HomeMy WebLinkAbout16508 (9) CITY OF DIAMOND BAR Nr�
- - DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suitc 140
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� ADDRESS;��"'_���1L�.,�11�,C:C�t�S,� !�_r.— DATE GATION [ � i Q—�, NUMBER I,�_ #/C � � ��`
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� „ ISSUE TYPE OCC
APN LOT �j �,> TRACT J�c?fsJ G.�7 6ATE CONST. GROUP
� owNER (�/��1"- ,�.13rnC;
ADDRES3 ,��� �.� r i `�i 7't' �' ) ZONING SETBACKS
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� CITY_��1�„ ZIP�(„� TEL.`IN�%-74)'7`�'/r>(j �RONT RW C)
APPUCANT �E�. REAR ❑
� SIDE(SIDE STREET RW ❑
GC?NTAACTOR_ SiDE ❑
� cDDRESS ZIP 7EL. PROPOSED t1SE 4J �' �
� ARCM/ENG/ �,'� /' � �/}
� DESIGNER-��I L' � � 6�"�'bt <:�r`, iC--'f-t S�,n/'.,__ _.
NO.DWEL. NO. NO.
AQDRESS ��+;�-�r� �J�'- UNITS STORiES BEDR(7QMS
� CiTY�_�� ZIP 1r',�l�:�TEL.7��-S`S"rl•�)���
y bESCRtPTiON S4.FT. F CTOR PSF ADJ.AREM! UATlDN
� QWNER-6UILDER DEGLAHA7tQN SFR/ADQ(REM j,. � ;� �`�
p I HEREBY AFFIRM UNOER PENALN pF PEMIRV THAT I AM EXEMPT FqOM THE IX7NTRACTORS LI• Ge�'80QICdR}0/I ti''� �� '��`
U3 CENSEUWFORTHEfC7CL(xNINGREl�SON(SEC.7a31.5BUSINESSANDPROFE5510NSCODE:ANYCITVOF {/) � <' V
C.1 CqJ1((yWHICMHEQUINESAPEAtAtTTOCbNSTt�lC7,KTER,7MVRqYE,DEMOUSH,ORREPAIRANYSTtiIJC- W P8ti0ID8Ck
TUNE,PHIOR TO ITS ISSUMICE,AlSO REpUlREB THE APPLIGANT FOft SUCH pERMIT'4 HlE A SIGNED
� $TATEMENT THAT HE OR 5HE IS LJCENSEp PURSUANT TO THE PFlpVIS10NS OF THE CbNTAACTORS U- W
GEMS£l�tW�CHI.PTEA A{COMMENCiNO VniH SEC7iON 7000}OF DIVISION 3 OFTHE BUSINfiSs AND PRO- u" PpOUS(18
FESSpNS(X![lE)OHTNATl+EORSMEI9E%EMPTTMEREFROMNJESTi1EBASi5FOP7HEALiEGEDEXEMP� �
TIOH.ANYVIOL�YIONOK6ECTION70J1.6BYANYAPPUCANTF4RAPERM�TSU&lECTSFHEMPiiGRN7T0 � Re-Roof
f„� FCMLPENK7YOFNOTMI)RETHANFIVEHUNDflEDDOILARS(fbao),�:
� Oi.l1SQ1NNEROFTHEPROi'ERTY,ORMYEMPtOYEE5WITNWAGE5A5THEIqSOLECAMPENSATNNJ, CI CW71fi19fCfdi
WILL DO TNE WORK,l�ND T4E SiRUCT4JftE kS N07 1N7EN�ED 4R Of'FERED FQR SALE(SEC.104i,BUS4 J
� NE9S AND PipFESS10NS CODE:THE CCHJ7'FlACTORS LICENSE UW DOES NOT APPLY Tp AN OWNER OF �
PROPERTY N4i0 BUiLDS Op�MPROVES THERE9N,AND WHO DOE9 SUGM WORK HIMSELF QR HERSELF OR
� THfl(:Util1 MIS Qfl NEA ONM fMPi.OYEES,PqOV�ED Tii�T faUCN IMGflOVEMENTS ARE NOT INTENOED OF m
� C7FfEREDFORSALEIF,l1oWEVER�HEBUN.DINGORIMPNOVEMENTISSIXBWi7HY10NEYEARdFCOMPI.E-
1'IOFI,THE OWNER-9UILDER WILL HAVE THE BURDEN oF PpOVMG THAT HE OH SME DIO N07 8UI{A oR
�^. � IAiPROYE FOR THE PURPOSE 4F S.LLES.
yy� E71.ASONMFROFTfSGPROPEN7Y,AiAEXtIiJSNElYC6NTRACTMGVtfiHllCENSEDCOMTMCTORS
� � 7o poNSTqUC7'ITIE PpOJECT{SEC.10M,9USIN8SS AN4 FAfiFFS510N5 CODE:tHE CONTRAG70R51i- Ve�U9tion ADJ.AREA
��� CENSE4AWD4E3Nt1TAPPLYTOANONMEROFAPRO�FRTVWHQ9U1LDSdRIMPftOYE3TMEflEDN.AND ' '
WFWCONTMCTSFtTRSUCh'PR6JECTSVfliHACONiRA('T4N(S}UCENS£�PURSUNJTTOTHECONTRAG QUANYITY" QESCRiPTiON FEE
TW1S uCENSE UW.l. � /
❑i AM EXEMPT UNOER SEa 6.d P,C.FOR THIS REASON Q R✓ '
3 _ " 2 ��`
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�ATG OWNEa �"
a ` W �'t`,.-
� LICEN^�ED CONTRAGI'flRS DECLAAATION W ^�—' �
� i HEl�9Y A�FtRM UIV�Efl aEhtAITY OF PERJURY iHAT IAM LICENSED UNDER PROVI519NS OF CHAPTEq �
p, 4{COMMENGINO WITFI SECTk�N 7p0o�Of DiVt5�OF/30F THE et5ME5S ANO PRUFE55iONS CODF..AND Z
K YY LICENSE IS IN Fl1LL FORCL"AND EFFECL m
Q UCENSEC(ASS��___. LIGNO. ✓ / /.S ��7 � .".f� �
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� WORKERS'COMPEN3ATlON DECIARATiON � �
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Z �J� l I4MhY5ANDYfiItMAtNTAlNACERiifICAiEOFCONSEMTOSELF-MSUREFCYRWORKERS' _ — �,{J
rn� P£NSATKNY.ASP:RQV4DED9YSEC710N37WOFTHEiA30ftCQpE,FOftTMEPERFORNANCE U � ' 'd ' � �-�
Q THE WORN F4R W1{�CH THIS PERMIT IS ISSUED. � } ; `
� t ' L�
AVE fND`N�LL AtAM�AIN WORKffiS'tAA1FENSATION INSURANCE,AS PEOl1IqED BY SEC710N
Q � 37000FTHE GiflOR C�.IDE,GUR THE PERFORMANCE OF TNF V{ORK FOR WHICH THI pERMITIS '` '�-i „1• �/) �N
0 ISSUED.M1'WO S' ATIONlNSU ANCEGR DPOI YNVM ARE; CONSTRUCTION �`�'�b-�.
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� t�sEciIONNEEA .,TOEGut.P�.EiEoOFnfft�ERMi6FQRONEfA.M1XiEUoouaAs(t�aolCaLEsS} PLUMBING ��`7 ' . - ' 'J
W �.,i -� .
Z ICERT'IFYT!}ATk1THEPERFOflMAHCEOfTHFY{4+1f(FQRWHICHiHISPEAMiTlSi55UED,i MECFIANICAL __ �:]v.� . �, (,�j � �'�.a/
C„J SHALLNOTEMPLOYANVP�RSONINANYMANNERSOASTOBECqMESU&JEC7TOTNE �
(/� WORKEflS'COMPENSA(ION lAW5 OF CALIFORNIA.AND pOREE TNAT IF I SHWLD BECpME INSPECTION FEE , _ 'ry
� SUB.lECTTOTFfEVtORt:ERS'CX�MPENSATIONPttO�n3iONSOFSEGTipN370tlOFTHELpBOR �SSUANCE _,,, I '-�1�+ ��+��-� �
CO�E,I SFIALI.FO HN�I7H CONPLY WtTN THO5E PRqV15tON5.
� " �' SMIP y � �— �
p OATE� APPLICANT: ��_,1,�,� �l (\�l,, .—/� �•
� WAflNINLi:fAItUftE TO SECUR£WORKER5 Ct»dPENSATtON COVERRGE IS UNUWFUI,pNP SMALL BE ENERGY PJC �M
� SUBJEGTANEMPLOVERTOCPIIUINALPENALTIE5ANCqYfIFWESUPTOGNEHUNDREOTHOUSAND ENERGYPERMIT � __ _„ I � l ^� , `
OULLARS(5700,000).IN A[7DI71OrJ Tp THE CO5T OF COMPENSATION,OAMAGES AS P%OVIDEO FOR IN - �
.rJ SECTION37080FTNEL480RG3D[,iNTEREST,ANpAT�OflNEV'$F6E5. , , �.���.
� _ RETENTtON FEE: ,_,_ _,,,_
� Ct?NSTRUCTIQN IENDiNG AGENCY PRE-ALT FEE: �.... ... ,_, _.� M
/
� i NERE9Y AFFiRM UNOER PENALTY OF PEpJURV T T 1'HE1iE IS A CqNSTRUC fION LENOM(i AGENCY =__-���� __
: ' r
FpR TtiE PERF{}RMANCE OF THt�WORK FOR WH 7/Ny�5 PEfliA17I5 i5`�`{UEO(SEC.30H7,CfV.C.f.
�.�
� LENDEft5NMAE��..✓L.v`„" � r G��7+„`.' / \`�.� `��„+IF--_....
1_ LENDER'SAO�RES5_ ..__. \
W ICERTIiYiHRTIHAVEREADTHI;iAPPLICA710NANDSiATETHATTHEABOVEMFOWAATK7NISCORRECT. TOTA�!-EES , �� �U 'J
d IRGREE TD COMPtY WITH AtIC(tt AND COUNTY ORDINANCESAND STATE L4WS REUTING TO BUILDING
� CONSTRUCTION,AND NEPEBYAUTFIORIZE AEPRGSENTATfYES Of TNIS COUMY tt7 ENTEA UPON THE
� ABOVE-MENTIONED PROPERTV Foq SP[CTION PVRpO5E5.
� � CQMMEN7S,_„ ,
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P£RMI E NAME 4P TJ
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Uy SW EOFPER EE ��DATE +�c�' � �.�� --���"i Y.
= qECPt Nd. ,�.1 CJ L PAID BY � YAUDATlON�. x��....._
�' WHITE—De arlment Go YELLOW—Finence Co PINK—Asseasar Co GOLCfENqOEf—File
p py, py, py, Copy,GREEN—AppiicanYs Copy
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVE�OPMENT SERVICES
21660 E.Copiey Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION 14'
10
JOBSITE R'7
i
ADDRESS
APN LOT
TRACT�'S-2(sJ �" �
1
OWNER%JN(
r./7Qme^>
S 1-c
2 i2
ADDRESS fX tJn/7 24&-+ r r'7
CITY r Ii>,1 ZIP � T'E�.�L:4 7'17-_y41 j
APPLICANT TE�.
CONTRACTOR_
ADDRESS
CIl'Y ZIP v TE�.
ARCWENG/
DESIGNER,c'y K(,-r, <:�c;q s2 i�G r
ADDRESS
CITY 'T�3*"ZIPS TEL.7JJS::54-)9777
OWNER-BUI�DER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE t_AW FOR THE FOL�OWING REASON(SEC.7031.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
COUNTY WHICH REQUIRES A PERMITI"O CONSTRUCT.ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY STRUG
TURE. PRIOR TO ITS ISSUANCE.ALSO REQUIRES THE APP�ICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS UCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE IAW(CHAPTER Y(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE A�LEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031.5 BY ANY APP�ICANT FOR A PERMIT SUBJECTS THE APP�ICANT TO
A CIVIL PENA�TY OF NOT MORE THAN FIVE HUNDRED DOL�ARS(8500).):
01,AS OWNER OF THE PROPERTY.OR MY EMP�OYEES WITH WAGES AS THEIR SO�E COMPENSATION,
WI�L 00 THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044, BUSI-
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE tAW DOES NOT APP�Y TO AN OWNER OF
PROPERTY WHO BUI�DS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF, HOWEVER,THE BUI�DING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE-
TION,THE OWNER-BUI�DER WIL�HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUI�D OR
IMPROVE FOR THE PURPOSE OF SALE).
^I,AS OWNER OF THE PROPERTY,AM EXC�USIVE�Y CONTRACTING WITH �ICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044,BUSINESS AND PROFESSIONS CODE:THE CONTRP,CTORS LI-
CENSE t_AW DOES NOT APPLY TO AN OWNER OFA PROPERTY WHO BUI�DS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH'PROJECTS WITH A CONTRACTOR(S)�ICENSED PURSUANT TO THE CONTRAG
TORS LICENSE�AW.).
0 I AM EXEMPT UNDER SEC. B.&P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DEC�ARATION
I HEREBYAFFIRM UNDER PENALTY OF PER7URY THAT I AM �ICENSED UNDER PROVISIONS OF CHAPTER
0(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY�ICENSE IS IN FUL�FORCE AND EFFECT.
Nj
5'/
i
LICENSE CIASS_
, LIC. NO.
/
/3
DATE .-L CONTRACTOR Pd �=rZE'i"
WORKERS'COMPENSATION DECLARA,TION
I HEREBY FFIRM UNDER PENA�TY OF PER]URY ONE OF THE FO�LOWING DECLARP,TIONS:
HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
PENSATON,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
THE WORK FOR WHICH THIS PERMIT IS ISSUED.
AVE AND WI�L MAINTAIN WORKERS'COMPENSATION INSURANCE.AS REQUIRED BY SECTION
3700 OF THE�ABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THI PERMIT IS
ISSUED MV WO 5'CONPE[NSAION INS7 U�iANCE CARRI D POL'Y NUM ARE
CARRIER C�
i
+
f
ICY LS{sABER-�LCL,j(
C
�OL
(THE SECTIIN/
NEED IT BE CCMPkETEDOF THE PERMIT IS FOR ONE R04DRE0
DOL�P,RS($100)OR�ESS(
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHAL�NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUB]ECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE�ABOR
CODE,I SHA�L FO HWITH COMPLY WITH THOSE PROVISIONS.
I
CANT:
DATE
APPL
WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UN�AWFUL,AND SHAL�BE
SUBJECTAN EMP�OYER TO CRIMINAL PENALTIES AND CIVI�FINES UP TO ONE HUNDRED THOUSAND
DOLI�,RS(8100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE,INTEREST AND ATfORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENA�TY OF PERJURY T T THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE:WORK FOR WH THIS PERMIT IS ISSUED(SEC. 3087,CIV. C.).
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION.AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR SPECTION PURPOSES.
\-9v�
PERMITf E NAME(PIII T)/mar
5IG E OF PER EE DATE
(1::�
PRESS
FIRM�Y
APPLICATION PERMIT
DATE
- 1
NUMBER
jC
1
ISSUE
OCC
TYPE
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ^
REAR
n
E
SIDE/SIDE STREET RW ^
SIDE ^
PROPOSED USE
N0. DWEL. N0. N0.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. Ff. F CTOR PSF ADJ.AREA/V UATION
SFR/ADD/REM
U) GarageJCarport _
w Patio/Deck
L
L.I
LL Pool/Spa
0
Re-Roof
Z
Commercial
m
Valuation AD�.AREA
QUANTITY DESCRIPTION FEE
W Cori
1�
r
W I
Z
Q 7-
U
72j _,I l.
Q
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CONSTRUCTION L•I
P�AN REVIEW 1 I t
ELECTRIC '�_�•�
P�UMBING
MECHANICAL S•-�� �'J
INSPECTION FEE
ISSUANCE
SMIP
ENERGY PJC
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
TOTA�FEES
COMMENTS
RECPT. N0. PAID BY VALIDATION
WHITE-Department Copy,YE�LOW-Finance Copy, PINK-Assessor Copy,GO�DENROD-File Copy,GREEN-Applicant's Copy