HomeMy WebLinkAbout14814 I „ '" CITY OF DIAMOND BAR �r�
�� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES ��.='>
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117 PRESS
��'�'� � BUILDING PERMIT APPLICATION FIRMLY
� JOBSITE l � , ' , � ���l(l�(a� DATE CATIO ��, NUMB R #/C
o ADDRESS____�_�� �t� �t
c� ISSUE �-(� TYPE , OCC
APN LOT TR CT _ DATE << �i CONST. GROUP
p OWNER ��
LL ApDRESS O • L ZONING SETBACKS
� CITY ZIP 1 TEL REART � ❑
APPUCANT TEL. SIDE/SIDE STREET i RW ❑
� CONTRACTO ''�" SIDE L]___
� ADDRE S '" /_ �.�,,,��
� CITY ZIP TEL. —' PROPOSED USE J��'f/-ri-1_—
� o ARCH/ENG/ � - _
� DESIGNER NO.pWEL. NO. � NO.
Q AD�RESS UNITS STORIES BEDROOMS
� CITY __ ZIP 7EL.
� — DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
Q, OWNER•BUILDER DECLARATION SFWADD/REM
I HEREBY AFFlRM UNDER PENALT'OF PERJURY 7HAT I AM F.XEMP7 FROM THE CONTRACTORS LI� G&MdQB/C3fPofl
W CENSEUIWFOR7HFFOLLOWINORERSON(SEC.1031.50USINFSSANOPROFESSIONSCOOE:ANYCITYOR . (n
U COUt7YYWHICHREdUIRESAPERMtTiOCONSTPUCT,ALTER,IMPROVE,�EMKILISH,ORREPAIRANYSTRUC- W pTtiO/DBCk
� T1RE,PRION TO ITS ISSUANCE,AL50 RECIUIRES THE APPLICANT FOfl SUCH PERMI7 TO FILE A SIGNED �
� STATEMEM 7HAT HE OR SHE IS LICENSEO PUR5tlANT TO THE PROVISIONS OF THE CONTRACTaRS LI�
CENSELAW(CHAPTER9(COMMENCINOWITMSECTION]000)OF�IVISION30FTHE8lASINESSANDPRO� � POOUSp9
� FESSIONSCODE)ORTHATHEOFlSHEISEXEMPTTHEflEFfl041ANDTMEBASISFOR7NE�LLEG[PEXEMP�
U TqN.ANYVIOLATIONOFSECTI0N7IXi1.5BYANVAPPUCANTFORAPERMITSUBJECT$THEAPPLICRNTTO ' Z Re-Roof .a
A CIVIL PENAL7Y OF NOT MORE THAN FNE HUNDREO OOLLAflS(SSoo).):
❑I,ASOWNEqOf7HEPROPERTV,ORIdYEMPLOVEESWI7HWAGESASTHEIR50lECOMFENSA7�ON, � Comme�cial -
�'� VALL DO iHE WORK+wD THE STRUCTURE IS NOT IN7ENDED Oii OFfEREO FOR SALE(SEC.7C44,8L1SI- J
NESS Af10 PROFESSIONS COOE:THE CONTRACTORS LICENSE LAW UOES N07 APPLV TO AN OWNEfl Oi
N PflOFERTYYMOBUI�O50RIMPNOV&STHEFEUY,ANOWHOOOESSUCNNIORKMIMSELFORHERSELFOfl � -
�:' 7MROl1GHHISOPHEROWNEMPLOYEEB,PROVIDEOTMATSUCNIMPFlOVEMENTSAR'cNOTINTENDE00q ' m
W. OFfERED FORSALE IF HOWEVER7ME BUILDING ORIMPROYEMENT IS SIXA WRHIN ONEYEAfl OFCOMPLE
Z �TION,THE OWNER�UILDER WILL HAYE THE BURDEN OF PH�VIkO THAT HE OR SHE DID NOi 9UILD OR •
� IMPROVEFORTHEWfiPOSEOFSALE).
U 1,AS OYMEH OF THE PROPERTV,AM E%CLUSIVELY CONTRACTINO WITH LICENSED COMPACTORS
! W�,,,, TOODNSTHUC`Y THE PROJECT(SEG 7064,BUSINESS AND PROFESSIONS CO�E:THE CONTRAGTOR5 L6 '. V8Il18HOf1 ADJ.AREA__._.,
W CEN&ELAWDOESNOTAVPLYTOMIOWNEROFAPqOPEfl7YWHOBUIlD50AIMPROVESTNEREON.ANO +
Z�• WFqIXINTMCTSFORSUCMPPQIECTSYYITHl1CONTRACTOR�S)LICENSE�PURSl1ANTTOTHECONTRAC- QUAN DESCRIPTION Y FEE
70p5 LJGENSE LAW.�.
p� ❑i AM EXEMPT UNpEF SEQ 8.8 P.C.FOR THIS REASON �, Q
3.� --- U
�
u" DATE OWNER_ __ -- - U
Z W __.—
�! LICENSED CONTRACTORS DECI.AAATION W I
� IHEt1E8YAfFIFMUNDERPENALiYOFPeWURVTNATIqMLICENS[DUNDEHPROViSION50FCHAPTE�i i � �
p,;� B(COMMENCINOWITHSEC710N70D0)OFOIVISION30FTHEE1l15INE5SAN�PFlaFE55!�NS�DE,NiO Z
3C IAYUCENSE IS M FULL FORCEANO EFFECT.
W m
o LICENSE C S � LIC.NO.���� _, j
—+.'� a
�; D CONTRACTOR _ �' __..—
�' � WORKERS'COMPENSATION DECLARATION y Q
�� U
� IH qEBYAFFIRMUNDERDENAITYOFPERIURYONF.OFTHEFOLLOWINGOECLARI�TIONS:
� z
a
P� __INAVEANDWILI.AIAINPAINACF.fl'iIFICATEOFCONSENTTOSELF.IN5l1REFORWOflKERS' 2 --
Z
COMPENSATION,ASPROVI�ED6YSECTION37WOFTNELABONCn�E,K]FTHc'Pi:HFaRMANCE V
OF hIE WOFK FOR WHICH THIS PF.PAIIT IS ISSUEO. �
�
��� � �HAVEf�`1�WILlMAINTAMWORKEPS'COAIPENSATIONINSUliANCE,ASNEDUIREDeYSECTioN
�Q 37000FTHELABOPCODE,FORTiEPERtORM/�CEOFTHEWORKFOqWHICHTHISPERM1715 -- ��j�
� ISSUEO.MY WORKEflS'COMPENSAYbN INSURANCE CAPRIER AND PULICY NUMB�R ARE: CONSTRUCTION __ _ __ __.. _ .-L Y/ �_��
� �P c FRIER_, �� I�S� PLAN HEVIEW T
Z \,�A�.icvNuueEa---�7.PX7��I��.�. -- ELECTf11C --'--.. .._. ,.^__ ._ �
Q V
� (iHISSECTIQVNE�NO'fBE00MLETF�01"T}{EPERMffISFORONLFWN�REODOl1PfiS(SfOo)ORLESS} PLUMBING _____-,_ _-_ __. _.,, .___
W ICERTIFY7HATINTiEPEflFORMANCEOFTHEWORI(FOflWH�CHTNISPERMITI5ISSUED.I � MECHANICAL �
Z _"__ ___'_'__ __"_
(} SHqLLNOTEMPLOYANYPEfl50NINANYMANNER50A5708ECAMESUBJECTToiHE � -
�' WOflKERS'COMPENSATIONLAWSO�CAIIFOfiN�A,AtrDAGREETHnT1�I5HOUL�9CCOME . INSPECTIONFEE _.___. . +�_ � `
�� SUBJECTTOTHEWORNEftS'COM4ENSATIONPROVISIONSOFSECTION3.'OOOFTHELAOOR �
� CA�E,ISHALIFORiHWITHCAMPLYWITHTHOSEPRDVISIONS. ISSUANCE _,___ ___._.���_�=._3�/ ] �
� SMIP �}�3-=L-.�}4.%i�'--'-- Z-rr�K- .'.
p '�AYE:__ APPLICANT: _ "'_'_ '-'_ � <
W ENERGY P!C t�4 � .
� WAHNING FAILURE TO SECURE WORKERS'COMPENSATION CAVEHAGE IS uNL�WFUL,AND StIALLBE -'- '-��'���� -"- '-----
� SpW1pR5�oo,o0a),�NAOOTIRONTOTHECOSTOFCOk1PENSATIONUDAMAOESASPROVID OFOflNN ENERGYPFRMIT y"°���'(�?�'�:�,�'�''Z �� _
¢ SECTION37080FTHE LAROR(YIUE.INTEREST.ANO ATTORNEI"5 FEES. _"V�(�G��-�__!___ _
RETENTION FEE: � .7�e F��'��f
W CONSTRUGTION LENDING AGENCY PRE-AL7 FEE:
� —'-- ..-- ----- '--
� � IHERE9VAFFIfiIAUNDEHPENALTYOFPEFiJl1RY1HATTHF.REISACONSTRUCI'IONLENDINGAGENCY ____ ___ _ _ _
FOR THE PERWPMANGE OFTHE WORH FOfl WHICH THIS PEflM1T IS ISSUED(SCC.3087,CIV.C.).
,7.� _-. _. .._ ._"' _
w
y � lENOER'S NAME _ - - ___ __ __
� F_ LENDEH'SAPOfiEss_, -. __. --
` w ICERTIFYTHAiIHAVEPLMTHISAPPUCATIONMI�STATEIHATTHEABOVEINF�RMATroNISCORRECi TOTAL rEES J/ II /' '
� � IAGflEETOCOMPLYWITHALICITYMlDCOL1NiYORDINANCESANDSTAT[LAWSRELATINGTOBUILOMG � �� �
CONSTRUCfKKJ,AND HEflE6Y AUTHOPIZE REPRESENTATIVES OF THIS COUNTV TO ENTEq UPON THE
� Z A90VE�MENTIONE�PRO�EflTYFORINSPECTIONPUflPD3E$. COMMENTS_,_ . _ _. _
� _ - ..
' � .�-'_ _,
m PEflMITfEENAMElPftI ' - --
4
[n —. � -
� SKiNATURE�FPERMI D T
= RECPT.NO. PAID BY VALIDATION._.___ _
� WHITE—Department Capy,YELLOW—Finance Co PINK—Assaseor Co GOL�ENROD—File Co GREEN—
py, py, py. ApplicanPs Copy
_.__. _..,. _..._ e__
_ i _ _
�.. � y
.. ' ._ "` (^ 7 3�+ 1
i.. i �
F - f P p♦'�� € 1 x � � -' 3, �.1 I '� 1 �Y� � i � �I { ro �.�,
��tY s s�r,�r ( ' ,� E r . , "-�r �� de�t
r��p � � ' I �.I �
� �r� fi ' �: °� � i I i _ i � � �� =a � r � v,'v r � .
i - , �;C �;. i i I . �.. i � fi�
° �-� ��i ' � � j . � - ' - ' � - � �. � 1
� � tj , i � � . 3 � �. i ."I _, � ...i .:�, �_ R C � '] ,.
I �) �
'� '�f� "� ry � �. ' � � � i i i�,�j � i � 'i v � �
d s;"j ' I f i � �. . , .. I � ��' .
� ;. : i , . ; � i I i ' � { I i I i ` � ��„�r � .
{ ,
� � �f � ,� �Y � � P _�� i � ��� ��� ,
. I � I t I I 1
= i � �
r �� 9x i�= F' ( i � I � � � . ` � I F , _ � � � _ �7 . � � �''"�� �'
� .:,� �� ��,t �3,. I I i I ,, 1 . ' . , '�t . _ �`i__ � .-� i � f - I I � i� 1 � ; � � �
, . „ ,... �:_. :-.t,', i i I i . ; � i � i ' — . . i , ( . � F ,_ i.. � .
_. +
t � ' � � �. I I j . I V`I . � _ �' E � �,, � �i � �� !-� , �� ( ' � I�3 .
� : � : I I : . :�j I 1 � �
. �{ q�
� h
: � . : 1 � i ` � i : i � � I I � �V 1 � � .3 I � f _ �'� .
�f i
` ' �
. �.
; i • ; . : , � i . � � � 1, _l. _ - _ ..._r._. �_�_ � . � '�" � .,
+ � �
L.
' �_ L
!I . ( �, I i � � � I I i �� Ri��l� i . � � I i !' I ��� � � ��: �
!a k � I � � � I ! � j ' � � � � � '\ 1 J' � , ' . ', • i I F� � . �>" .
i � i � i j : � : i
- j i , � � . LW� i v I ' I i i. ' 7 I ' �r ( .
I i . ' � , { � � ; ! ; '� ,. I , ' , -I i �
y . i � � I � j I � � , r'�` -a
� � � . . i � . '. � � . i � � , � . � ` /
� I � _ � ' _ . � i , �- i i '. � � � . �� � � � � j q+zAP j - .
� i - ' I . � (�_�`y � . � 'I i _ � � � . � � �� I � , I E �t�, '� �"� '
. � i i \ \`''� . �'i . . . . � I ".i. - ,
i �� '�. ` �' ! (I '�i '� � � �I I � � I f � I I � .r ..I-� 1 Ytt��., �•1 .�
� � � i . � � �� � � ����� �' V ��i. . '._�.1. i I 'J_� ..a - ' .�"r' s �i�.
r ` � �
� � �� I - I . , � � 1#�'�z .I � ..� G- , j � ,�i E ..� . . r' Y 5 .
� � ' I ' � 1 � - C i I �, I � r ,Fr I 1 ,I zE� I t� r �� � �r�_ � ..� r � �,'Y � � §'
� ; � i ' - ! � i I - � I '. �;`� � � i i � __3 i t.� � . i w� � � � � -...;
� . � ,��� � i , i _ 1 , I" ���
, � � , � � . , � i I � ` � ���. .i�r� + ^� �
j ! � : �i � I � �� � '; i i I ,.I nl ? � �I�� r ,n{ '�j 7 C . �'�i � `� .
I r. � , .� � . . I �r' .
� � '� i i i � � ; i � I ��t i ;� ; � i i I `. I, � i " � i�i ��r� � Y� � ���� ,� "
� � . ( � '�, � , �I i I �9s3 . I. � . I 1( �t�,', i � I �� r ��� z�. �� .Y.:
� � i ' I � , '_ � i . . I.. �� � Y � ;��
� - I � � � � , � I � � 1 �
y -- ' . I I . ; . I I i ,��� � . ! 1 , � ' ( I li • S��� � '� �I F.
. i � I � � . � , � . � i
I -'. ; ,
, � � � I ' ;> ; , � � ; , � ' , �
�
� i , i � ! � ,,�, � i � � :
� . � : � � ; I i - � ; ' � _ �,��t� � _ ..J � ..._� � ( �� �-- '- � � � - t � _? :
�
� I i ( _' . ; . . �- �• - ..,... ` , _... `.. I_ i .
� i � I j i i � � � I I j I I ' , '� � ��I
I � � � t , I ' � � : ' I I � ; ' � r �
� � ; ; I � ' i ' i �. ,I I ; i i ; � � ( :, I ! I , j � i I ' �, .�
:
� � � � i i I �� ,
' ��. �� , i � , i �:" � � �i- ' � � ' i i _ _ I ' -�-
� , �
� , . I ;
� � I � � ; ' �� � �- ; � ', _� � -� �; �-� � i � �
, ! � i I � 3 I � I � �
; � ( i � i � � � i i ' i , " � � ; � i � ' , � � � � I ��
,' i , ' i . . � � � . , � I i i . i � ' ; � i � ':"
, � ' � � i l i � �' ��,
` �i � � � i � � I I � I 1 ` � { ��;°
, � i , , f ', � � � �} ,#
� ! � � � ' i . � , ` - ; i I � i � ' , i � � ' . i t ��d�
�� � ��� I � i �I I � j ( ! . , I � , � � � � , � i �' ��_ � � ��i��;
� , ;
, � , � i .__.�..
� , , . _ ._........._ .... ___-.__.. . ._,... .. ... . .
, ; ..._.._. ..� . t.,.. . .. �,_.. ..._