HomeMy WebLinkAbout12-735 r _ �1�`_ CTTY OF DIAMOND BAR ., DEPARTMENT OF COMMUNITY&DEVELOPMENT SERYICES . � 21810 Copley Drive,Diamond Bar,CA 91765 PRESS 'r (909)839-7020 Fax(909)861-3117 Building Inspection Notline(909)839-7027 � ���^���W BUILDING PERMIT APPLICATION FIRMLY � JOBSITE �6 � /' APPLICATIO PERMIT �J��P/C o ADDRESS ��fS�� � ��ny�� � ��� ���� - DATE << � NUMBER '`� J a ISSUE TYPE OCC � APN LOT TRAC7 DATE �L�CONST. GROUP p OWNER �"�� �"', � /'�4��Ty ��u�� ZpNING SEfBACKS p ADDRESS �-�- V � '� FRONT RW ❑ ' � Z CITY �:_M+cti���n.� ZIPG�Z�I�7EL�I�)Pao��/� REAR ❑ o APPLICANT TEt. SIDE/SIpE STREET RW ❑ � CONTRACTOR �Ay�I {�"DJ �� SIDE Q I � ADDRESS � ✓ ' PROPOSED USE � CITY ZIP�z7dTEl.(` 1 w ARCHlENG! z DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEOROOMS. � C�7y . ZIR TEL � DESCRIPTION SQ.FT. FACTOR PSF AW.AREANALUATION Q �OWNEH•9UILDER DECLARATION � SFR/ADD/REM O 0 I MEREBY AFFlRM UNDER PENALTY OF P£NURY TFUT I AM EXEMPT FROA1 TME CONiMC�OR3l1- Ci0�8gBIC8lpOfl W CENSEUWFOR7HEFOLLON�NOREASON(SEC.7o31.6BU5INE55N�DPROFE5510NSODDE:ANVGTYOR (n . . U CIXJMT`(WHICHREOUIRESAPERMITTOCONSTRUCT,NLTE�l�PROVE.DEMOLISH,ORREPAIRPNY9TqUG W Pgt�0ID8CI( �ZNAE,PRIOR TO RS ISSUANC�AL50 NEW�RES 7HE A➢V\iCANT FON SUCii PERMIT TO FtLE A SfONEO w � STATEMENT THAT HE OR SHE IS LICENSED.VURSUFlNT TO THE PROVISIONS OF THE COMRACTOR3 L4 � P . � CEN9E UW(CNAPTER Y(COMMENCW(i NATH SECTION 1000)OF DIVISION 7 OF h1E BUSINES9 AND PRO� � Q FE`.+SbNS COO�OH THAT HE OR SHE IS EXEMPT h1EREFROM M�D THE BA515 FOR THE ALLEOED E%EMP- y� U 71pN.ANYV101A710NOFSECTION7o3t68VAHVMMJC�NTFORAPERMITSU&IECTSTHEAPPLM.ANT70 RB-ROOI dOU � ACML VENALT`�QF ti�7 MORE TNAN FME NUNDRED DOl1JJLS(f5oo).}. , � ❑�ASOWNEROFTHEPROPERTY,oAMYEMPLOVEEgNRTNN'A6ESASTHEIRSOLECOMPENSA770N, � �mmercial . Z N7LL DO iHE WORKµD TNE 9TRUC7URE 19 NOT�NTEN�ED OR OFFERE�FOR 9ALE(4EC.-)o,�,BU51- J . � NESS AND FROFESSIONS COOE hIE LONTMCTORS LICEN9E UW DOES NOT APPLY 70 AN OWNER OF j 7ROPEPTYN?IO&1�1.D80RIMPROVESTHEREON,ANDNM1IODOESSUp1WOi1KHIMSELFORHERSELFOfl m Q TMROUGN HIS OR MER OWN EMPIOVEE3.PROVIDED THAT SUCH UIPROVEMENTS ARE NOT PITENDED OR W pfFEqmPDRSALEIF.HOWEVER7HEBlALDWUOFIIMPROVEMfNT1SuOLDWITMNONEYF�IROFCOMPLE- 0 TpN,.THE OWNERANLDER WILL MAVE T7E BURDEN OF.PROVINO THAT HE OR SHE DID NOT BUILD OR � � Z MPROVE FOR THE PURPOSE OF ShtE). . . _ ❑1ASOWNEROF7HEPROPEHfV.AME%CLUSNELYCONTFiACTINOWfiHLJCENSEDCONTRA(.TOfL: ' � � ' � w[[ TO CONSTRUCT THE PRQIECT(SEC.7oN.�BU51NE53 AND PROFESSIONS CODE:7HE CANTMCTbRS LI- VBIU0lI011 ��ODb ADJ.AREA� W CENSE UW DOES NOT APRY TOAN OWNER OF A VROPENTV WMO BUILDS OP IMPN6VES THEREON.AND . �- � WIiOCONfRAGTSFORSUCHPROJECfSWfTHACONTRAC70R�5)LICENSEDPURSUAHTTOTHECONTMG QUANTITY DESCRIP770N FEE � T00.S UCENSE LAW.�. O ❑I AN E%EMPT UNDER SEC. 8.d P.C.FOR T11S REASON U T � ` '/O S� 3 2 — f�f/ � OATE � OWNER . (~j Z W � UCENSED CONTRACTORS DECLARATION J � ¢ W [L 1 HEREB�AFFIWM U�tDER P£NALTY OF�VERIURY THAT I MA�LICENSED UNDER PRONSIONS OF CFIAPTER � � bd i � e � � 39 d 9(C�MMENCUKi MATH SECTION 70001 Of DIVISIQN S OF THE BUSINESS�NO PROFESSIONS CODE,ANP Z X MY LICENSE IS W FULL FORCE AND EFFECT. m L1J yr' � � LICENSE CLASS �—� [ IIC.NO. 1� ( J � V � CONTRACTOR d . .. DATE W � WORKERS'COMPENSATION DECIARATION � .� V � 1 HEAEBv AFFIRM UNDER PENALTV OF PERJUHY ONE OF THE FOLlON7NG OEClA1UT10NS: ZQ O _I HAVE AND N�LL MNNTAIN A CEHTIFICATE OF CONSEIJI TO SElFaNSURE iOR WORKEFiS' Z � . . . . . Q Cp1ApQi5A7iOf7,/5 PROVIDED 8Y SECTION 3100OF THE UBOR OOOE,FOR TME PERFORMANCE W OF THE wORK FOR MMKKYi TH13?ERMI7 t3 ISSUED. � � w _IHAVEANDWILLAWNTAW�WORKERS'COMPENSA710NINSURANCE;ASREWIREDBVSECTION Q 37000FTHE LABOFl CODE,FOR THE PERFORMANCE OF THE WOHN FOR NM1tlCM iH15 PERMI715 �I S• � � CSSVEp.),5Y Wpqf(ER5 C01.IPENSATION INSU�R(ANCE CARAtEH AND POLICV NUMBEH ARE CONSTRUCTION� j CARRIER �?�"'� ��1/Iv1 PLAN.fiEVIEW � pO�ICVNUMBER J�Q� ���* ELEGTRIC . . Q 0 (trussEcna+lJ�wieECOARErH>aFn+Eea�.�rsFoaa�HUra7EooaLAfis(s�oo)or�tEssl PLUMBING . . . . W 1 CER7IFV TUT IN hiE PERFOPAAANCE OF THE.WORK FAH WMICM TNIS PERMIT IS ISSUED,1 �MECHANICAL Z L} SHALL NOT OdPIOV ANY PERSON W ANV M/WNER SOAS TO BECOME�SUBJECT TO THE INSPECTION FEE � WORI(ERS'COMPENSATION UWS OF CALIFOPN�A.AND AGREE THAi IF 1 SHOULD BECOME . SU8JEC7 70 7HE WOPo(ERS'COM7E T10N P VISIONS OF SECTION�7D0 OF THE UBOR ISSUANCE - �/� , 'i('� OCOOE.I SHALL FOiRHWIlH CWdPLV HO P V IONS. . . I � S/7 p DATE:� APPLICANE� �SMIP J WARNWO:�FNLLRETOSEpJREWORKERS'COMP SATIONCOVEMGEISUMAWFUL.ANDSHAI.LBE E�IERGYP/C . J SUBJECY�N EMPIOYER TO CRIMWAL PENALTIES AND CML FlNES UP TO ONE HUNORED iHOUSIWD � � ppyApg(5100.000),�N ADDIT70N TOTHE CAGT OF CAMPENSATION,DAlAAfiES AS PiiOV1DED FOR 1N ENEROY-PERMIT . J SECTION 370e OF 7HE LABOR COOE INTEREST.AND A7'fOqNEYS FEES. ' RETENTION FEE: �`G � . .Q w CONSTRUCTION-LENDING AGEN6Y PREAL/T�F�E�E: � �. 1 HEREBY AFFIRM UNDER VENALTY OF PEiiIURV THAT THERE IS A CONSTRUCTION LENDWO 11OQ3CY. OJ'�'/T.�� 1 O� �FOR 7HE PERFORMANCE OF THE WORK f-0R WHICM TMIS VERMIT IS ISSUED ISEC:3oV7,CIV.C.). Z ' W �� LENDER'S NAME . .. . . . . . F_— LENDERSADDRE53 T ' � �� /`���� /�J(u�, � �If,ERTIFVTHATIHAVEREADTViISMR�CATIONAND3TA7ETUTTiE�BOVEPIfORMAT%)N�9CORRECT. IOTAL FEES �-�`^"� , " V W I A(iREE TO COMPLY N7hl ALL CRY AND COUMTY ORDPIANCES AND STATE UWS RELAT WU TO BUILDIN6 � � CONSTRUCTION.MID HEREBY AIffF10R12E REPRESEN7ATNES OF THIS COVNT770 EN�ER UPON THE � ABOVE-MEMIONED PROPEFTV�FOR INSPECTION 7URPO.iES. . � Z i �, / COMMENTS � � -//ONE�= J � m PERMfTTEE NAME(RINT) � . . . . . . . . . . ¢ �Z u� � SIONATURE OF PERMITTEE DATE� RECPT.NO. PAID BY VpLIDATFO � WHITE—DepaRment Copy.YELLOW—Finar�ce CoPy.PINK—Assessor Copy,GOLDENROD—Flle Copy;GREEN—Applkanl's Gopy CITY 4F DIAMO(�!D BAR � • INSPEC�'10�1 REC4RD j �rc � �- " 'a� � '4's?�3�' �o ,A�� �-��:':r s � _�' p �-. 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