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HomeMy WebLinkAbout12153 � '� � �� CITY OF DIAMOND BAR � DEPARTP,4ENT OF COMMUNITY&DEVBLOPMENT SERVICES 21660 E.Copley Drive Suite 190 � ;,,,_�,,� (909)860-3195 Fae(909)861-3117 PRESS i BUILDING PERMIT APPLICATION __ FIRMLY � JOBSITE . . .. - Q `� L�• �j' ,r-+ y� APPLICATION � �y '�J� PERMIT�7,I {',J��P/C ADDRESS L�J ?- �� 6,ti�>'V`�- ��� d�� DATE `�`' Z " /Lii• NUMBE 1 . # � APN LOT TRACT �SSUE TYPE OCC DATE CONST. GROUP p OWNER I`r�{��/Y�� _ `p ADDRESS_� ��5 S J�<%C."!-����i:i.. ZONING SETBACKS � —' - CITY �o-'•�_ ZIP /%G s TEL `r ` `�_ ?: r1� FRONT RW ❑ APPLICANT `Yli .�.a�f�i�"" � TEL. S REAR U-.------ SIDE/SlQESTREET RW n__ � CONTRACTOR l f�' ,,.-�� ��.- •% SIDE `—" u__ Q ADDRESS �3L. %-' _ " ;✓-r'.� i � CITY_ �--�3; �,w....< ZIP �)7c�EL��1 '"'�s�.p�' PROPOSED USE ,� C^'r'.;�'' �" '.. „�yLg"� C� �'Z G� � wo ARCWENG/ _ L . - `�; ,. .y DESIGNER ''p'�"'° t=C.' C ' ' •„ � � NO.DWEL.t-��'�Cs,_�,.-�!C NO. . . �� j�,/' � ADDRESS UNITS � �: C�TY Z�P 7EL. — STORIES _ BEdROOMS � y DESCRIP'fION SQ.FT. FACTOR PSF ADJ.AREANALUATION ' p�. OWNER-BUILDER DECLARATION ` O SFWADD/AEM � Q I HEREBY AFFIRM UNDER PENALTY OF PERJUHV TNA7 I AM EXFMPT FROM THE CONTRpCTORS LI- GBIe 8/C8 rt W CENSELAWfOR7HEFOtLOWINGREASON(SEC.7q31.58USMESSAN�PROFES510N5CADE,/WYCINUR , (n 9 � � C.� COUNTYWHICHflEOUIflESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOUSH,OqpEPA1flANY5TRUC- W patio/Deck �� 'NNE,PRIOR TO ITS ISSUANCE.AL30 REUUIRES 7HE APPLICANT FOR SUCH PEflMIT TO FILE A SIGNED W � BTATEMB�R hIAT HE OR SHE IS#JCENSED PUR6JANf TO THE PAOY751PYS OF THE CONTRACTORS lf- SS CENSE UW(CWIPTER e(COMMENCINO WITH SEGTION�000)OF DIVISION 90F THE BUSINE95 AND Pfl0- � POOUSPd I � FESSpN500DE]ORTNATHEDHSHEISEXF�IPTTHEHEFROMANDTNE9ASISFORTHEALLEGEDEXEMP• + TION.M1YVKf1AT10NOF5ECT10N703f.5BYANVAPPUCANTFOFAPEqMITSUBJECTSTHEAPPLICANT70 Ra-Roof ,,;)� � � AqyILPENALT'OFNOTMORETFIANFNEIIUN�REDOQllARS(SSDJ).): ' � ❑I,ASOWNEROK7HEPROPERTY,ORMVEMVIAYEESWITHWAOESASTHEIRSOLECOMPENSATIDN, CCmmBICia! 1NLLD0 THE WOAK,AND THE STRUCTUqE IS NOT INTENDEO OR OFfERED FOR SALE(SEC.7066,BUSI- ! J N NESfi AND PFpFGSSIONS GDOE:TNE CCNTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNEF OF j � ➢ROPENiYYfFdOBU1L�SORIMPROV�STHERE0.Y,AN0VMODDE95UCHWOHKHIMSEIFORHERSELFOA —__ W` TNflOUGHMI60qNEROWNEMPLOYEES,PppVIDE�7HATSUCHIMPPOVEMENTSAqENOTINTEN0E0dR m � Z OFFEREDFORSALEIFFiOWEVER,THEBUILDINOORIMPROVEMENTIS50tDW1THINONEVEAROFCOMPLE- `TION,THE OWNEF}BUILDER WlLL 1iAVE THF 6Ur70EN OF PROYIMG THAi H'c OR SHE OID NOT OUILD OR ' � IMPROVE FOR THE PUHPOSE OF SALE). � ,W. . v�.�OYMEROFTHEPROPEATY,AMEXCWSIVELVCONTMCTMGWITHL�CENSEDCONTRACTORS [ �' .70 CONSTRUCT TH[PROJECT�SEC.70fa,BUSINESS AND PflOFES510N5 CODE:TME CONTRACTOR9 LI� Valtldli011 ���.✓ 'w ' .A ADJ.AREA �7 W CBJSEIAWDOESNOTACPLVTOANOWNEqOFAPHOPEFNWHOBUILDSORIMPqOYESTHEREON,AND � -- - - - y � TORS�ENSEL�WORSUCHPROJECiSNATHACONTMC70R(S)LICENSFDPURSUANi70THECQNTRAF 'QUANTITY DESCRIPTION FEE ' J �Q ❑I AM EXEMPT UNDER 3EC. ,B.S PG FOq THIS REASON . e( � V . u" DATE OYINER '----'— ' h Z, __. . W ; �F� LICENSED CONTHACTORS OECLARATION � I q W � Q !HENEBYAFFIRM UNDER PENlLLTY DF PEflJUflY THAT 1 AM LICENSED UNDEfl PROVISION9 OF CHAP7EA � � ��S•. 9(OOMMENCW(iWIhISECTION7000)OFDIYISION30FTHEBUSINESSAN�PPOFESSIONSCODE,AND Z -x' MY LICENSE IS IN FULL FORCE AND EFFECT. YJ `f� t/ m +J � UCENSE CLASS `- �t i�J LIQ NO. !�f ��T� �� - , � f �W DATE�=Z'�' P.^�CONTMCTOR. L. t�-'^'����_rt�_/ " J 1 :� "�� WORKERS'COMPENSATIONDECLARATION `���}.L, Q � IHERF.BVqFfIRMUNOERPENALTVOFPEiUUqYONE�FTHEFOCLOWINGOECLARATIO�` �U � � z 0 INAVFANDWlLLMA)YTAINACER7IFICATfOFCONSENT�OSELFdNSUAEFORWONKERS' ¢ � _'_ _ COAIPENSATION,ASPqOVI�EDBYSECT10N37000FTHELAHORCOOE,FOHTMEPEflFORMANCE U � Q' OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. W � w' �_I HAVE AND WILL MAINTAIN WOqKEqS'COMPENSATION INSURANCE,AS fl[QUIqEf19Y SF:CTION � -- ` - �� Q 3100 OF 7HE LABOA CODE,FOR iHE PERFORMANCE OF THE WOAK FOR wHICN TLIIS PENM1i 1S �,, �� ISSUE�.MYWORKERS'COMPENSATIDNINSURANCECARRIER/W�POUCVNUMBERAflE� CONSTRUCTION \/ 1 � " �j� CARRIEfl��L� -.. --'— ---�---- %1��_ PLAN HEVIEW ,.z, POLICYNUMBER l�aJ f''���� ELECTRIC .Q --__ 1•��'� - ___-. __._'_- .0' (IFlt55EL'iqNNEFpNOTBE00A4LE(mOFTHEPEqh4({SFOfiONEHINDqEDDOLLMS(5fao)WILESSJ. PLUMBING � _'_".—'._.'__'____'-.'_ [l.l -%�Z.. 1 CEflTIFYTHAT IN TH�PEFFORMANCE OF TME WORK fOfl WHICH THIS PERMIT IS ISSUE�,I MECHA�JICAL ���,. SMALL NOT[MPLAYANy pERSON IN AtJY MANNER 50 q5 TO NECAMF SUBJECT T9 THE ----"" � (p; WOflKEqS'COMPENSATKKJlAW50FCALIFOLiN1A,ANDAGFEETNATIFISHOIILOBECOME INSPF_C7IONFEE J r. " SlJ&IECTTO THE WORKERS'COMPENSATION PROVISIONSOF SECTIDY 97000F TH[IABOR i s CODE,I SHALL FOP7NWI7H COMPLY WITH THOSE PROVISIONS. ISSUANCE ` � Q. __�'_ '""'__'_�� � p'. OATE: APaucAN7: _ _ SMIP ____ ____ � I J, WARNINGFAILURETOSECUREWORKERS'COMPEN5ATIONCOVERA0EI5UNUWFUL,ANDSHALLBE ENERGYP/C � � ^ "���� SUBJECTANEMPLOYERTOCRIMMAIPENALTIESN4DCIVILFINESUPTOONEHUNDREDTY10U5qN� �'"' ^ ,�` p's';i� ' — � JDOLlAflS(5700.000),INADDITIONTOTHECOSTOFCOMPENSATION,DMIAGESASPPOVIDEOiORIN ENERGYPERMIT ;, SECTION370BOFTHELq80HCODE.INTEf1E5T,ANDATTORNEY'SFEES. - � �C� RETENTION FEE: ,� �/ {a'� CONSTRUGTION LENDING AGENCY PRE-ALT FEE: ^ `� �` -�------------�- ..�; I HEREBYAFFIRM UNDEfl PENALTY OF PERJURY THAT THEflE IS ACONSTRUCTION LE.NDING AGENCY FORTNEPERWRMANCEOFTHEWORKFORWHICHTMISPERMITISISSUED(SEC.3o97,CIV.CJ. "'—'-' - --- __ Z W � � LENDER'SNAME , '-- ^-""'""—�----- — F- LENDER'6AODRESS,.^_ __.__ � ICEqTIFVTNATIHAVEREADTHISAPPUCATIONANDSTATETHATTNEABOVEWFORMAT10NI5CARRECL TOTAL FEES 1 y IAGREETOCOMPLYN7TMAL4CITYANDCOUNTYOFiDINANCESANDSTATELAWSNFLATINGT09UILDINp � CCINSTRl1CT10N,pND HEflEOYAJTFqFIZE REPRESENTATIVc'S OFTHIS COUNTY TD ENTER UPON iHE Z, ABOVE-MENTIONEDPAOPERTVFORINSPECTION,PURPOSE5. COMMENTS ,�.. p rj f �9 � ' _ _„_ _— +�.m l —`'_�C't7✓:'L//✓� (.�F"�lq`.a .__' _.. I PERMITfEE NAM (PRINn , _ ___ .. � ���1 �.�_,` !�j. . y°i ����;`(/j� SIGNATUpE OF PEHMffTEE DATE ���S RECPT.NO._ PAID BY �/�� VALIDATION��' .�+'� I WHITE—Depertment Copy,vELLOW—Financa Copy,PINK—Assessor Copy,�OLDENROD—File Copy,GREEN—ApplicanPs Copy / ____ a� .� q.: q _z _ .._. � , _._. ....�..... .....€ I � is� T ji � 7 7 � � .' ,9 3 a ��r�y..�� 4 . � ���.i t. 1 ._:.I. .I i . 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