HomeMy WebLinkAbout18633 _ �� CITY OF DIAMOND BAR
1R DEPARTMENT OF C01vIIv1UNTfY&DEVELOPMENT SERVICES
6`�,�i�� 21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117 PRESS
�"�»»� BUILDING PERMIT APPLICATION FIRMLY
� JOBSITE
Q ADDRESS�� �- _�� � ��, APPLICATION ; 7 PERMIT y/C
o �-- DATE � NUMBER__/1� ..�tt
ISSUE
`^ APN L,LT TRACT____ DATE__ �M1 B`"' ONSL GROUP
p OWNER f " `t �
o ADDRESS�� �' ZONING SETBACKS
Z CITY�yL IP'��l��_ TEL.`�04�__�_,/�, FRONT Ryy �
� APPUCANT TEL_ l' REAR � —
z SIDE/SIDE STREET RW ❑
m CONTRACTOR_�„_� A SIDE � _ —
ADDRESS �!�
O ��—� �A�� s '— PROPOSED USE � S L//1�E � �
CITY�,�,,.;,__ ZIP�]l� TEL.(o�G i-O j �, �a
oARCH/ENG/ _
W DESIGNER NO.DWEL. NO.
a ADDRESS NO.
cn UNITS STORIES BEDROOMS
� CITY ZIP__ TEL.____
� DESCFIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
� OWNER-BUILDER DECLARATiON SFR/ADD/AEM
O
Q I HEREBV AFFIRM UNDEq PENALTV OF PERIURV THAT I AAA EXEMPi FROM THE CON7RACTORS LI- G0f8J8JC2fy0fS
W GENSEUWfOWTHEFOILOWIMOREA50Nl5'cC.)03�.SBVSINESSAN�VWOfE5510NSCODE:ANYGiYOR (f�
U CAUNTYWHICFIREOUIRESAPE9MITTOGONSTRIICT,ALTERIMOROVE,DEMOLISH,ORREPpIRANVSTRUC-
w NRE.PRIOR TO ITS ISSUANCE,RLSO REOUIRES iME FPPLICANT iOR SUCH PERMIT TO FlLE A SIGNED W P2IIO/DBCI(
cC STATEMENT THAT HE OR SHE iS LICENSED PUflSUANT TO THE PPOVISIUNS OF THE CONiRAGTORS LI-
� CENSE LAW(CHAPTEF 9(COMMENCING WiTM SECrION 7000)(]F�IVISION�OF TME BUSINE55 AND PRO� u' POOUSpO
O FESSIONSCODE)OqTHATHEORSHE�SEXENGTTHFR�FqpMANDTMEBA5�5FO9THEALIEGtDEMEMN� �
V 710N.ANVVIOV.TIONOFSECTiON7oa�.5HYANV4PPLiCAN�FORAPEFiMRSU9JEGT5fr�fAPPIICANT70 Z He-Root
� ACIVILPENALTY OF NOT MOPE THAN FIVE HUNDRED�OILARS(55001)�. -
� ❑I.ASOWNEROfT4EPROPERTYCRAtYEMOLOYEESWi'nW4GE5AtilNfIR50LECOMPENSAT�OfJ. � Coff1f110fcial
Z W1LL DO TME WORK,AND THE STRUCTURE IS NOT IN'ENC[0 OH OFFEFFD�OR SALE(SEC.IOd6,BU�I� J
� NESS AND PqOFE5510N5 GODL:TME GONTRAC70RS LICENSC UW DOES NO'APPiV TO AN OWNER OF ?
PROPERTV Nh10 9UILO5 OR IMPROVES THEREON,AND WHO DOES SUCN WORK MiMSELF OR NEFSE�G OR
� THROUGNHISORHEROWNENIPLOYEES,PROVIUEnTMATEUCHIMPROVEMENTSARENOTINTENDEDOR m
� OFFEREDFORSALE.iF,HOWEV!=R,hiE9UIlDINGORIMFROVEMENT15501DW:TYIINONEI'EA90FCONVIE�
Z TION,THE OWNFR�9UILDER WILL HAVE THE BURDEN OF VROVING"HA7 HE OF SME DIO NOT BUILO OR
� IMPROVEFORTHEPURPOSFdFSALE�.
w CI,ASOWNEROFTHEPPOPEPTYAMEXCLUSNEL'/CONTRACTINGWI�HLICENSEDCONTRACTORS
� �O CANSTRUCT THE PRQIECT(SEC.]oaa,BUSINESS ANO PROFESSIONS CODE:TME CONTRACTORS Li� V81U0fiOf1 � ADJ.AREA
W CENSEUWDOESNOTAPPLYI"OANOWNEROFpPROPERTYWHO�l'JI'..f?SORIMCROVESTHEREON,AND
WHO GONTRACTS FOR SUCH PI7WECTS WITH A CONTRAC70A(S)LICFhSED PURSUANT TO TH[CONTqAC-
� roHs ucEr+se�nw�. OUANTITY DESCRIPTION FEE
Y —
0 G I AM EXEMPT UNDER S'=C. __ B.6 P.C.FOq THIS REASON Q
� �
LL' DATE OWNER ¢
z -- U
� IICE:NSE�CONTRACTORS OECLARATION W
Q
Q I HEREBY AFFIRM�NDER PENNLTY pF PERJVRV THA71 AM LICENSED VND'eq Pi70V1510N5 OF CHAPTEq �.� �.��
d 9(COMMENCING WITH SEGTION�000)OF OIVISION 30F THE BUSINE55 AND PPOFESSiONS CODE,ANp Z
LX MV LICENSE IS IN FULI FOHCE AND EFGECT.
\1
� LICENSECLASSyr '� LIC NO. � �� �,
U DATE '� �J '��5.� CONTRACTO(7 Q� d
W
� WOFIKERS'COMPENSATION DECLAFATION a
� I HEf1EBV AFFIRM UNDER PEN4LTV OF PERJURY ONE OF THE FOLLOWING OECURATIONS: U
� z
� �I HAVE AND WILL MAlNiA1N q GER?iGICA7E OG CONSENT TO SELF�INSUAE FOR WOFNERS' _
Z bJMPENSATIpN,AS PROVIDED BY SECTION 3�0o OF THE LABOR CODE,�OP THE PERFORMANCE U
O ,/ OF THE W09K FOft WiiICH THIS PERMIT IS ISSUED. �
w /]�I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE.AS REQUIREO BY SECTION
Q4 3>oJ OF TH£LABOR CdJE,FOR THE PEAFORMANCE OF THE WORN FOR WHICH THIS PERMI115
ISS�JED.MV WORKER!�COMPENSATION INSU9ANCE CARRIEF AND POLICY NUMBERARE'. CONSTRUCTION
J — —
� GARRIEF `L��� �N/� PLAN REVIEW
� POIICV NUMBER���j y S�fp � ��CJL:�! '— �-- ELECTRIC
¢ --
� (1HISSECTpNNEmNC�TBECOMPLETEDOFTFIEP�W-N�ISWHONEHVI�ORED!)OLIARS(StOp)ppLEss). PLUMBING
W —
Z �CERTIfV THAT IN THL pERFORMANCE QF THE WORN FOR WHICH THIS PERMIT IS ISSUED.I MECHANICAL
CJ SHALL NOT FMPLOY nNV PCRSON IN ANV MANNER 50 AS TO BECOME 5119JFf.T TO THE —
(/) WORKERS'COMPEN�ArION IAWS OF CALIFORNIA,ANO AGqEE 7HAT IF��SHJUCO 9ECOME INS?ECTION FEE
SUBJECT TD 1HE WORKERS'COMPENSATION PROVISIONS OF SECTION 3]0o OF THE tABOR T—�
� CODE.ISHALLFORTNWITHCOMPLVWIIHTMOSEPROVIStONS. ISSUANCE ____ _ . ��7 ��—
� —'—
p DATE'. APPLICANT: .. SMIP
w ._ —_' — "__" .__—__—
J WARNINCi:FAILURETOSEGUHEWORKERS'COMPENSqTIONCOVERAGEISUNLAWFUL,ANDSHALLBE ENERGYP/C
J ____
� SUBJECT AN EMPLOYEH TO CRIMINAL PENALTIES AN�CIVLL FINES uP IOONE HUNDRED TFIOUSAND ENERGY PERMIT
DCILARS(S1W,000),IN ADDI'ION TV TME GOST OF GOMPENSATION.OPMAGES Ag PROVIOED FOF IN a_�_
J $ECTION 3ICB OF THE LABOF�,COOE.WTEREST,AND ATTOFNEY'S FEES. � ��
w RETENTION FEE:
O CONSTPUCTION LENDING AGENCY PRE-ALT FEE: _
� IHEREBYAFFIRMUtvO'cRPE'JALTYOFPERJUFY;HATTI1EliLISaCONSTPVCiIONLENDINGAGENf,V
d FOR THE PEHFOHMANCE OF THE WOFK FOR WHICH TMIS GEFMIT IS ISSUE��SEC.]OB),CIV.C.). �
Z
w
j LENOEN'SNAME ,___ _ —
�
F— LENDER'SAD�qE55
� TOTAL FEES ^7 '
w I GERTIFV TMAT i MAVE FEAO TMIS APPLICATION AND STATE THAT THE ABOVE IhFOqMAi1C1N IS CORAECi
� I AGREE iU�OMPLY WITH AI.L CITY AND COUNTV ORD�NANCES ANO STATE LAWS RELAiING TO Bl11LDING
� CONSTRUCTION,ANU HEPEI3V qVTHORIZE AfPfiESENTATIVE50F TIIIS COUNTV TO ENTER UPI�N THE
Z ABOV�IONEDPROPEYtTVF INSPEGTIONPUR�OSES COMMENTS_..
� -�'r�u L -�,�� ----- - -
�
� _ - _
QPER �E NA/ME�IPRINT) � _'_
`n �� .�/C/ �� I_? ���?_�
C!j GN .�(T�Ri DPE PERIU� — .. ._. DATE— -- � __
� RECP?.NO. � _PAID BY ��Z VALIDATIO
WHITE—Department Copy.YELLOW—Financ2 CODY.PINK—Assessa Gopy,GOLDENROD—File Copy,GREEN—ApplicanYs Copy
�,ar�.�
,. � a , �����.�'� �, �� .� , . ,
" i �� � ',� ��� � .
•
_
, _
�,/;, _ ,.r-�c�,�; _
� __
��a <<. �., �
_ ����� w�� � _ __ _ �
. _ _._.__ ___
_ _. _ _ ___ _.
__ _
_ __. _ _.. _
_ _ __
_ _ _ __ _ _
_ __ . _
__ _ _ _ _ __ __. ___
_ _ _ _ _ _ :
. ___ _
e ,��m ,,� ��
�� ���� !� .
� � —� — —--
�� "��� '' "hM°', _ _
, � � ,
��� � �
��'� ��� _ _ _
� �� _ _ �
"� �� -
��:
_ _ _ _ __
� _
" �
pF�, _
�, �