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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 . 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