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HomeMy WebLinkAbout15681 CITY OF DIAMOND BAR � -- -- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �v Zi�o s.c���y nr;.�s��i90 PRESS � (909)860-3193 Fax(909)861-3117 �'���� BUQ.DING YERMIT APPLICATION FIRMLY o DDRIESS O� L DATEICATION � ' � Q� NUMB R� � �1�p0 � � ISSUE "�'� TYPE ' . aCC APN LOT TRACT DATE CONST. GROUP � OWNER -,�j'JFL._rYl Q.�'� "��i// VJ14�1I�. � ADDRESS1���L�i'�' L.iI . T�(3 ZONING SETBACKS CITY ZIP�,�'�'L.��o►�o?Z REART RW ❑❑ APPLICANT TEL. SIDElSIDE STREET RW � CONTRACTOR SIDE ❑ g ADDRESS pqOPOSED USE �;i��t': „ �-__ ���-� CITY 'LIP TEL.�s��� � ARCWENG/ . � DESIGNER ` � � NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP , TEL. y DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFq/ADD/REM O 1 F�flEBV AFFlRNI UNDER PENALTY OF iERIURV THAT��M E%EMP7 FAOM TME CONTNACTORS L�- G0Kgg1C8fppK CENSEIAWfOR7XEFOLLOW�NGNEASON(SEC.70.91.6BUSINESSANDPROFESSIONSCOOE:ANYCIIYOR (J) OpUNTYWFi1CNItE0U1RESAVERAIRTOCONSTRUCT.ALTE0.�PROYE,DEMOLISH,OHNEPNRANVSTRUG W P0�1 6Ck lUi1E,iRldi TD RS ISSUANCE ALSO NEOl1WE9 7HE AGPLICANT FOR SUOi PERLI�T TO FILE A SIONED. . W MATEMENT TFIAT HE OR SHE 18 IICENSEU PURSUMR TO 1'/1E PROVISIONS OF T!E OONTMCTOii3 U• CElSE LAW(CFIAPTER�(COMMENCINa WRH SECTION 1aoo7 UF ONISION f OF TNF BUSINE59 ANO PRO� u' Dfl FE59qNb COOE�OR THAT HE OR 9HE IS E%EA�T THEREFHOM AND THE 0ASI5 FOR THE N1EDE0 ENEMP-. 7qN,ANYYqLATIONOFBECTION7091.6BYNY'/MPLIGANTFORAPERMIT8U61ECTSTHEMPLICANTTO Z qe-poo� �„_ A CML VENALTY OF NOT MDFlE 7W W iNE MUNDHED DOLURS(i600).�: _ O 01.1150MRIEROFTFIEPROPERTI',ORMYEMPLOYFESWITNWAOESA5711EIRSOLECOMPENSATqN, � ❑ CDttIT91C181 � MALL OO iNE WORK,ANO THE 6TRl1CILRE IS NOT MRENJED OR OffERED FOR 5ALE(SEC.1Wr,BUSh J NE65 AND PROFESSIONS WDE THE CONTMC70F15 IICENSE lAW OOES NOT APGLY TO AN WNNER OF � � PRDPERTNYYFiOSUIIDSORIMPIbVEBTHEREON.ANOWVqO0E56UCHVAOHKMIMSELFOpH�RSELFOR Q 1HqO1qHH50RHERONMEMMOYEES,iAWIDEDTN78UCNIMPROVEMENTSMENOTINTENDFDOp m OOFFEREDFOASALEIF,HOWEVEILTHEBUROINOORMPROVEMENfW60LDVRR�NdJEYEAROFOOMPLE- � 1K7N,711E OWNER�BUIDER N7LL MAYE TFIE BURDEN OF PROV WO THAT HE OR BHE DIO!qT BURD QR YVROVE fOR TME RJFlPOSE OF 6ALEL � ❑I.ABOWNEROFTHEPROPERT7,AIAE%ClUSiVEl1'CON7N�CTINOWRHLICENSEDCON7MCrORS TO CON6TRUCT TME iR0.1ECT ISEG 70N,BU61NE55 AND PROFESSIONS CODE:THE CONTMCTONS ll• V81U8I1011 G ADJ.AREA CB1SE LAW OOES NOT MPLY TO AN OWNER OF AGPOPEHTY WHO BUILDS OR IMPROYE9 TNEREON,►ND 1NpCpNTqACTeFOq&1CHPROJECTSWITH�OOHfRACTOR(S�LICENSEDPUR3UANTTOTMEOONiMG • QUANT DESCRIPTION FEE � TORSl10ENSEUW.�. '� O 1 MI IXEMPT UNDER 8EG B.i P.Q FOR TilS REASON U 's u' D117E OWNER V � LICENSED CONTRACTORS DECLARATION � � W IHEREBYAFFlWAIRIDENVENALNOFPEIWHYTHAT�AMUCEN6EDUN�ERPROVISIDNSOFCHAPTER � � �(CO►YAENCING WRM BECTION 7000)OF DM910N e OF THE BUSINE39 ANO PROFESSIqJS CODE,AND Z X YY UCENSE IS N F11LL FORCE Mq EFFEC7. m LL g � UCEN3E S Llc.NO. Z- �+ � �" J a�� coNrrac�roR O a WORKERS'COMPENSATION�ECURATION � � I MEiIEBY AFFIIW t1N�ER PENALTY OF PEfUUHY ONE OF THE FOLLOWING OECLARATIONS: Z ,. , C _IHAVEANCWILLMNNTNNACERf�FICATEOFCON6ENTTOBELF-INSUREFORWORKERS' � • ' • � OWIPEHSA710N,ASVROVIDE�BYSEC710N7/OOOFTIIELABORCODE,FORTHEPERFORMMICE C� OF 1F1E WDRK FOR 1NHICH h115 PERAl1T IS ISSUEU. LL' � �I HAVE AND WILL YAIMAMI WOPKERS'OOMPENSATION INSURANCE,AS REWIREO BV 9ECTqN � 3700OF7NE 1A90R C�DE.FOHTME PERFORMANCE OF 7NE WORK WR MMICH 1HIS PEAMI7IS ISSUED.MYMORKERS'WASPENSATIONINSURANCECARRIERANDPOLICYNUMBER�RE: CONSTRUCTION � �� � CARRIER��A'�� • �fJ II�R . PLAN REVIEW � POLICYNUMBER � ELECTRIC '' p (MssECOp+NE�ha7BEad.sLEIFDOFnEPEFlMr6P0aoNEHUrnfiE000uArLsRlao�aaLEss? PLUMBING .�.� , NE Z 1 CERTIFVTNAT IN 1HE PERFORMANCE OF 7HE WORN FOR WHlpi TNIS PEFlMIT IS ISSUED,I MECHANICAL (� SHALLNOTEMPLOYANYVERSONNIWYMANNERSOASTOBEGOMfE5l1BJECTTOTHE , � MIORKEAS'COUPENSATqNUW50FCALIFORN10.M10AGREETHATIFI6HOUlDBECOME WSPEGTIONFEE w � S SUBJEC7i01HEYYORKERS'CONP[N3ATIONPROVISIONSOFSEC710N770oOFh1ELABOR ISSUANCE llrT 'I LQ �f11h� � CODE,I SHALL WFihM/1TH CONPLY WIiH TMO6E PROVISIONS. 0 SMIP �ll U � p pATE: APPLICANT: �n. W ENERGV P/C —�"i C�F DJAMC)Nb bAk WAFNINO:FMLURETOSECUREwORKER3'CAMPENSA7qNCOVERAGE1SUNlAWFUL.IWD9NKLBE JILDIN�AND 5�F'�'T"y � BUBJECTNIEMPLOVERTOCRIMINALPENALTESANOCIVILFWESUPTOpJEHUNDREDTHOUSIWD ENERCiYPERMIT � WU�RS({tOD,OOG�,N�DDfl70NTOTHE COSTOF COMPENSATION,CAMAOE6 AS VROVIUED FOR IH ¢ BE4TIONl70lOFTMELABORCODE,INTEHEST,ANDATTOFWEYSFEES. RE7ENTIONFEE: r d CONSTRUCTION LENDING AGENCY PR LT E: O � 1 XEREBVAFflqM UNOER PENALTY OF PEfiIURY iHAT THEHE IS A CONSTRUCTION IENDWG AOENCV 2 PoR iNE iERFOFMANCE OF TME WORK FOR WHltli THIS PERM�T�S ISSUED(SEC.loY7,CIV.C.�. W � LENDER'S NAME � LEImEH'SADDRE35 � � ICERTIFT7NATIWNEREADTHISAPiLICATqNAND9TATETHATTiEABOVEINFORMAT10NiSCARRECT. TOTAL FEES d I�GREE TO CAMPLY NATH ALL GTY AND COUMY OFiDINANCES ANO STATE lAW3 PELATINO TO BUILGINO CONSTRUCTION,AND HEHEBY MRHORIZE REPRESENTATIYES OF i1i15 COl1N7Y TO ENTER UPON ME S�i ABOVE�MEH7qNEDVROPERTV WRINSPECTqNPURPOSES. � EMS 5 �' �� m PE0.MITTEE NAIAE RINn Q � � � &GNANRE oF PERMI7TEE DA7E � .. �, p Cf RECPT.NO. PAID BY VALIDATION WHITE-0epartment Copy. 'LL inence Copy,PINK—Aasesaor Copy,GOLDENR06-file Copy,GHEEN--Applicanl's Copy � CiTY aF DfAI'tJEt)ND B�,F . � • It�v�PECTIQ� RECOE�C'� .. r��a�'�.�°1�'_ � ��' � ���„-'``�� �.�' ���;���,`- .. ..��� ,-����`r'�t��.� ,... _,, .. �. .., , . . 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