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HomeMy WebLinkAbout15104CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190 (909) 860-3195 Fax (909) 851-3117 rte' BUILDING PERMIT APPLICATION JOBSITE ADDRESS�C��C_ APN LOT TRACT OWNER ANC, [ Ci- ADDRESS CAt:J3 iA 7�T3D � CITY ZIP TEL.C$6 APPLICANT �c�'I_ TEL. CL3 fr'f 7 CONTRACTOR Q I/�1`7aN Aa -K INS ADDRESS—L ( D .- CITY "D ZIP TEL jSdJ.s2j -2n ARCW'ENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION 1 HCnCBY AFFBIM UNDER PENALTY OF PERJURY THAT 1 AM EXCMPT FROM THE CONTRA—FIS U. CENSE UW Fon THC FOLLOWING REASON (SEC. 7031 B B;JSINESSAND PROFESSIONS CODE. ANY C:TYcn COUNTY WICH RECUnESA PERM"TOCONSTAUCT,ALTER IMPROV[, EIVOLIFI,OnREPAnMIYSTRUC- TURE, PnIDR TO RS ISSUANCE, ALSO REWIRES THE APPLICANT FOR SLCH PERMIT 10 FELE A S.GNED STATEMFNT THAT HC OR SHE R LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS U- CE45E UW (OIAPTER P (COMMENCING WITH SECTION 70DC) OF DIVISION 3 OF THE BUSINESS AND PRO- FESSIONS WOE) OR THAT HE OR SNE IS EXEMPT THEREFROM AND T11E BASIS FOR THE ALLEGED E %EMP• TION ANY VIOLATION OF SECTION 7031.5 eYANY AAPLICAN7 FOR A PEnM!T SUWECTS TME APPLICANT TO A C)Y.L PEMALTY OF NOT MOnc THAN FIVE FU NDnED DOLLARS 155w)), O 1, AS OWNER Or THE PROPCnTY.On MY EMPLOYEES WITI WAGES Ai THEIR SOLE COM-ESSATION, WILL DO THE WOFFC ANC CTURS THE STRUE HOT INTENDED OR OFFCRED Fon SALE (SCC. 7344, BUST. NESS AND PROFESSIONS CODE. THE CDN. RAC T ORS LICENSE UW DOES HOT APPLY TO AN OWNER OF Pf10F'FRTY WHO BULLS On MPROYES THEREON. AND WI lO DOES SUCH WORK HIMSELF OR HERSELF CR THROUGH HIS al HER OWN EMPLOYE ES, PnOY.DEO THAT SUCH MPR3VCMCN7SAnr NOT INTENDED OR OFFERED FOR SALE IF. 7CWEL'EFLTHE BUILDING OR MPRCVCMF.N7. IS SOLD WITHIN ONE YEAR OF COMPLE• TION. 111E OWNER-BU1LDEn WILL IUVE THE OU14DEN OF PROVING THAT IHE ORI SHE 00 NOT BUILD OR MPFOVE FOR THE PURPOSE OF SALE). O L AS OWNER OF THE PROPERTY, AM EXCLUSYELY COT NTRACTING WITH LICENSED CONTRACTORS To CONSTRUCT TRC PROJECT (SEC. FON. BUSINESS AND PROFESSIONS CODE THr CONTRACTORS LI- CENSE UW DOCS NOTAPPLY TORN OWNER OF A PROPE RTYW0IO BJILUS On IMPROVES THEREON. AND IMC CONTRACTS FOR SUCH PROJECTS WI THA CON T RACTOR(S) LICENSED PURSUANT TOTHE CONTRAC• TORS LICENSE LAW). O I AM EXEM7T INDCn SEC. _B APC FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERAUnY THAT I AM LICENSED UNDER PROVISIONS Or CHAPTER a (COMMENCING WTH SECTION TOW) OF DNISCN 3 Or THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS IN RAL FORCE AND EFFECT. DATE LICENSE CUSS' � CONLA TCTO i/G_ WORKERS' COMPENSATION DECLARATION 1 [�3, I HCnrBY AFFIRM UNDER PENALTY OF PERJURY ONE Or THE FOLLOV/`1G C ECURATONS _I NAVE AND W LL LU,'NTAN A CEFr...rICATE OF CONSENT TO SCLF-IN SURE FOn WO9KER5' COMPENIO SATON. AS PROVIDED BY SECTION THE LABOR COLE. FOR THE PCnrOr.MAN--C OF THE WORK FOR WHICH THIS PEr.MIT IS ISSUED. _I WfC AND W'LLMAMAN WoRKEns ooMPENSATCN INSURANCE, AS REOt'RrD BY SECTCN 3100 OF THE LABOR CWC, FOR THE PFRF oRNANCC Or THE WORK FOR W1101 TdS PERM T 15 rSSUCD. MY WOnKER!r OOMPENSATON NS' MNCC CMnIER ANL) POLICY N,IM3ER ARE cJuln:rn L`� 1 2 (� PDLIcYNuMnEn 00-0�iL_ (RGSEC.IDNNC©CI.fTEFORd2 NOTBECO PIE EDOrTEPKPL]f4�fXX1A'S (S•3C)CR LLS) 1 CERTIFY TUT N 7HC PEnronmA.4CE OF THE WOR( FOR WHICH DIIS PERMIT S ISSUED. I SMALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO TINE WORK FJ RS' COPEN SATCN LAWS or CALIFOrwA. AND AGREE THAT IF I SHOULD BECOME SUaLCCTTO THC WOnKERS OOMPENSATCN P•'IOVISONS DF SECTION 3700 or Tr•C LAnoR CODE. I SHALL FORTHWITHCOAL LY WITH THOSE PROVISIONS. GATE: v4S__J Ego APPLIOANT: WAFLY'NG FARUnETO SECURE woiaCns,COMPENSATION COVERAGESUM,AMULANDSIIALLBE SLIMECTAN EM? OYER TO CRIMINAL PENALTIES AND CML FINES UP TOONE HNDRr 0 THOUSAND DOLLARS (S 100.0X01. IN ADDITION TO THE COS T OF WMPUNW IDN, DAMAGES AS PROVIDED FOR IN SECTION 37CF Or THE LIIDOR CODE. INTEREST., AND ATTORNCYS FEES. CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM UNDER PENALTY OF PENURY THAT THERE IS ACONSTFIUCTON LENDING AGENCY FOR THE PCnrORMANCE OF THE WORK I On W1410 THIS PERMIT IS ISSUED ISEC, 3397, CIV c). LENDERS NADIDE LENDERS ADDnCSS 1 CEn7:rY THAT I (HAVE RrAD TMS APPLICATION AND STATE THAT TILE ADCVE NrorwA'XYI 15 CoRnCCE 1 AGn EE TO COMPLY WITH ALL CITY AND COUNTY C(CINANCES AND STATE LAWS RELATING TO BU'LD'NG CONSTRUCTION. AND HCRrBY AUTHOBJ2E RFPnrSCNTATIVES OF THIS COUNTY TO ENTER L'PON T14C AD, VEAICNIIDNED PROPERTY FOR INSPECTION PUnposEs. C.11 PEnANITTEE N L°- I SCNA4UItC O .LL' DATE PRESS FIRMLY APPLICATION PERMIT P/C O DATE ': NUMBER A ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDEISIDE STREET RW ❑ SIDE ❑ PROPOSED USE SJA� Ih1�Tr4(,i 1 L �=lfGf r �. c• o rc. (E Ir c� NO. DWEL. NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREANALUATION SFR'ADDIREM U) Garapa'Carpc:t WPatio,'Dodl L- PDOL'Spa Zno -Roof C D �C, C, Commercia! m Va'uation — D O D ADJ.AREA QUANTITY DESCRIPTION FEE cL 1. t1LLJ CL . r U LU W I I J .UID C7 . -r-o TTI T) AT C G U Z 6 x U w / CONSTRUCTION PLAN REVIEW ELECTRIC PLU'.1B,N0 MECHANICAL INSPECTION FEE - ISSUANCE SHIP ENERGY PH'C ENERGY PERMIT RETENTION FEE: PRC -ALT FEE: TOTAL FEES COMMENTS RECPT NO. _ .� PND BY _VALIDATION WHITE—Do^vAR:nor.-Ccpy. YELLOW—FIrenco Copy, PINK—Assoesor Cory. GOLDENROD --Filo Copy, GREEN—Applicant's Copy /.loy