON3TRUCTION LENDINO AOENCY FOR THE PERFOFiAIANCE OF TFIE WOPoC FOR WHICH THIS PERMIT IS i55UED(SEC:JOD7.GV.C.). Z ' W �Z� LENDER5NAAIE . . . J F— LENDER'SAODAESS � �� � � � CERTfi`/THATIHAVEqEAD7Vi19APPL�T10P1ANDS7ATETHATTFiEABOVE�NFONMATIONI9COMEC7. TOTAL FEES , /�� / REETOCOAIPLYN7THALL MIDCWNTYORDINANCESANDSTATEUWSREUTWGTOBU4.DINO . CO 7RUCTION,lJ1DHER FUZEREPRE �ATIVESOFTMISCOUNIYTOEHlERUPONIHE . _ Z EMIONEDPqOP RTY.FO WSPECTION aoses. COMMENTS ' � o �J � PERMITfEENAM P P!T) � . . . . 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" � FIRE DEPT.FINAL FINAL HEATING HEALTH DEPT.FINAL FINAL ELECTRIC DEV.FEES PAID INAL PLUMBING ENERGY FINAL PLANING FINAL ENGINEERING 0 COMMEfVTS _ --��� �� �" Z 3 � R� �Z.• SEPTIC TANK SIZE SEEP PIT/U SIZE ,pl, '' i :�.. � ---