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HomeMy WebLinkAbout10733 (5) / ;. , - CITY OF DIAMOND BAR / COMMUNITY DEVELOPMENT DEPARTMENT 21660 E Copley Drive 3uite 190 PRESS (909)860�3195 Paz(909)86I-3117 ""'� BUILDING PGRMIT APPLICATION FI R M LY � JOBSITE 7 S9�j� �/I i/ ll�.D� 7( /� APPLICATION �.r��'� PERMfT /O�3� P/C ��0 o ADDRESS e�o o �/�`�i"� .fS/5r v/� DATE NUMBER N g issue nrPe occ . APN LOT TRACT DATE CONST. • • GROUP p OWNER � "' ADDRES ZONING SETBACKS � CITY IP�T EL. FRONT RW � � APPLI A � ' " TEL. SIDEJSIDE STREET RW ❑ r� CONTRACTO G, SIDE ❑ � ADDRESS p �� Z1P _ ROPOSED USE n—s � /2� o ARC NG! � . � DESIGNER NO.DWEL � ••, NO. � �'• ` NO. ADDRESS UNITS �" �STORIES � • � BEDROOMS � CfTY ZIP TEL. y DESCRIPTION SO.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER•BI:ILDER DECLARATION SFWADWHEM O p 1 NEREBYAFflRM tMDER PENILiV OF iERA1RY THAT I AM EXEMVT FROM TME CONTMCTORS L4 G818(�BlCBfpOK W CENSEUWFORTMEFOLLOWMOREIISON(SEG70.71.68USN1ESSANDYROFESSiON5000E:M1YGIiYOR (n C) COUNiYWNIp1RE0URES1lVEiWITTOCONSTRUCT,KTE1lMPROVE.DEMOlJSH.OHREPAIRAHYSTAUG W P6�iO1DBGk I� � . L TURE PPIOH TO RS ISSUANCE.AL50 REOUIRES iNE MPLICAI�(T FOR SUCF1 PEIWIT TO FIIE A SiGNED f S V� STATE4EM THA1 NE OR 511E IS IICEN5E0 M1RSU/N7 TD iNE VRONSIONS OF THE CONTRACTORS l4 W � CENSE Uw(CIUPTER 0(C0114ENCPNi YAiH SECTION 7000)OF DIVI510N]OF 7HE BUS�NE55 MID Vq0 � POOVSPd . ' � FESSIONS COOE)OH TIUT HE OR 511E t5 EXEMPT TNEREFROM N10 THE BA515 FOR TME/LL.LEOED EXEAw- TION.ANYVIOLA710NOFbECTIDN7olt.6BYANYA➢PLICANTFORAVERYITSU&1ECTSTMEMPLICANTTO Z RaRoot A CML VENALTY OF NOT►qRE TMAN FNE HUNORED O0.LM5(i5o0�.k 0 ❑IASGMMENOFTHEVROPERTY,ORMYENPLOYEESWITIWACESASTMEIR50LECOYPEN5�710N, � CpmmBfClel � � Z N7LL DO THE WOAK.AND TM[STRUCTURE IS HOT W7ENDED OR OfFEHED FOit SALE(SEG TON.BU54 J � NESS AND VROFF5510N5 COOE:THE CONTAACTORS LICENSE UW OOES NOTAPPLY TO AN OVMEN OF = PROVEH7Y YMIO BUlDS Of11uPROVES TNEREON.AND NMO DOES SUCN N9RK MIYSELF OR FIERSELi OR � � THROUG/1 HIS OR NER ONR1 EMVLOYEES,VROVIDED THAT SUpI W PROVE4EM5 ME NOT WTENDED OR m W OfiERE0iOR5ALE.F.HOWEVERIMEBULDR:00RMVROVEA1ENi1350lDVATMWONEYFAROFOOMPLE• Z TION.7ME OwNER�BUROER NnLL II�VE TME BUROEN OF PROVMO TMT XE Ofi SME OD NO7 BUtD OH = WPROVEFORTMEVURPOSEOFSALEI � O l AS OWNER OF TNE PROPERTI:AM E%ClUSNELY CONTMCTN6 YATN LICENSED CONTMCTORS � TO CONSTRUCT iHE VR0.IECT(SEC.7ou,BUSINE35 AND VROFESSIONS CODE 7/1E COHTM.CTORS LL V81Wf10R AOJ.AREA W CENSEUwpOESHOTAPPLYTOANOYMEROFAiROPERTYNn10BUILD90RWPpOVEST/EREdJ,AXO � W/qCON7MCT3FOR5UCHPRq1ECT5WIMACONTMCiOR(S�LICENSE7PURSUlWTTO7HECW.TMP OUANTITY DESCRIPTION FEE � TORS LICENSE UW). � O I AM IXEMPT UN�ER SEG B.t P.G FOR THIS REIISON Q � ' 1�� 3 � � � D�TE OwNER . . � LICENSED COMRACTORS OECUlRAT10N W � IHEREBYAFFlP/JUNDERPENILTYOF7ERlUiIYTFUTIAAILICFNSEDUNOERPROVI510H40FCH4PTEH � d 0(WYYENCINOWI7HSECfION7000lOFdYIS10N]OFiHEBUSINESSMOPROFES510NSCWE.MA Z W LICENSE IS N FUIL FOitCE AND EFiECT. `�sy �� /pJ� m . .. � IICENSEClA3�! ����_-7�G LIC.� • �`� D� j . V DATE CONTMCTOR �� � a W � WORKERS'COMPENSATIONDECLARATION iJ� � = U � INEpEBYAFFIRMUTAERGENALTYOFGERIURYONEOFTMEFOLLOW�NOOEQ,ARA7qN5: Z � _IMAVEFIJDWILLAUM7A1NACfRTIFICATEOFCdJSEMTOSELFJNSUREiORWORNERS' _ . COMVENSA7qN,ASVRONIDE0BY6ECT10N77ooOFTHEUBORCOOE,FORTNEPERFORMANCE w OF iXE WORK FOR W111p1 TNIS PERAIIT IS ISSUED. � O 1 HAVE AHD W�IL AMMNN W0�1NER5'CM�PENSATION INSUIIAI�Cf.AS RE WIRED BY SECTION Q �700 OF THE UBOR CODE,FOR THE VERFORAWICE OF iME WORK FOR WHiCH TM�S PERMIT IS /�� ��� J ISSUE�.MYYy�15�F5CONVENS TqNI E ERANDVOIIL'(NUMBER11ilE: I - �� j GAIVER ✓ �1 PLAN REVIEW l r � POIICYNWBER �- .1 _/ . J� � (R455ECIqNNE�H0T8E00MF�ETmOFMPERAf�6PoR01EH�00l1Ai15 OO�OR I PLUMBING Z ICER11FY7HATNTHEGENFORIAANCEOFTHEVfORKiORYA11pITH�SVEi1MITI5155UED.l MECHANICAL (,7 SHALLNOTEAI7LOYANVGERSONWI�M/MANNERSOASTOBECOUESUBIECT70TME Uj WORKERSCOMPENSAiqNLAW50FG1LIF0 I11, AGR TMATIFIS DBECOME INSPECTIONFEE SUBJECT TO THE YVORNERS'C01dPEN5AT P IS F SECTION 7 HE l►BOR /� / �j e sti v coMv�r wi v �+ � � ISSUANC. • '�S pOATE: • APPLICJINT: �✓ MIP � � CJ!/ W J WAAN�NO:f�LURETO SECURE WOiIKER PENS�TION OOVEMGE IS UNUriFl1L.AlA SMALL BE ENERGY P/C � 6UBJEC7ANEMPLOYENTOCRIYIWLLP IESANUGVILFINESUv700NENUNDREDT110U5�ND ENERGYPERMI7 DOIURSIf100.000).NADORIONTO STOFCOMPENSATqN,D�UAA6ESASVROV10EDFORM w� ¢ BECf10N])aOFTNEUBORCOOE, REST,ANDATiMWEY9FEE5. ' flETENTIONFEE: i.O oW. CONSTRUCTION IENDING AGENCY PRE•ALT FEE: O � IMEREBV�FFiRUUNDENOENALTVOFVERrt1MTNATTHEHEtSACONSTRUCTIONLENDH6AGENCY z FOR TNE VERiOR1AMICE OF iME MIORK WR WItld171115 VEHYIT IS ISSUCD�SEG l007,CN.C.). W � LfNDEN'S WWE � �S LFNOERSAOONE55 ' w ICERTIFYTWTIHAVEPEADi1tl5MPLICATIONANDSTATETNTTIEABOVENFORMATIONISCORRFCT. TOTAL FEES , �O3 �/� � IA�REETOCOMVLYN7THALLCT'ANDCOUHTYORDINANCE9INDST�TEUwSREUTWOTOBUl01N0 - `•� � GONSTRUGi1p�ANOMEREeYAUT1qR12EREPRESEMATrvE50F71uSCOUN7YTOENTERUPONME . � ABOVE#IEN710HE0 PROVER7Y FOII PlSPECiDN PUNPOSES. COMMENTS � � / _ '• m OERW7TFE . � � .a � ..� . ,. � (A 6101N PE I E � O�7 � � RECPT.NO. �s�� PAID BY l • � VALJDATION WHITE—Depertment Copy.YELLOW—Finence Copy,PINK—Assesaor Gopy,GOLDENROD—Fik Copy,GHEEN—Applkanfs Copy (J �,.. ..r.s '.' ... . . .•,�� . . ' . • . ;'.," . . . ..�.��.- . ..:'�..: . . , . . -. ...� � . -c.'. ., . -,. _ _... , � .. , • . • . ` ' --� CITY OF DIAfJ�ONd:6�AR �`�- , ..�..., ., . � .. �� , .�. � . -:, . . _ _ . . . . , If�1SP�C�i IOfi� REGaE?� ': !�� . 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