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HomeMy WebLinkAbout14650 ^ � _ CITY OF DIAMUND BAR` DEPARTMENT OF COMMUNITY dr.DEVELOPMENT SERVICES � > zi�oE.coP�y���s�c�i90 PRESS , (909)860-3195 Fax(909)861-311T -�'.' BUII.DING PERMTi'APPLICATION �FIRMLY � JOBSITE i I/_ �,.��/��f� �• DATE CATION NUMBE� � X� o ApDRESS � W `�L+� � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP � OWNER �_ � / � ADDRESS C�6� �� ZdNING SETBACKS CITY OrrA �5�-r ZIP TEL. �-" FRONT RW ❑ APPLICANT TEL. REAR O &IDFJSIDE STREEf RW O CONTRACTOR G�P�/��� V " SIDE p p� ADDRESS I 0 • � � r . CITY UsL! ZIP 7? TEL��Cf�'t -[! / PROPOSED USE +P� ARCH/E�TG/ � DE5IGNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS CITY ZIP TEL. y DESCRIPTION SQ.Fl: FACTOR PSF ADJ.AREANALUATION Q OWNER-BUILDER OECLAHA110N SFRIAODIHEM O � 1 MEREBV AFRRM UNDEA VENALTY OF PERRIRY TNAT I AM E%E/APT FRdA THE CONTRACTOii3 U- G�reQ���rt C�ISEtAWFOR7NEPOLLOM�INGREAfiON(EEC.7o316BUSINESSANUPROFE5510N90�DElWYGTYOR (n OOUtTYYY}IIpIREOVIHESAPERMRMO0N5TRUCT,K�Rr,ronovE�DEMOLISH.ORREPAIRANYBTRUG W PatlaJDedc TURE.PRqR TD ff8 IBSUIINCE,AL80 REOUIRE9 THE MPUCM(T FOR SUCM►ERMfT TO FlLE A BIONEO W � STATEMENi THAT ME Ofl SHE IS LICENSED PURSUIWT TO TNE PROVISIqVS OF TME OONiRACiORS LI• CENSE lAW(CNMTEH i(COMMENqNO WfTH SECTION 7000)OF DIVISION]OF TF1E lVSINESS AND PRp- � •POOVSpd FESSIONSOOU�Oil TlNT XE OR BHE R E%EMPT THEREFROM AND THE BASIS iOR TMEALlEOED EXEMP- TION.ANYVIOlAT10HOiSECTIdJ7071.68YANYAPPLICMIiFORAVEiBAITSl191EC78THEAPPLICANTTO Z qo-Root � A CIV1l PENALTY OF NDT MORE TIAN FNF MUHDRED DOlURS(i5a0}): 04�4�NIEROF7HEP(IOPER7Y,OIiMYEMPLOVEESWITHWAOESA97HEIHBIXECOMPEN8A7pN, Q COmmBlClel MKL 00 TIE NWAK AND THE BTRUC'NRE IS NOT IMENDED OR OFFERED FOR S1LLE 18EC.7o1a,BUSI- J � PIpVERfYMlqBU0.D50RIMVHOVES�EREQV,/N1DW11DSDOESSIIG/WORK MSEI ORN�ELFOR � � Ti1R0U0FIWSORNERONNEAWLOYEEB,PRDVIDmh1AT5UCHMPFOVEMENTSARENOfM7fENDE00R m OFFERm POli6ALE IF MOWkI'ER7ME BUlpNO ORMtPpOVEMENf IB SOID YM7MW ONE YEAROFCOMPLE- TIDN.TNE OWNER�UILDER WILL NAVE TTIE BUROEN OF PROVING THAT ME OR BHE pl�MOT BUIID OR YPRDVE FOR TIE PURPOBE OF EALE�. W 04��MMEROFiNEVROPER'IY,AMEXCLUSIVELYODNTfUCTINOWITNLICEN5E�CONTHACTORS � TO CONSTRIKTTlIE PHOJECT(BEC.fOM,W&NES9 MJO PROFE95qN8 CODE:THf COMRACTORS LI- VflIU8S1 ADJ.AREA CENSE 1AW DOES NOTAPPLYTO AN OVYlIER QF A PROPEATY W1i0 Bl/MD6 Ofl MAPROVE6 hiEHEON,AN� wracartiucrswnaua�vnaEcrsMnn+�cormucro�us�uceNSEovunsuu�rtron+eca+rn,� pUANTITY DESCRIPTION FEE � 7nns uc�risE tww.l. J . , e C , O I AIA EXEAAPT UI�ER SEC. 6 6 P.C.FOR THIS HEASON Q O✓�' G.X��S �/1 � � .17i /�-� � DATE OWNER F"' � W �� /�'/!�( 'Z/ IICENSED CONTRACTORS DECIARATION � W � 1 NEREEYAFFIRM UN�ER VENALTY OF PER1Uf1Y TIMT Il1M LICENSED UNOER PROVISIONS OF CNAPTER � ��COINAENCOq WRM 6ECTION 70a%OF DMSION 90FTHE BUSMESS ANO PROFESSIONS CODE,AND Z MY LICEJVSE 16 N Fitt1 iOHCE M�EFFECT. � ��E� C-�9 � ���.,�. Ce St��g C� � w,s� a-a-g —°`� corrrR^ ' �— - � WORKER3'GOMPENSATION DECLARATIO /��/+l �J ! yIHEREBYIIFFIAMUNDERPENN.T'OFPE0.RIRYONEOFTNEPDLIAWIN6UE MTIONNlO � I Z � �IWIVEANDWILLMAINTAINACEfifIFIGTEOFCON5EN770SELF•INSU FOR RKERS' _ COMPENSATpN,ASPROVIDEDBYBECTIONB)OOOFiFIELABORCOOE, EPERiORMANC OF THE WOAK POR WHICYI T1119 PERLtlT IB ISSUED. � �I WNE AND W1LL MAIMNN WOAKEii3'COMPEN9ATION INSUiLWCE,A5 RECUIRED 8Y 8 /� Q 970U OF TME IABOH OODE,FOR 7NE PERfi�fi�IMICE OF 7NE WOPK FOR WHICN ERMIT IS / / ISSUm.MYWbFiKERS'COI�IPENSA710NINSURANCE ARRIERANDPOLICY B£RARE: CONS CTION � � c�RwER � PLAN R W � POLICYNUM6ER I � OC� �' L�CTR � (Rf6sECl�wr�N078EooLNEfmaF7HEPERNRI6FIX+ M11ORm R�0%�ilEss} PL ING Z 1 CERTIFY 7HA7 MITNE PERFORMMlCE OF TNE WORK POR W H THIS PERMIT IS ISSUED. ECHANICAI Cy7 SMALLNOTEMPIAYANYVEPSONNIANYMANNERSOASTOBE �fSIBJECTTOTHE (n WOR1(ERS'OOAAPENSA7pNUWSOFCALIfORNIA,NiDAOREETHA � INSPECTIONFEE � + � SU&IECTTO THE WOFiKERS'COMPENSATqN PflOY1510NS OF SECT�ON 970D OF TME OOD,Isf� FOnnimifrcour� sqn�s. • ISSUANCE p DA7E: �6 � AaPucn . .___v' Z 1' SMIP nflfln �� � WARNINO:FAILURETOSEWREWOAKERS'COlA ENSATIONCOVER EISUNLAWFIJL,�NOBWSL�BE ENERQYP/C �� �y BUBJECfIWEMPLOYERTOCRIMMALPENALTIESMl�CIVILFINESUPTOONEHUNDPEDTHOUSMI� ENER6YPERMIT �„ DOlLAR5(llo0,000),INADCIl10NTOTHECOS70FCOMPENSATION,OPAfA0E3ASPpOVIDEDPoRW /� /� � 6ECTION 970!OF7HE UBOR CADE.IN7ERE3T,AND AT7OHNEY'S FEES. FlE'IEMTION FEE: l�IT 1�1(1�r c�, CONSTRUCTION LEN�ING AGENCY PRE-ALT FEE: B�TII.D� • O g1 XEREBYAFFIiUA UNGER PENALTV OF PERJURY TNAT THERE IS A CONSTHUCTION LENDItM AQENCY z FOH 7HE PERFORAMNCE OF iHE YVORK PoR WHIGI TMIS PERMIT IS ISSUED(SE4�w7,GN.C.). W � �ENDFA'8 f1AME � LENDERSADDNESS � ICERTIFYTNATIWVEREADT113MPLICATqNANDSTATETWITTIEABOVEMGORMATqNISWRRECT. 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