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HomeMy WebLinkAbout13980 (25) �� _ CITY OF DIAMOND BAR ; DEPARTMENT OF COMMtIHITY dc DEVELOPMENT SERVICES 21660 E.Copley Drivo Suite 190 (909)860-3195 Fax(9Q9)861-31t7 PRESS '�°� BUII.DING PERMIT APPLICATION FIRMLY N JOBSITE r APPLICATION PERMIT P/C -o�r � ADDRESS�,,S3S Rc.l Yl-� C�. D �. DATE � �NUMBE � �/`� � APN LOT � TRACT S �--2 �SSUE , T�nrPe occ � —�-+- � DATE CONST. GROUP OWNER L.► o�. ADDRESS ZONING $EBACKS CITY � IP 9/� TEL — FRONT RW O APPLICANT TEL. REAR ❑ SIDEISIQE STREET RW p CONTRACTOR SIDE ❑ g ADDRESS PROPOSED USE �_�'���c� Cvv�- - CITY 21P TEL � ARCWENG/ ��p� DES�GNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. �n pESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANAlUAT10N Q OWNER-BUILDER DECLARATION SFRlAOD/FEM O I IIEREBV AFFIfW INVDER PENAL7Y OF PERAIRY TW,T I M/EXEMP7 FRON 711E CONTMCTORS U- GBfBQB/C81pOR CENSEUWPoRiHEPoLLOWNOREA90N(SEC.70.17.68USINESSANCPROFE5510NSCOOE:ANYpTYOp (n CO(plTtWMIGiREaARESAPFAA1R1000N5TAVC7.ALTERMPROYE.DEMOUSM,ORHEPNRM1Y8iRUC• W P81bNBCk NRE,VRIOR TO R'8 R9WNCE,AL30 ilEOUIqES THE APPLM.hNT FOR SUCH PERMIT M FIIE A SbNEO W RATEMENT'M�T ME�R 3ME IS LICENSED PURSUANT TO TMff Pf10VISIONS OF TME CONTRNGTOHS U- CENSE LAW(CXAGTEN i(CdIMENCNIO N1TH 9ECTION tnm�OF DMSION 7 OF THE B113 W E93 AN�Pq0• LL' Pool/Spa FE88pN5 OOOE)Op TNAf XE OR BHE IS IXEMPT 7HEREFROM M1D THE BASIB WR THE ALLEOEO EXEMP- TqN.ANYV10lAT10NOF8ECTIONToe1.6BYANYMPl1GMIfFOHAPERMITSU9JEC75TNE�PYLICAN7T0 Z Re•Haof 1„� AdV4.PENALT'OF NOT IIORE TiAN FNE NUNDpED DOLURS(f60o�.): � � OI,ASOVAIEROFTHEPROPER7Y,OR►IYEMPLOVEESWITHWA6E6A9iHEIqSOLECOMPENSATION, C01flrtIBfClfll � N7LL DO 7lIE WOFK,MIO THE STRUCTURE IS NOT INTENOED pR OFFEHEO FOR SALE(SEC.70H.BU51- � IESS AND PROFES$IONS OODE:TN[CdJTMCT00.5 LICENSE UW DOES NOT AOPLY TO/JJ OWNER OF ? VROPERTY YNqBUI{D9 OR MPROVE9 71iEREON,MJD 1Ni0 DOES&Upi WORK HIM9ELF OR HER6ELFOR � TNIIOUOMNISOqNEA�NEMPLOTEE9.GROYtDEOTWITSUCMMPROVEMENTBIIRENOiINTENpmpp � Cd OFFERED WN BALE IF,FION�E1fEiLTHE BUILdNQ 011 MPiqVEMENT 1S 60lDMAiNIN dJE YEIIROF CaMVtE- TqN,h1E OWHER�UILDER WiLL HAYE THE BURDEN OF PROVINO THAT HE OR SHE�ID H�T BURG OR 111PROVE FlOiR TNE Pl1NPOSE OF SALEF �y OI,ASOWNEROFTMEPROPER�Y.AME%d.U51VELYCONTMCTINOWINIICENSEDCONTMCfOR3 � TO CONGTIRICT TME Pip.1EC7(8E0.7W�.BU91NE59 AND VI�FESSIONS CODE:7HE CONTRAClOR9 LI• �/eWet1011 ADJ.AREA CENSE IANf DOES PpTMPLY TOAN ONMER OF A PpOPERTY WMO BUILDS OH YAPHOYES THEREON.AND WVqCOMAACTBWHSUCHPRO,IFCTBWITHAOONfRACTORI3ILICEN6EDPUR5W1M70h1ECONTMC pUpNTITY DESCRIPTION � FEE � TCRS UCQlSE LAW.�. . . O I AM E%EA/PT UNDER BEC. &i P.C.PoR THIS PEASON � U 1� • � • DATE � OWNEP � � UCENSED CONTRACTO S DECLARATION —� � w � IMEREOVAFFIRAIUNOEHPENILLTVOFPE0.IURYTIiATIMIIJCENSEDUrAENPNOYISIONSOFCHAPTEF � �(COMYENCWOVA7NSECTIONTOOO�OFDIVISIONeOFTHEBUSINESSANDPROFES510N5CODE.NlD Z MY tICENSE IS M FUl FOHCE AND EFFEGT. � � LICENSE CUSS LIC.NO. � � DATE CONTRACiOfl a � WORKERS'COMPENSATION DECLARATION a � INEHE6YAFFl1IAIUNDERPEWLL7YOFPERJURVdJEOFTHEFOLLOWINGDECU�MTpNS: � • Z , , � �IXAVEANDN7LLMAINTAWACEiRIFIGTEOFCONSENTTO6ELNNSUREFORWOqKERS' a � GOYPENWTqN,l18PROVIDEDBYSECTION97000FTHELABORCO�E,FORTHEVEPFORMANCE � ' OF7HE WORK FOR NMItl1 THI9 PERMI7181SSUED. � B{- _IIIAVEMIDM7LLMAIHTMIMlOFKERS'COMPENSIITIONINSURANCE,ASFlEWIREDBY8ECT10N f � Q 77000F TNE LA60R CODE.FORTME PERfORMNlCE OF THE WORI(FOR WHICMTHIS PERMIT 19 . L Y 6SVEU.MY NVR7�AS'CONPENSATqN IN3l1RANCE CARRIEH M1U POUCY NUMBER ME: CON$TAUCT�ON � c�aaiEn PUW REVIEW X/��'s�' '��� � ��YN��R ELECTRIC 1 1 1J� i `� � (n�ss�qNr€�r�oieEcv.eiErmact�PEA+rrsw�ove�+EoOawwsRtrolaqtF55F PLUMBING Z 1 CEHi1FYTIMT IN iHE PERFURMANCE OF TME WORK FOR WF11G71 THIS PERMIT IS ISSUED,I MECHANICAL (� 91�LlNOTEMPLOVANVPER50NINANY4ANNER50A3TOBECOMESUBJEC7707HE (p M'ORKER9'GMIPENS�TIONUWSOFCAUFORNItiANDACiREETHATIFI81i0ULDBFCOA�E INSPECTION FEE S BUBJECTTOiHEWORKERS'COMPENSATIONPROVISqN50F5ECTWN37000FTHEUBOfl CODE,1 SNALL FORiNYVITH COMPLY W1TM 7}iOSE DiioV15iONS. ISSUANCE 1 O p DATE: APPL�GNT: SMIP r � WARNINO:FAILURETOSECUNEWORNERS'CAAIPENSA710NCAyERAGEISUNUWFUL,ANDSMALLBE ENERGYP/C �y SUBJECTANEMPLOYERTOCRIMiN�LPENALTIESANOCIVILFWESUPTOONEHUNOREDTHOU8AN0 �NERGYPERMIT DOLLAFlS(i1a0,000L W l�DDITION TO TiE COST OF CONPENSA7pN.DAMIIOES�13 PfWVIDE�FOR IN � SECTIONf7000FTHEUBORCODE.INTEREST,ANOATfORNEY'SFEES. RETENTIONFEE: �' OCANSTRUCTION LEN�ING AGENCV pRE•ALT FEE: � INERE6VAFFIRYUNOERPENALTVOFGERJUNYTFiATTHEfiEISACON5TNl1CTI0NLENDINGAOENCY .� Z FOfiTNE PERFORMMICE OF TNE WORK fOR WHICN TNIS PERA/R IS ISSUED(SEC.1oY],CIV.C.R 4J � LENOER'S NAME HS LENOER'SADONESS D w I�RTIFY iMAT I HME READ THIS APRIG1TqN AH�ST�TE 11NT TIIE ABOVE INF011MATION IS C011RECL TOTAL FE ES � � IAOHEETOCOMPLVWITFIALLCRVANOOOUMYORDINANCESANUSTATEUNSRELATINO70BULDINO � CONSiflUCT1IXy AND MEREBYAU7/K)RI2E REPRESEN7ATIVES OF T11S COVNTY70 EMER UPON THE ' hBOYEJ+IENTqNED YROFERTY FOq INSPECTpN PURP0.SES. COMMENTS � J m PEIWITTEENIWE IMn Q � N SKiNATU E F PERMI E DICfE RECPT.NO. PAID BY VALIDATON WHITE—DepammeM Copy,YELLOW--Finance Copy,PINK�1lsnesaor Copy,60LDENROD--FIb Cq�y.GREEN—ApplicanPs Copy . . . . . . � .. .. .ri. . . . .. � .. • . . . . . .. . - . . . . , . . . . . . ' .. y . �. � ... '�' - � . . ... 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