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HomeMy WebLinkAbout14001 (14) �_ , CTTY OF DIAMOND BAR DEPARTMENT OF COMMUNITY d�DEVELOPMENT SERVICES � 21660 E.Copley Drive Suite 190 RESS '����� BU)ILDINGSPERMIT APPLICATION FIRMLY N JOOSITE t'r' APPLICATION PERMIT Q P/C o ADDRESS �T`'�� Q ua I �' �u h� �� �� DATE NUMBER�� ft � ISSUE TYPE OCC APN LOT TRACT �ATE CONST. GROUP g OWNER H ADDRESS��{ L�A C- u�F1� R- ZONING SETBACKS CITY ZIP TEL. - t FRONT RW ❑ APPLICANT TEL. _ REAR ❑ SIDFJSIDE STREET RW ❑ CONTRACTOR �P(e4 YiDLvI� I�D�l.NCR SIDE ❑ g AODRESS 1 G,3l� T.�K G, n/2- pROPOSED USE T � � �� CITY "D �T_ ZIP TEL.��l/� ARCHlENG! DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. N pESCRIPTION SO.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER•BUILDER DECLARATION SFR/ADD/REM O I NEREBY AFFlRM UNDER PENALTY OF PERJUIIY TXAT�AM EXEMM FROM THE CONTRACTOHS ll• G8f9oB/CflfpOR CENSEUWP�RTNEFOILOWINGflEA,SON(SEC.70.71.68USINESSANOPROFESSIONSCODE:ANYGTYOR (f� COUNTYWHIp1qE0UIRE8APERMR70WN5TRUCT,ALTER.IAAPROVE.DEMOLISH,DRHEPAIRANYSTRUG �J,J PBtIdDeCk IURE.PRIOR TO ITS ISSUANCE.ALSO REW WES TME MPLICANT POR SUCH PEHMIT TO FILE A 810NED W �iATEYENT TNAT ME ON SHE IS UCENSFL PU0.4W�NT TO THE PIbVIS10N3 OF THE CONTMC70NS ll- C£NSE U1W�CHAPTfiR 0(COMMENCMO WRH SECTION 7a00)OF DIVISION]OF THE BlJ51NESS AND PIiO- � ���PB FESSpNS OODE)OR TFNT HE 011 SHE IS EXEMPT THEHEFpqA AND THE BASIS FOR THE 1LLlE�ED E7�EMP• TqN.ANVVqLAT10NOF9ECT10N7097.6BYANYMPLICMlTiORAPERMITSUBJECTBTHEAPPLICANTTO Z qe-q�1 Z p ...- � ACMLiEfULTYOFN07MORE7HANFNEMUNDRED�OLtAR3(f5W).1: ❑I,1�SONMEROFTHEPROPERTY,ORMYEMPLOYEESWITHWAOESASTHEIRSOLECOMPFNSATpN, C� C0171RIBfC18I Ylp100 THE WORK MA THE BTRUCNF�IS NOT INTEN�EO OR OFFERED fOR SALE(SEC.7oN,BU34 �,J NFSS ANO PROFES510N5 OOOE:7HE CONTRACTOHS LICENSE LAW DOES NOT APPLY 70 AN OWNER OF = � PROPERTYMII108ULDSOR\IPRDVE9TFEREON,ANUWHODOESfiUCfIWORNHIMSELFORMEHSELFOR ¢ TMROUGHNISORNENONME►IPIDYEES,PI0DV10EDh1ATSUCFIWP90VEMENTSMENOTMTENDEUOR � LLI p�EpFpqgALE1F,F10Mf€YER'�MEBULDINGORILIMWVEAI@LfIS50lDW11HINONEYEAROFCOhiPLE• TION,THE ONMER-BU4DER 1MLL 1UVE TME BUfiDEN OF PROVNKI THAT NE ON SME DIO NOT BUILD OR MiRDVE PoRT11E PURPOSE Of 6ALE} ❑1.AS OWNEROF 7NE PROPERTY,AM EXCIUSNELYODNTMGTN6'MfT1 LICEN9ED CONT0.ACTOR9 TO OOWSTRUCT TME YRDJECT(SEG 70M,BUSINE59 MID YROFESSIONS OODE:TME CONTMGTORS ll- V9IU81IIX1 ADJ.AAEA CENSE lAW OOES NDTMPLY TO AN OVMlEH OF APROPER7V WFiD BUIWS OR NAPHOVES h1EREON,AND WFbGONiRACTSPoRBUpIPROJECTSWITHACOMTRACTOR(9)LICENSEDPURSUMITTOTHECONTMG QUANTITY DESCRIPTION FEE ,;;f � t0R5 LICENSE IAW.�. J �1 AM IXEMPT UNDER BEC. B.1 P.C.F00.7HIS REP.SON U 2 LL' pATE OWNER V � J 6 IICENSED CONTHACTORS DECLARATION iy � I NEREBV AFFINA UNOER PENAL7V OF PERJURY�'YUi I W UCENS€�UN�ER PROVISIONS OF CHAPTER � �(Oq1AlENCqlI'i WITN BECTqN iva0)OF Dm510N 3 OF THE BUSINESS�IJO PROFE5510N5 OODE,AND Z W UCENSE IS N NLl FORCE A!A EFFECT. n m � LICENSE CUSS � � _T UC.NO. ,� I 'Z 0 / 2 � � o�� ���9�_ coNTw.cToa � l�t f'7 ti' WORKERS'COMPENSATIDN OECLARATION Q � INERE9YIIFFIRMUNOERPEWILTYOFVERIUHYONEOFTT7EPDLLOWIN6DECLAMTIOh15: U � Z Q Q �IHMEMAWILLYAMlTAINACERTIFICATEOFCONSENTTOSELF-INSUREiORWORKERS' 2 Z OdAVENSATION,A3 PROVIDEO BV BECTION7f0oOF THE LA60R CODE,FOR THE PEAFORMANCE U QOF TF1E WORK PORNMICM 7l71S►EqMI7IS ISSUE�. � _I MAVE AND WILL YAINTIUN WORIfERS'COMPENSATION INSURANCE,AS REWIRED BY SECTpN O L 87000FTHEUBORCODE,FORTHE7ERfORMANLEOFTHEWORNWRWFIICMTHISPERWTIS i 199UED,YY WORKERS'COMPENSATION INSUMNCE CARHIEF AN�POLICV NUMBEH ARE: CONSTRUCTION � CMRIER �^��'�� � .N'� PLANREVIEW � Q� rairorNuweEn /i l n��'7 B�� ELECTRIC � T� � (mss[cnordr��noreEmRs��oFnfvEaNrtsroaa�tu�noaWsltioo�aa�ss7 PLUMBING � 1 CERTIFY7HAT IN THE PERFOIiMANCE OF iHE WORK FOR WHICH THIS PERMIT IS ISSUED.1 MECHANICAL �' S4ALL NOT EMPLOY NiY VERSON M ANY MANNER SO AS TO BECOME SU&IECT TO THE � YYOMEH5'COMPENSATqNUWSOFCN.IFORN1l1,ANDAOREETHATIFISNOULOBECOME iNSPECTIONFEE `- SUBJECTTOiHEN'ORKERS'COMPENSATqNPROY1510NSOFSECT10N370oOFhIEU80R �� � COOE.�1 S�HlLL�FOQHTMMTH CAMPLY WITH TMOSE PFiOVI�5J10P15. /� ISSUANCE p OATE:_���� / ' APPIIcnNT: �V �Q .�.�=L.�— SMIP �� � � WARNINO:FAILURE TO SECURE WORKERS'COMPENSATION COVEMGE IS UNUriFUL,AND 5HIILLBE ENEFlGY P/C � bUBJECTANEMPLOYERTOCWMINALPENALTIESANDCIVILFINESUPTOqdEHUPDREDTHOUSAN� ENERGYPERMIT r pOLUFS�ttoD,000).WAD�ITIONTOTHECO5TOFCOMPENSATION.�MIAGESASPROVI�EDFORIN � SECTION710lOF7HELABORCODE.INTEFEST.ANOATTORNEY'SFEE9. RE�ENTIONFEE: � CANSTRUCTION LENDING AGENCV PRE•ALT FEE: � �v f.�F.'f A,T 1 NEREBV AFi1RM UNDER PENALTV OF PE0.IUHY THAT THERE IS A CONSTRUCTION LENOWO AOENCV �TY���L_F',�)�/� Wfi TNE OEHFONNANCE OF THE WOiiK FOF WHI6i THIS PERMIT I615SUW(SEC.90%,dV.C.). � � i3IJ.L',.DiNG�':I��v�`,��;.:,T, LENOERSNPME LENDER'SAODHESS I CERTIfY THAT I WIVE REAOlH15 APPLICATIDH AND STATE THATTHE ABOVE WPoRIAATqN IS CORRECT. TOTAL FEES / ° 1 AONEE TO COMPIV WITH ALl CT'AN�COUMY ORDINMICES AN�STATE UWS REUTMIO TO BUILDINO CONSTHUCTION.AND HERFBV AUTMORIZE REPRESENTATIVES OF iHIS COUNTV TD EMER UPON TVIE LL ABDVE-MENTIONED PHOPERTY FOR INSPECTION PURPOSES. COMMLNTS � t m PERMITTEE N T) Q N � 61GNATl1R F TTEE UATE � RECPT.NO. PAI�BY VALJDATION WHITE-0epenmanl Copy,YELLOW—finence Copy.PINK—Aseessor Copy.GOLDENROD--File Copy,GR� " nt' Copy ,. . ,� ., , . .y� . • . . ., .. , � , : , # . •r � ,. ... . r � . . �. , . 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