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HomeMy WebLinkAbout17057 (40) J� CTTY OF DIAMOND BAR � � DEPARTMENT OF COIvIIvtUNITY&DEVELOPMENT SERVICES 21825 E.Copley Drive ' �,._ '�` (909)860-3195 Fax(909)8b1-3117 PRESS �'�� BUILDING PERMIT APPLICATION FiRMLY � JOBSITE �.:n��� o ADDRESS �ZI �• PALO �JC�II�G(� DATECATION�^ �/^O� NUMB R�7��7 �/C T � ISSUE TYPE p�C APN LOT TRACT �ATE CONST. GROUP p OWNER Cn IC o ADDRES� ' 'y N' w � �(1Q ZONING SETBACKS �w CITY ZIP TEL. ' "' FRONT Ryy p APPLICANT f3U lA/LC,/fA TEL.'f�N?7�t�9n_� REAR p zd SIDE/SIDE STREET RW ❑ � CONTRACTOR SIDE ❑ � ADDRESS • o CITY ZIP `�1Z0� TEL.�' '��-°!� PROPOSEDUSE R. Kl. - L . o ARCWENGI ! � `" DESIGNER --�-s.�°��S � �r.g �i.i NO.DWEL. N�. NO. n. ADDRESS = CIN ZIP TEL. UNITS I STORIES I BEDROOMS_;L � cn DESCRIPTION SO.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDEROECLARATION , � SFR/ADD/REM � 1 HEREBV AFFINA UNOEF PENALTY OF PE0.NRY THAT I AM EXEMPT FROIA iFIE CONTMCTORS ll� G8f8 JB/C81POR W CENSEUWiORTHEFOILOWIN6REA50N(SEC.70�1.SBUSMESSANDVROfE55iON5CODE:/WVCITYOR (n U COUNTYYMICMREOUIRESAPERMITTOCONS7RUCT.A7ER�PflOVE,DEMOLISH,ORREPARANYSTRUC• W patio/Deck � NHE.PHqq TO RS ISSUANCE.QSO REOUIRES THE APPLICANT FOR SUCH PERM��TO FILE A SIGNE� W � STATEA�ENT THAT NE OR SHE IS UCENSEO PURSUMIT TO THE VROYISIONS OF iMA CONTMCTORS lb � � CENSE UW�CNAP7ER 9(COMMENCWO WITH SECTION 7000)Of�IVISION]OF TNE BUSI�ESS AND VqO� POOVSpd FESSIONSCOOE�ORTHATHEORSHEISE7lEMUTTHEFEFROMAh�TNEBASISFOPiHEALlECEOE%EMP� (� V TION.ANVVIOU710NOFSECTION7071.SBVANVAPPLICAMFORAPERMIiSU&IECTSTHEAPPLICANTTO Z Re-Roof A GVIL PENALiV OF NOT MORE h1AN FIYE MUNDRED DOLURS�fSOC).): � OL�30YMEROFTHEDROPERTY,ORMVEMPLOYEESWI7MWAGES/STMEiRSOLECOMPEN5nT10N, O COmmBICl21 WILL DO THE WORK,AND TME STRUCTURE IS NOT INTENOEO OR OFFERE�FOR SALE(SEG 70U,BU51� J � NE55 M1D CROFESSIONS CODE:THE CONTMCTORS IICENSE UW DOES NOT APPLT TO AN OWNER OF � PR07EHTY WHO BU0.D5 OR IMPROVES THEREON,ANO MMO OOES SUCH WORN MIMSEIF OH HERSELF OR � TMROUGHHISORMEROWNEMFLOYEES.pROYIDEDTHAT5l1CHIAIPFOVEUEMSARENOTMTENDEDOR m O OFFEREDFORSALEIF,HOWEVERIMEBUIDINGORIUPROVEMENTI550LDNnTMINON[YEAROFC01AvlE- z TION.THE OWNER�BUI�pER N^.LL HAVE THE BURDEN�F PROVWO THAT NE OR SHE D�D NOT BUIID OR � pAPROVE FOR THE PURPOSE OF SALEJ. ' �y,� 04ASOYMEROFiHEPROPERTY,AMEXCLUSNELYCONTMCTINOWITNLICENSEOCDNTMCTORS � TO CONSTRUCT THE PRQlECT(SEC.70N.BUSINESS AND PROFESSIONS CODE'.7ME CONTMCTOFS LI� V8I113�IOf1 A0.1.AREA W CEHSEUWOOESNOTMPlY70ANDWNEROFA7ROPERTYWHOBUILOSORIM�ROVE5TIEREON,ANO � Y.TIOCONTMCTSiORSUCHPROJECTSWITHACONTMCTOR�S)IICEY5E0VUR5UAMTOTHECONTMG QUANTITY DESCRIPTION �E Y TOHS UCENSE LAW). I, � OIAAIEXEMPTUNDERSEC. B.IP.C.FOFTNISREA50N Q � U � OATE ONT'ER F� Z W � LICENSED CONTRACTORS DECLAHATION I W � IHEREBVAFFIRNUN�ERVENALTVOFPERNRYTHATIAAILICENSE�UN'JERPPOVISqN50CCNAVTER �. p„ Y(COMMENCMQWITHSECTqN700o�OFON15iON]OFTHEBUSWESSANDOPOFE5510NSCODE,AND Z X W LICENSG IS N NLL FORLE ANO EFiECT. ��, 0 UCENSEsCLASS l_^39 LIC.NO. �/d �/� j V OATE 9 �� �' Q, COMRACTOR d W � WORKERS'COMPENSATION DECLARATION I., a NI MEREBV AFFIqM UNDER PENALTY OF VERIURY�NE OFTHE FOLLOYnNG DE(.1AfUTqNS: Z Q � �INAVE/WOWILIMAINTAINACERTIFICATEOF�pNSENTTOSELF•INSUR'eFOAWORKERS' _ COMPENSATION,ASPROVIDC�BYSECTKNIS7o00FTHEU80RCO0E,FORiMEOERFORMANCE U Q OFTHE WORK FOF WHIp1 TNIS PERMIT IS ISSUED. ''� � � _I HAVE/WO WILLMAINTAIN WOWCERS'COA�7ENSATION INSUFLWCE,AS REOURED BY SEC710N 07oa OF TNE UBOR COOE,GOR THE GEFFORIAANCE OF THE WORK iOR WNICH THIS PERMIT IS 9p. 3 O � ISSUED.MY WORKERS'COMPENSATION INSURANCE CARRiER IWD FOLICYNUAIDERME: CONSTF�UCTION � CARRIER PLAN REVIEW Z� ra�cYNUMBER ELECTRIC ¢ � (nasSEci�n�mw78E�.slEtmccnEVEw.arswaon.���oalu+sK+m�on�Fss} FLUMBING --�----"----_—^ �—�--^ Z ICERTIFYTMATINTNEGERFORMA4CEOFTMEWORKFORKH�CMTM'S�ERA!1T1515SUED,1 MECHANICAL �I1�f�� �\�' ' I `��J ('J SMALLNOTEMPLOYMlYPENSONINANYMANNER5011STOBECOM[SUBJEGTTOTHE (n WORKERS'COMPENSATIONUWSOFLALIFO ANDAGRCETHATIFISMOULDBECOME INSPECTIONFEE SUBJECTNTHEWORKERS'COMPENSATIO VISIONSOFSEGTqN7700DFTHELABOR s cooE.�sw�ucoanrvnnicor.�v�vwi oaovis�or+s i ISSUANCE - � SMIP O p DATE:�_� APPLICANL '..� J WARNINO:FAILURETOSELUREWORKERS' MPENSATpNCOVERAGEISUNUWFUL.ANDSMALIBE ENERGYP/C r• J . �y SU6JECTANEMPLOYERTOCFIIAINALPENAlTIESANDCNILFWESUPTOONEHUNDREOT/qUSAND ENERGYPERMIT � DOLUiiS(f 100.000).IN ADDITION TO TNE COST OF CqAPEN5AT10N.OAAIAGES AS VPOVIDED FOR IN J SECTION�)OeOFTHELA00RCO0L,INTER[ST,AND�TTOMIEYSFEES. '� R�ENTIONFEE: ��v Q aw. CONSTFUCTION LEN�ING AGENCY pRE-ALT FEE: O ' � IHEREBVAFFIqMUNDERPENALTYOFPE0.)Ui7VTHATTNEREISACONSTRUCTIdJIFNDINOACENCV FOR THE PERFORMMlCE OFTHE WORK FOR WHICH THIS PERAIIT IS ISSUED�SEG]09],CIV.C.�. Z W � LENDER'S NAME F'� IENDERSADOFE55 � w ICERTIFYTHATIHAVEREAOTHISAPPLICATqNANDS'ATETMATME�BOVEINfOiiNATqNISfARliECT. TOTAL FEES /�� �D � IAGREETOCAMPLYWITHALLCRYANDCOUNTYCRD�NANCESMlDSTATELAw.iRELATWGiOBUILCiNG � CONSTRUCTKKi,ANDHEREBYAUTHORIZERE7qE5ENTATIVE50FTH15COVNT'ITOEMERUPONME Z ADOVE�MENTqNED PROVERTY FORINSPECTION VURPO5E5. '. COMMENTS � � V'"7��� m VERMITf N (PRINT) '. Q cn — �—O / � SICNA eOFPERMITTEE OATE �, � � RECPL N0. � PAID BY US VALIDATION WHITE—Department Copy,YEUOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—Fiie Copy,GREEN—ApplicanCs Copy '�� , - . .. . . � . . _ .. .: .. . , . , - . . . .. . . . . , � _;.�,,- -_ r,r- �..5 . . � .'i: :i.�i. r� ,...a f.��-.i � 1T�'•....�: :.;`.... � �y�. r. 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