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HomeMy WebLinkAbout16070 (34) y...:...:..�....,�....... , CITY OF DIAMOND BAR " - - DEPARTMENT OF COMMUNTITY dc DE'VELOPMENT SERVICES ,� *; � . 21660 E.Capley Drive 5uite 190 (909)660-3193 Fax(909)861-3117 PRESS 'TM'�� BUILDING PERMIT APPLICATION FIRMLY y JOBSITE �i/� /v. �__ L L /G�ir� ��^ APPUCA710N PEHMff P!C � ADDRESS '7 A%iG.EJ/' DATE�/�f 6� NUMBER_�� i � ISSUE TYp6 p� APN LOT TRACT DATE CONST. GROUP � OWNER O p ADDRE S �1 s �ZONING SETBACKS � CITI( r 21P ^ TEL. DO FRONT RW ❑ APPLICANT d�s TEL � SIDEJSIDE STREET RW ❑ � CONTRACTOR S �� SIDE p ADDR S ^ � � PROPOSED USE � n ' � �p y��V(„ 8 AFlCHIENG/ �� 21P 91A� TEL.� /^3t�97 ''.���..!��'��.+�. F ADD ESS NO.DWEL. •.. ,. NO. NO. � y CITY ZIP TEL.,� UNITS ` STOAIES BEDROOMS rn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q ONMER-BUILDER DECLARATION , SFRlADDh1EM O � 1 HERE$Y AFFlRY WDER PENAL7Y OF PE0.AIRY 1H�T I JWI E%EMPT FROM THE CONiRACTONS LI- G8f8g6/CBfpOR CENSEUIWFORTIIEFOLLOWINOREASON($EC.70]7.6BUSINESSANDPROFE&SIONSCOOE:ANYGNOR (� COUHIYMMIp1/IEOUIRE3APERMRTOOON6TFNICT,KTER,M7flOVE,DEMOl1SH,ORflEPAiRM1Y5'iRUC- ; W patio/Deck IURE PRqR TO IT9 i53lJANCE,ALSO REOUIqE3 TME APiLICANT FOR SULM PERMIT TO F4LE A eIGHED � lTATEMEM TU1T ME GI SHE Y9 LICENSm PUNSUANT TO TME PROVI5iON5 OF TNE CONTMCTOfiS ll• ;� � � CENSE LAri�(7UVTEFl a(COMMENCINO WI7H SEC710N 700a)DF UIV4410N S OF TME BUSINE59 AND PRO• POOUSpe FE5310NSOOOEIORTWITHEOHSHEISEXEMPTTIIEAEFROMANDTMEBA515FORTHEALLE�EDEXEYP• �; (� iION.ANYVpLATpNOFSECTION7031.6BYANYAGPLICANTfOFAPERMIT6IHIECTSTHEMPLICIJlTN :; *� qg-F{{pp� ��. � A CIVIL VElfALTY OF NOT MORE TUN FlVE HUNDRED Ddl�RS(f5o�.�: ; � OLA40NMEROFh1EPROPERTY,ORMYEMPIAYEE8W17HWAGESASTHEIF50LECOMPENSATq/1, '' Q (`,pmmBfCl81 - WILL DO TNE WOq(,AND THE STRUCTURE IS NOT INTFND6�pR OFFERED FOR SALE(BEG.Ta�,DU51� : ,�J � NESS MID PFqFES910NS CODE:ME CONTMLTDi45 LICENSE LAW DOES NOT 11PPLY TO AN pWryEH OF ;; ..��' PNOPER7YYIFiDBUILO50fl NAPROVESTHERBON,ANDYR1000ES BUCH WORKHIMSEIFORHERSELFOR � 1MROUGIIMISDIiNEROWNEMPLOYEES.VHONDED7H�TSUp11NPROVEM€M3ARENOTINTEN�EOOR � � aFFEAED F1�R 9A.E IF.HOWEVER 111EBU4DWOOR IMPROVEMENTIS SOLD WRHINONEYEAR OFCOYRE• � TIOPI.THE ONRiEWBULDER N7LL HAVE TNE BURDEN OF PIIOVINO 7HAT HE OR SNE DID NCT BUIID OR MAPRDVE FOR SME PI1NPo5E Of BALE} ' �. W OI.ASOYMEROFTiEPROPERTY,IUAE%CLUSNELVCONfMCTINOWRHLICENSEDCONTMCTOfl3 � TO CONSTRUC'f T11E PqD.IECT(SEC.7011,BUSINES6 AND PfiOFE5310N5 CODE:THE CONTRACTOfl4 LI� �/BII181I011 � �� � ADJ.AREA CENSE LAW DOES NOT MPLY TO AN pIM�ER OFAFROiER7'!'M70 BUILDS OR IMPRDVES iHEREON,M1D � � WFqCONiRACTSFOReUCHPROJEC7SYN7HACON�HAGtOR(S�LICENSEDPURSUMfT70TNECONTMG � QUANTITY OESCRIP710N Y iunsucQ+seuw.� FEE � O 1 AM pIpIVT IRIDER SEC. B.�P.C,FOq THIS REASON q _ + � U � WTE ONTIFR_ , u � LICENSED CONTRACTORS DECLARATION w � IXEREBYAFFINIAUNDERiENALTYOFYEfl1UHYTFMTIAMLICENSEDUW�ERYFpVISIONSOFCHAPTER ,�« � /(OOMMENCWCN77NSECTIDN700o)OFDIVISION90FTMEBUSINE59ANDPPOFE551QYSCODF.AND � LL� MY UCENSE 19 W FULL FORCE AND EFFECT. � � 4CENSE LIC.ND. � � n�� coKrFucToa � S.' � WORKERS'COMPENSATIONDECLARATION ��/7�,�.�C,� �.' y1MEREBVAFFIREfUNDEHPENAITVOFPEIUURVdVEOFh1EFOLlOWINODECLl1MTqN5: ` � O �IHINEANDWILLMAMTNNAGEH�IFICATEOFCONSENT708ELF•INSUREFORri'OqKERS' � Q OOL1PFAl5ATION.ASPROVIDE�EYBECTION�7000FTHE�ABORCODE,FOR71/EPEHFOiLVANCE � Q OFTHEWORKFOrtWHNl/THISPERMI7ISISSUE�. � �_IFUYEANOWILLMAIMAINWORKERS'COMVENSATIONINSURANCE,ASREWIREOBYSECTIDN te Q a7ao OF TT7E LA60R COUE,PDR 7ME PER WRMANCE OF THE WOPof FOF NMICH TNIS PERMIT IS �� � ISSUED.MY WORK��sr'OOMPENSATI NSUR E CARRIER AIA POLILW Nu1dBER ARE� CONSTRUCTION � +�`� � CMRIER ✓��P�. �rt.c� PLAN REVIEW � POLICY NUMBER �� � ELECTRIC 0 (mssecrnNrx�nNo'reeaor.aFreooFnfrEw.rrswr+ar�r�►�o iao�oq PLUMBING 7� � I CER7IFY TNAT IN TIiE PENFORMANCE OFTHE WtlRK FOR WHICH 71MS PERAIIT IS ISSUED,1� MECHANICAL ��� SMUL NO7 EMP�OV MIV PERSON Rl ANY IMNNER 90 AS TO BECOME SUBJECT 70 7HE � � WORKERS'COMPENSATIONLAVYSOFCAIJWRNIA,ANDA6qEETFMTIF15MWLDBECOME INSPECTIONFEE SUBJECT NTHE MKMKERS'COMPENSATqN PHOVISIONS OF SECTION 9700OF THE UBOR -�j CODE,ISMALLFORhIWI7NCOMPLVWIiH7HOSEPROVISqNS. ISSUANCE � , �'•i� p �AtE: APPLKJWT: SMIP _ /�� � ENERGY P/C C WANNIN6:FNWRE TO SEIXJRE WOflNERS'COMPENSATqN COVERAGE 19 UNLAWFUL,NID SNALL BE YSUBJECTANEMPLOYERTOCRIMWALiENALTIESNl�GNILFINESUPTOqVENUNOREO1/qU511N0 ENERGVPERMIT ��'l�'fy��"i 1 Liq D011ARS(il W,WOJ,W ADDIiION TO THE COST OF fAMPENSATION,DAM�IGE9 AS PNOYI�ED Fqi IH g /ry.. J¢ 6ECTION]7as OF 71E LABOR COOE,IN7ERE5T,ANDATTORNEY'S FEES. RETENTION FEE: `j -� ` T�V D OCONSTRUCTION IENDiNGAGENCY PRE-ALT FEE: � � IMEREBYAFFlRMUNDERPENALTYOFPERIUHYTHATTNEREIS�CONSTRUCTIDNLEN�IN(3AOENCY Z FON 711E PERPDRMI/iCE OFTME WOHK FOR WNIA17}IIS PERMIT 15155UE�(SEC.90B7,qY.CJ. W � LENDER'S NAME � LENDERSADDRES3 � ICER7IFVTHATIIUVEREAU7HIS�PPLICl.710NANOSTATEiF11177HEABOVEWFOHMATpNISCOqRECT. TOTAL FEES �" f' /~��J � IAGREEiOCOMPLYYYITXKLCfTYMIDCOIRITYOROINFNCESANDSTATELAWSRELATINOTOBUILUING CONSTRUCTION,M1C HEREBYAUTIiOH2E REPRESENTATNES OF 7HI5�UNTVTO EHTER UPON 7HE � ��//! � ABOVEMEMIONEDiNOGERTYFORINSPELTIONPURPO5E5. 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