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HomeMy WebLinkAbout14114 (29) CITY OF DIAMOND BAR � -- --- DEPARTMENT OF COMMUNITY&DEVELUPMENT SERVICES � . 21660 E.Copley Drive Suibe 190 (909)860-3195 Fax(909)861-3117 PRESS ��`�'�±� SiJQ.DING PERMIT APPLICATION FIRMLY JOBSITE �- APPLICATIO PERMIT P/C ���� o" �/�/Pi� / I 1 I �l ADDRESS � � DATE � NUMBER ` k � ISSUE TYPE C APN LOT TRACT DATE CONST. GROUP � OWNER � � �N��.L�- CLI�� ADORESS ZONING SETBACKS CITY ZIP TEL. FRONT RW ❑ APPLICANT TEL. REAR ❑ SIDElSIDE STREET RW ❑ CONTAACTOR D.r�u.�i c f},ur_ sc.�.ol,rl� SIDE ❑ g ADORESS �-- _�T PROPOSED USE ti/ �'�:`} I �+,_S (���C� CITY -�,-Tr/�r�Z- ZIP�1 TEL �� �- B ARCFVENG! � DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS CITY ZIP TEL. y pESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION �� ONMER-BUILDER DECLARATION SFFVADDIHEM 1 HEREBY AFFXOA UNDER PENALTY OF PERJUNY TFWT I AM EXQAPT FROM THE CONTrt4CTOH9 LI- G8I80�8�K CENSEUIWPORTNEfOLLOWINGNFA50N(SEC.70.71.68USINEeSANDPNOFES510NSCO�E:MIYGT'OR (n . COIAlttYNiIC11REWIRESAPERMR1000N57RUC7,ALTER�PROVE.�EMOUSH.�flflEPAIRANY8TRUC- W PB11dDBCk • .�� 7URE PR�OH N ITS 189UANCE.ALlO 1IECUIRES 7HE MPLICANT FOR 6UCM PERAl1T TO FILE A 61ONE0 BTATEMEM THAT HE OR SHE IS UCENSm PURSUANT TO 1TIE PROVISIONS OF THE COMTMCIORS ll- . CENSE UW�W�PTEFi Y(COMAI[NCWO YVITN 6ECTIDN 7000)OF OIVLSION�OF iHE BUSINESSAND Pib- LL PooUSpa FESSIONS OOOE)OR THAT ME ON SNE IS E%EMOT T/iEREFpOM AND 7HE BA315 FOR THE ALLEaEO EXE4P• iION.AN1'VqLA7qNOFSECTION7o37.6BVANYAPPLICANTF01tAPERMITSUBJECTS7HEMPUCN7TT0 Z Re-Roof ACIVIL VENKTY OF NOT MORE TIAN fNE HUNDRED DOLLJIH3(t5aq.�; OL�D�Mh�EROFTNEPROPERTY,ORIAYEMPLAYEESWITNWACiESA5TF1EIR80LECOMPENSATqN, COrtIRIBI'CI81 '�. WILL DD 7ME WORK AND TIiE STRUC7URE IS NOT IMENDEO OR OFFEREO FOR SALE(SEG.7W4,BUSI- � 1E33 AND YFqFESS10N5 OOOE:7ME CON7MCTOIiS LICENSE lAW DOES NDT MPLt TO AN OYYNEN OF � P1iOPEitiYYhiOBUlD30RMIPIiOVESTHEREON.AN�WF1000ESSUqiWORNFpYSELFpRHERSELFOR = � TNilOUGH MI6 OR YIEROWN EIAPLOYEES.iR0111DED 7W�T BIN�i MAVROVEMENTS�RE NOT NTENDED OR m OFFERED PORBALE IF.lIDNiEVEi�iMEBULdNAOR IMP110VEMBfT IS SOL04A7HINONE YEAR OFCOYPLE- TION.1}IE 01NNEREUILDER N7LL NAVE TNE 6URDHJ OF PFOVINO 1tIAT HE pR 8HE DID NOT BUIID OR MViqVE FOR 1HE PURP06E OF MLE). � �y 06ASONRIEROF7HEPROPENTKANFXClUSNEIYCONTMCTINOW1THlICEN5ED0ONTMCTORS . ' � TO CONS7RUGTTFIE iROJEGT(6EC.t0u,lUSINE35 AN�PROFE5910N5 GODE:THE COMRACTORS LI- VpW�tI0f1 �' ADJ.AREA CFNSE UW OOES NDT MPIY 70 AN OWNER OF A PItOVER7Y WFIO BUMS OR IMPfOVE9 TXEFlEON.AND mpconrnr.c�sronsucnvr�cTswrn+�ca+rw�cra+(s�uceNsmrimsuurtmn+eoa+rw� pUANTITY �ESCRIPTION FEE � TORS IICENSE IAW.). O I AM IXEYPT UNDER BEG 8.i P.C.iOR THIS RFASON U lL � DATE ONMER ' • V � LICENSED CONTRAC70RS DECLARATION w � I IIEHEBY AFFlHY UNDER PBIALTY OF PEFUURV THAT I M1 LICENSEO UNDER PROVISIONS OF CHAPTER � � �(C04MENCWOYVfTH8ECT10N7000�OfD�YIS10N90FTNEBUSINESSANDPROFES510NSC00E,AND Z �j� W UCENSE IS IN FLLL FORCE AND EFFECL � LICENSE CIJ.SS CZ,��I_ C���_LIC.NO. ? Z- /�+F�� � 1� �1 � � DATE / CONTRACTOR_�/ ��(�f�,� d WORKERS'COMPENSATION DECLARATION a � 1 HEREBY FlRM UNDEX PENALTY OF PERRIRY ONE Of THE PoLLOWINO DECLARATqN9: Z � _IWNEANOWA.LMANITAINACERTIFlCATEOFCONSENTTOSELF•INSUREFORWOFIKERS' _ Cd/PENSATION,A9 VROVIOED 6Y SECTION 370o OF THE I.ABOR COOE.Fdl THE PERFppNANCE �U OF7HE WOpK FOR WHICH TNI6 PEHMIT IS ISSUED. � � _I MAVE NYD WILL MAMI�MN WORKEFS'GOMPENSATION INSUMNCE,AS REW�RED BY 9ECTION �"� O 77000FTHE IABOR ODDE FORTHE DERFORMANCE OF THE WOHK PoH WHICHTHIS PERMR 18 /4 � � ISSUED.►IYWORKERS'COMPENSATqNINSURMICECARRIER.WDPOLICYNUMBERARE: CONSTRUCTION j'�'�— � / � CNViIER ��Ij'F� �_L(,/��(7 PLAN REVIEW � .+�Trl S ��� �' � ao��cr wuuaen ELECTRIC 0 5EC7ioNt�No7aeoa.w�FimaFn�a�rsr+o�aaeHna�noalu�sM�loFt�ss7 PLUMBING z I RTIFYTIAT M hIE VERFORMANCE OF THE WORK FOR WMICH 1HI5 PEP1.1�T IS ISSUED,1 MECHANICAL � NOT EMPLOY ANY VERSON W ANY MANNER 60 AS TO BECOME SUBJECT TO THE � KERS'CqAPEN511TpNUW90FCALIFORNIh��REET/NTIFIBFIWIDBECOME INSPECTIONFEE � U ECTTO7HEWORKER9'CqAPEN5A7qNPROV151ot1SOFSE� ON77000F1HEUBOR ^� , �� e,i sww, arr�win�cana�r rntr nase w�lSroHs. ISSUANCE S L p DATE: APPLICANT. `: . SMIP � T�� � WAPoYINO:FAILURE TO SECURE MNRKER9'COLIPENSATION OOVE I NUIWFVL,AND SHALL 8E ENEFiGY P/C �TmTY n�FT/D�l A M(�NTI$� �y BUBJECTANEMPW'lEHTOCRIMNALPENALTIESANDCMLFM/E PT EMUNUREDTFKK18MlD ENEfiGYPERMIT B{JJLDllVl7ANT�(���. OOI.LARS(t100.000),W AOOITION TO THE COST OF COMPENS�T N ES A9 PROVIOE�FOR IN k7f gf'�y�x� _�.1 SECTIOH37olOFTHELABORCO�E,INTERE5T.MI�ATTORN E5. RETENTIONFEE: � C "� Q���yyy 1 g. CONSTRUCTION LENDING AGENCY PqE•ALT FEE: , _,,,,� � � I FIEREBY AFFIRM UNOER PENALTY OF PERJURY TFIA7 THEHE IS A CONS7RUCTION LENOING AUENCV Z FORTHE PERFORMANCE OF THE WORK FOqNMICH THIS PERM�T IS ISSUED(SEG 70i7,qV.Q�. (�-s� W • � LElIDEN'SN4AE � LENDEIYSAODRE59 � ICERTIFY7HA71NAYENEADTNISAPPLICA7lONAN097A7E7MATTHE1190VEINFORM�TIONISODqRECL TOTAL FEES " r � 1 AOREE TO COMRY Wlhl ALL CRV ANO COl/NTV ORDWANCES AND STATE UN5 REUTINfi TO BUKDINO .�. �1 "� CONSiRUCTIdJ.AND MENEBY AUf/10RIZE REPRESENTATIYES OF 7HI5 COUHTY TO ENTEH UPON TNE � � ' � � C � � h90VE-MEMIONEO PROPERTY FOR INSPECTION 7l1HPOSES. COMMENTS '� '� �°�+`� � 1� �� _ m PERMITTEEwWE1PRINT� � Q � 81(iNATUREOFPERMI O�TE � RECPT,NO. PIUD BY VAtJDATION . WHITE—Depe�ment Copy.YELLOW-�Ine�ca Copy,PINK—Aaseasor Copy,GOLDENROD--Fi�e Copy.GREEN—ApplicenPs Copy �..w ... . .. . ,: - ..: .... . ... ...... , , � .. . .. �: �..:..n:�. . .. ,...�::.1.... ....�. . ... .,. . . . r .s�n �.'YY�1. n I • . � . �. i,.�... .. ...., cE�� t�F �a��r���� ���� �€�����.•�°��� ���ca�t� ; ,� . �- - $ � . �,. . � �y a;,e �g' �Y'el ' g k. + � .� ��t;,'� � . � ■ ��.:. 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