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HomeMy WebLinkAbout15404 �.�. _� _ CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY dc DEVELOPMENT SERVICES 21660 E.Capley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRE$$ BUII.DING PERMIT APPLICATION FIRMLY, o ADDR S5 �oy3 �Z�3_.S<f�if/iP/�/LA�t/.E' pA�CATION � 6�_ NUMBER f� � ISSUE TYPE OCC APN LOT TRACT OATE CONSI: GROUP g OWNER Y / f� ADDRESS ZONING SETBACKS W CITY � ZIP TEL. R�RT RW O qpp{.ICqNT TEL. SIDE/SIDE STREET RW O CONTRACTOR SIDE ❑ g CITY�Y£��i/1��1�1 ' ZI �TEL� PROPOSE�USE � 8 ARCHlENG/ � � DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS �� STORIES BEDROOMS � CITY ZIP TEL. y DESCRtPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER$UILDER DECLARATION SFRIADDhiE�A O ' I MEi1EBY AFFlAY IRJDER PFNALTY OF PEiWf1Y THA7 I AM EXEMPT iROM THE CONTRI1C70RS LF Garege/Carport CENSEUWPORTNEFOLLONYNOREA60N�SE47W1.6BUSWE98ANDPROFESSIONSCODE:ANYCITYOR (n OOUNfYNh9O1REOUIFiESAPENAAlfTOCCXJSTRUCT.ILLTERIMPROVE,DENOl19M.ORREPAIRANY81Al1G W PHIIO/DBCI( TUqE PliqR iG RS IS9UANCE.N.90 REW IRE6 71iE APRICMlT F�i 8Upi PERMIT TO FIL&A 610NED BTATEAIENT 7HAT XE OR BHE IS 110EN5ED PURSUANT N THE PNOVISIONS OF TME COHTW1CfORS ll- � CENSE UW(O/AFfER Y(COAIMENdN01NI7H BECTION i0001 DF D�VISWN 7 OFTHE BUSINE53 AND PRO- � PooVSpa � FESSpNS OODq OR7iUT/ff OR SHE IS IXEMPT iHEREiROAI AND TME BASIS FOR 7NE I�LLEOED E%EFAP- TqN.ANVVqLATqNOFBECT10N70f1.6BYANYAPP�ICAFITFOiIAVERMR6UBJECTSTHEAVDL16U1TT0 z �-Rppf � ACML►ENhL7Y OF NOT MORE 71MN FPIE HUNDRED OOLLFRS{tsoD�J: ❑4KOMINEROF7NEPilOPER7'I.OHMVEMPLOYEE9WI7HWAOESA57HEIR50LECOMPENSATqN, � �mmerGal W0.100 THE N/ORK AND iT1E 9TRUCTUflE IS NDT IMENDEO OR OFFEHED FOR SALE(8EC.90�I.BUeI- J NESS MW PROFESSIONS CODE:TXE CONTRACTORS LIGENSE UW OOES MOT MPLY TO AN OWNER OF � PpOPEATYWFIOBUIDSORIMPROVESTHEREON.ANDWFi000ES8UCHWORKNIM9ELFORHER50.FOR = � TMi1d10H Iq5 OR NER OWN EYPIAYfeES,PROVIDED TNAT SUCFI W PROVFMFNTSAItE NOT INTEN�EOOR m OFFEqEO WHBAI.E IF,IIOWEVE0.TME BUIIDINOOR IMPROVE4IENT IS SOLD WffXINONE YEAR OF WYPLE- TION,THE OMIIiER�BUILDER WILL iIAVE TME BURDEN OF PqOVINO h1A7 HE OA 511E 010 NOT BUIID OR � MFi10VEFq1THEPURPO6EOF8AlE1.; ' �i,AS OWNEROF THE PROPER7V.AM EXCLUSNELY CWRRAC7ING NA7F1 LICENSED CONfRACTORB TO OOIYS1RUCf TT1E►RWEGT(bEC.Td1,BV91NE93 AND►ROFE9910H5 CO�E:TNE GONiRACTOPS LI- VBIU8SIIX1 ADJ.AREA CENSE LAW OOES NDT APPLYTO Ml OWI4EN OF A PROPER7Y MIFIO BUILD9 OR IMPROVES THEREON.ANO WFIOOONTAACi8FORSUCNPRWECT3WITHACON�MCTDR(9)LICENSEDPURSUIMTOTMECONTRAG pUANTI DESCRIPTION FEE � TORS L10ENfiE IAW.I. . O I AM E%EMPT IMUER 8EQ d i P.G FOR TXIS flE11SqJ � U K �=' DATE ONRIER V ����qqq UCENSED CONTAACTORS OECLARATION W � I IIERFHY AFFIRIA 11NDEH VENALTY OF PERIURY TFUU INA UCENSED UNDER PROVISIONS OF CHAPTER Ur ��COYMENCINO W7fN SECTqN 7nao)OP�iVI510N 10F THE BUSWESS ANO PROFE5510N5 COOE,AND Z !C W LICENSE IS IN FUl iORCE ANO EFFECT. _ � LLJ � � LICENSE CLAS LIC.NO. � O� � p�►7� CONTRACTOR a WORKERS'COMPENSATIONDEC ION � ND N 1 HEREBY�IFFl WA UNDER iENALTY OF PEiUURY ONE OF THE FOLLO 0 DECLAFiAT10N5: U y Z Q � _I NAVE AND WILL IMBITNN ACERTIFICATE OF CONSENTTO BELFIN6URE FOR WORKERS' _ OOIADFNSATpN,ABOqOVIDEDBVSECTION�7ooOf-TMEI.ABORCOOE.f9RTHEPERFOXMANCE W OFTHE WORK FOR WHICN iH18 PERMIT IB ISSUEo. � G 4 _IMAVEANOWILLM/JMI1W WOW(ERS'COMPEN511TqNIMSUMNCE,A5RE0U1REDBYSECTION 97oD OF 7/iE LA90R OODE.FOII TFIE PERFORMMICE OF THE WORN iDR WMICH iHIS PERMIT IS Q ISSUE0.YY WOFKER'IX�MPEN9ATION INSUfUNCE GR0.1ER AND OOLICY NlIM9ER ME: G RUC N �,��� _ �� �{'� j CMqIER.l._` �� LI Pl � POIICYNUTAeER \]� v ELECTRIC � (iM6SEOTqNNEEaNOfB[Od,PLETmOF7FfPERMi�Bw�ataE�FiEDWllAftsR�W1�l.ESs1 PLUMBING � 1 CERTIFY TMT IN TNE PERFOP/AANCE OF 7NE YNORK FOR WFIICH THIS GEIWiT IS ISSI/ED.I MECHANICAL �' SHALLNOTEMPIAYANYPEH50NNAHYNANNEHSOASTOBECdAE6UBJECTMTHE � WOAKEh3'COMPENSATqNLAWSOFCALIFORNIAANDAOREETHATIFIBMOt1lABECOME <It��FEE S 8l�.lECTNiHE1YORKERS'COMPENSATqNiROVI510NSOFSECTqN�7ooOFINELA80R � ��� CODE.I SFWL FOFTMMiH COAAPIY WITH THOSE 7ROVIS10N5. � O I � ppTE: APPLICANT: � - � � ENERGY P!C WARNIN�:FAILUflE TOSECURE WORKEAS'CGdPENSATION COVERAOE IS UNUWFIA,AND 8F4LLLBE � SUBJECTMlEMPLOYEXTOCRIMINALPENJLLTIE9ANDCIVILFWESUPTOONEMUNDREDh10U5AND ENERGYPERMIT DOLLARS It100.000).Nl ADDITION TD THE COST OF COMPENSAipN,DAMAGES AS PROVIDED PDR IN � SEC710N91aOF7MEUBORCOOE.IN7ERE5LAN��iTORNEY5FEE3. RETENTIONFEE: CONSTRUCTION LENDING AGENCY pRE-AlT FEE: � IHEREBVAFFIRMUNDEHPENALNOFPERA1RY711ATTNEREIS�lCONSTRUGTIONIENDINGIWENCV FOR 7NE PEHFONMANCE OF TXE WORK FO�R/WIHICH THIS GERAII7IS ISSUEU(SEG.30W,GIK G1. � I.ENDER'S WIME �����r� � LENOER'SA�DRESS � ICEATIFY7HATINMlEREADiNISAPPLICATIONANDSTATETWITTHEABOYEINFORMATpNIBCORRECT. TOTAL FEES IlW REE TO COMPIY N7TN ALL CIT'MD COUN7Y ORDINANCES AND 37117E lAWS NEUTMfi TO BULDINO � CONSTRUCiION,AND HER�V AUTFIDRIZE REPRESENTATNES OF1}IIS COUNTV 70 ENTER UPON 7HE ABOYE-ME EO iROPERTY FOR INSPECTION Ml OSES. / CpMMENTS � � �. � 4 PERMR7EE , N � � RE ATE � RECPT,NO. PAID BY VALIDATION WHITE—Depenmenl Capy,YELLOW�Inence Copy.PINK—Assessar Gopy,GOLDENROD—Fle Copy,GREEN—AppllceM' Copy „ ...„ :.. ,.-..., •r� ......vw:,�..,,..�,. ...,.,.,,.�:•::,��,, ,....,... . .. . .,i . . . . � . .i. , ,r . . ' �; � . �. . . - .. . .. .. r... . . .. .. ... . ... �i � . . �i , , CITY OF DI�WiONQ B�4R .�.dc.� rr. Ihd�PECTiOh� RECORD �"�'” . .���.M. . ,,..wA. 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