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Home My WebLink About14157 tf J r� ��_ CITY OF DIAMOND BAR ' j ,,� DEPA1tTMENT OF COMMUNITY 8c DEVELOPMENT SERVICES 1 21660 E.Copley Drive Suite 140 (909)860-3195 Fax(909)861-3117 PRESS ��9�° � BUILDING PERMIT APPLICATION , FIRMLY �� JOBSITE �,U� �( ��.� �/��p q� �� DATEICATION�� ^ NUMBER �� #/C ADDRESS / �V t� �✓ � APN LOT �RACT �SSUE TYPE OCC � OWNER��`C-��n DATE_ CONST. GFOUP O " ADDR,�SS '�-c�_� �3`�1 1 �:`d �� ZONING SETSACKS � CITY iiJ��'(�`,'�� +9� ZIP TEL. FRONT RW CJ____„_ APPLICANT TEL. flEAR ❑___ SIDE/SIDE STREET_ RW ❑ � CONTRACTOR�3 ,..-- p 1 c�1 C- G.G'� ' SIDE Cl_ ADDRES � � 3 ti a CITY 1�1 fa ZIP ' I i Y3 TEL. � • s �TrJ: PROPOSED USE �� '� • w ARCW G/ � Z DESIQNER ' w NO.DWEL. NO. �I es� NO. � CDDRESS ZIP TEL. UNITS _ STpRIES _��•-- BEDROOMS � y DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREA/VALUATION � OWNER-BUILOER DECLARATION SFR/ADD/FEM Q 0 1 HEflE9Y AFFIRM UNDEF PENALTY OF PERIURY THAT I PM EXEMPT FHOM THE CONTRACTORS LI� Gef09B/Cd�DR � W CENSEUWWRTHEFOILOWINGREA50N(SEC.7037.59USINESSANDPROFESSIONSCAUE:ANYCITYOR (n COUNTYWHICFIREWIRESAPEflM1TTOCONSiAUCT,ALTEF,IMPROVE.OEMOUSH.ORREPAIRANYSTRUC- W Pd�IOJDBCK TUflE.PRK1R TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOH SUCH PEflM1T TO FILE A SIGNED W STA7EMENT THAi HE OR SHE IS LICENSEO PURSUANT TO THE PNDYISIONS OF THE CONTRACTORS�I. ' � � CEN3E lAW(CHAPTER B(COMMENCINO WITH SECTION]Doa)OF OIVISION 3 OF THE BU31NES5 AND PRO• � POOVSPB FESSIONSCODE)OR7HATHEDRSHEISEXFNP77HEREFROMANDTHEBASI5FOR7HEALLEGEDEXEMP• (� �j TION,ANYVIOLATIONOFSECTION7091.58VANYAPPLICANTFORAPERMITSU&IECiSTHEAPPLICANTTO z Re-Roof -[,�•J � ACIVILPENALTVOFNOTMORETHANFIVfHUNOREU�OLlARS(5500).�: 0 ❑I.ASOWNEAOFTHEPROPERTY.OflMYEMPLOYEESWITHWAGESASTIIEIR501FCOMPENSATION, � COrt1RIBfCIaI Z WILI OD THE WORK W'7D THE&TRIJCTl1RE IS NOT INTENDED Ofl OFFERED FOR SALE(SEC.7044,BUSI- J NESS ANO PROFESSIONS COUE:THE CONTFACTORS LICENSE LAW DOES NOT APPIY TO AN OWNER OF � PflOPERN'MiO8l11L�50RIMPROVESTHEREON,ANDNAi000ES5UCHWORKHIMSELFOqHERSELFOR � [[ THHOUGHHISOHHEROWNEMPLOVEES,VROVi�EOTHAT5IICHIMPROVEMENTSAREhOTINTEN�EDOR m Q ,OFFEREDFORSALEIF,HOWEVER7HE9UILDMGORIMPflOVEMENTISSOLDWITHINONEYEAHOFCOMPLE- Z TION,THE OWNER$UILOER WILL HAVE THE BUF�EN OF PROYING THAT HE OF SHE 010 NOT 9UILD OR � IMPROVE FOR THE PUHPOSE OF SALE�. ❑I,ASOWNEROFTHEPROPERTY,AAIEXCLUSNELY MRACTINGWIiHUCENSEDCONTRACTORS N fANSTNUCT TME PRQIECT(SEC,701d.BUSINESS ANO P OFESSIONS CODE:THE CONTpAGTORS LI• V81118�i0l1 �f AOJ.AREA W CENSELAWDOESNOTAPPLVTOANOWNEROFpPqOPEF FIOBUIIASORIMPROVESTHEREDN,AND -'�� - �----� ----- � NtIOCON�MCT3FOR5l1CF7PROJEC75WITHACONTRACT )IICEN5EDPURSUANTTO7HECONTfiRC- QUANTITY• DESCFIPTION FEE � 70R3110ENSE IAW.). � �AM EXFMPT UNDER SEC, B.8 P.C.FOR THIS FEASON Q � --- U — s, 2 � DA7E � _OYMER _.._-__._.. U W � LICENSED CONTRACT R9 DECLARATION W I � B IHEFEBYAFFIHMlJNOERPENALTYOFPERIUflYTHATIAMLICEN5E0UN�ERPFiOVIS10450FChIAPTER � � 9(COMMGNCW6WITHSECT�DN7o00)OF�IVIS�ON30FTHE8USINESSANDPROFESSIONSCUDE,AND � FIYLICENSE IS IN FULL FORCEM'0 EFFECT. !� :?�� ' m o LICENSE CLq55_4`� , B LIG.NO. �� __ __ ,., j� V OATE tb l4 " s CONTMCTOR _� ti'�� .__ J �W /r� j�� ` � � WORKFRS'GOMPENSATION D LARATIOPI � N IHEREBYAFfIHMUNDERPENALTYOFPERIURV04EOFTHEFOLLOWINGDF.0 ATIONS: � �J N G ____IHAVE0.NDWILLMAINTAI�ACERTIFICATEOFCAN�F:NTTOSEIfdY.SUHE OflWOHKERS' . COAIPENSATIDN,AS PROVI�ED BY SECTION a7oo of THE LkBOR CODE,FOR IaEp�9F N C� � OFTHE WORK FOR WHlqi THIS PERMIT IS ISSl1ED. � O � ___IHAVEANDN'ILLMAINTAINY/ORKER9'COMPENSATIDNINSURANCE.ASRFIXIIREDBYSECTION — — -- — ' e„L _ ,,,� Q 37o00FTHElA60RCODE,FORTHEPERFORMANCEOFTNEWOPi(FORWHICHTHISPEHMITIS �J 0 ISSUED.MV WORKERS'COMPENSATION INSl1RANCE CNflR1EF AND POLICY NUM9ER ARE: CONSTRUCTION J � CnRelEa__'_"_„__ ..__—_ 1'LAN REVIEW _. - -- --- ------ ----------- � POLICYNUMBER ELECTFIC � — �, _""—""_ -"'�� "'-'_ """'"_-_' 0 (11115SECIIONNEEDN07BE�.RETEDOFIHE �scnaonEMi��DREDDOtLMS(StooI0RLE5S� PLUMRiNG —_... .._.. .....--."'--- Z I CEflTIFY THqT IN THE PERFORMANGE OF THE K FOR WHICH THIS PERMIT IS IS9UEU,I MECHANICAL _„__.,__ � L'S SHqLLN07EMPLOYM'YPERSINJIN VMAMNE OAST08ECOMESUBJCCTTOTHF N WORKERS' OMPENSATION LAWS O ALIFOFiNIP D�GREF.TF1A71F I SHOULD BECOME INSPECTION FEE __. �� SI/BJECTT THE WORKER5 COMPF TION PRO IONS OF SECTION 37000F THE Il�AOR � CAD.IS LLFORTHWITHCOMPLY T THOSEP VI$�15. ISSUANCE �� I( � I .V. �.__-'�-�/'_� pDATE:�� f` 1 i AP%.ICANT: � �t' -----_- SMIP ��,��Y�.*- -----�-(,L w ' ENERGYP/C �.� �'d�'.i J WAFlNING:FAILUFiE TO SECURE WOPKERS'GOM SATION COVER�GE IS UNLAWFUL,AND SHALL BE .y - ---- q .L '-_" . � SUBJECTANEMPLOYERTOCRIMINAIPFNALTIES DCIVILFINESUATOONEHUNDREDTHOUSAND ENERGYPERMIT ��^��x.'.3l�' '"" e � DOLI.ARS(f10o,aoo�,INA�OITIONT�THECOSTOF MPENSATION,OAMAGE3ASPROVIDEDFORIN ---�-- '�ts� -----��- � � � SECTION 97080FhIE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. � ' , RETENTION FEE: _ .____.__._, ____ "-----'— ; pW„ CONSTRUCTION LENpING AGENCY pRE-ALT FEE: ' � --—-----'--- ��---- CC I HEHEBY AFFIRM UNDER PENALTV OF PL'RJURY THA7 THEFE IS A CONSTRUCTION LENOINO A�ENCY � FORTHEPERWRMANC[OFTH[WORKFOfl1YHICHTHISPEflMITISISSUED(SEC.3091,CIY.G.�. � � Z W '_ —_'_ � LENDEWS NAME _,--_ _______ _ F- LENDER'SADDRE55"_"_--'""'_'—_-"'-"_'_"_'..__...._' W ICERTIFYT TIHAVEREADTHISAPPLICATIONAND5TATEi}IATTHEA90VEINFORMATIONISCORRECT. TOTAL FEES �' d IAGREE TO PLY WITH ALl CITV AND COUNTYORDINANCES ANU STqTE UWS RF.LATINQ TO BUIIDIN6 � CONSTRUC ,ANDHEREBYAUTHORIZEREPRGSF.MAiIVE50FTHI5COUNTVTOENiERUPONTHE ZA90VEAfE E�PROPERTY FOR INSPECTION PURPOSES. COMMENTS = JC�n �(',�`�.1�� ----- -- — - m MITTEEN (PRINT) . .— � �.- � /� _J._ -- � SIQ REOFP RMITTE D E = RECPT.NO._,�._ PAID BY _VALIDATION _ ~' WHITE—DepaAment Copy,YELLOW—Finence Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicanfs Copy . . _ ..._..,.�_. __._. , ._.._ e .. r r d ��H : f d � � � 1 i ; . � i t f r f i '�1 "'�t�t� i y, a �� s � 3 � �,�, � � � ,. y a 'i' � � � ��. 3 � . �� ">�� i � � . � �' � � 1 r � � �� C , t � � I 1 , . 'I t 1 I _ . ' .Y .( �� 1 J 1 f��. � - r P ��,� t �.; } � � I , . � , ' 9 - J � �3 .I� � 4.� C t �y �F '1 : � . 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