HomeMy WebLinkAbout16853 (37) CITY OF DIAMOND BAR r��' J
- DfiPARTMENT OF COMMIJNITY 8c DEVELOPMENT'SERVICES � ��
a . 216b0 E.Copley Drive Suite 190 • �la S S'��S
� (909)860-3195Fax(90�861-3117 �-Jc �J� PRESS
����'�� BUII,DTNG PERMIT APPLICATION � FIRML,Y
4� JOBSRE i APPWCATION ��' ��} AERMIT p/Cir,
ADDRESS } DATE � NUMBER�� # �� '��
$ • ISSUE �a TYPE O C
APN LOT RACT�,� �I � DATE � °i'� CONST. GRDUP
p OWNER •
LL ADDRESS ZONING: SETBACKS �' ' � �
w � FROI,yT _ � - . . .
� C1TY � ZIP . TEL. � REAR .. '� � ' RW ❑
� APPLICANT TEL. SIDE/SIDE STREEf Ryy �
CONTRACTOR C� � 'Yi A•� SIDE , �
ADDREBS r
' � � �P 'PROPQSED U5E s , �•. '
I Q �F.S G;:l'.R� V �''��� ' ' '
) •� ADDRE .N0.DWEL. NO. ' NO. :
�'� CITY IP TEL '� ��TS STORIES BEDROOMS
,� _ _
�� DESCRIPTION 5�.FT. ACTOR PSF ADJ:AR ' ALUATION
^O ' ' OVYNER-BUILDER DECLAFlATION
SFR/ADDlREM ,, , • ' �
I ;.0 1 H6iE8Y AFqqM VNp6R PENALTY OF PERJURY THAT I AM F7�dPi FROM THE CONIpACTOpS LF
j'� CQ'ISELAWPDR7MEFOLLOYVPN3REASON�5R'..7031.69U51NE5SANUPROFES510NSCADEANYCI7VOH � Garage�Caryort .. ' � �' .
'.COUNiIWHIdiREd11RBAPEBA7fTOCONSTRUCT,AITER�MPAOVE.DEMOLISH.OtiREPAIRANYSiRUQ !11 Patlo/Deck
�TUNE.�PRIONTURSIS6UANCE,ALSOHEqUiR�^�EAFPLICANiFORSUCHPERMiTTOFl�.EASIGNFD w �
� � STA7ENENT'IFIAT 1ff Oq SHE IS LIC�NSm PUR.4UqNi 70 THE PR0IIISIDWS OF THE CONTpAC70pS lJ•
,CEN5ELAW(CHAFTERO�COMAIENCIHP"tiMf1Fi'SECTKIN"/Oao�OFDMSION90FTNEBU51NE68ANUPFto- � �PooUSPa � , � �- ' ' ' -� ' ;
.FFSS�OMS�D�OpaHATHEORSHE19EX9�1PTTHEREFROMANDTIffBA315FORT1iEA�LEOEDIXEMP- ;,(� � i
•TpN.ANYVpLI�TIONOFSECTI0N703t.69YpNTAPRICpNTFOpAPEf�ARSIR,lECTSiHEAPPLICANTTO � Re-Roof
� ,ACNkDFNALTIOFNOTMOPETHANCI�EMUNbNEPpOLLMS(i600LY '' ' '- -
OG�ISONRIER�7HEPROPEfl'IYORMYBARLO EV E W17HWAGESqSTiEIR50LECOMPEN5ATI0N, Ct Commerc(al
;WLL O'd THE WOHK M9 THE STRUC7`URElS NOTIFTEFUED OR OFFEfiED FON SALE(SEQ 70u,BU51. �
� A�SS ANO PROFESSIONS COD�TNEG:OMMCfORS LICENSE GAW DOES NOT MPLY TO AN OWTIEH OF .-� . . .. � ,. ....� ,� ,.
'PROPEFjTYNtiOBUp.CSORIMPROVE5IHEREOy,ANDN7fOD0E65UCHWOHKHMSEIFOFNE(iS0.foq ' � ' '
� j� THRq1QHiqSOqF1ENOWNEUPLOXEES,AHDVI0m7Hl78UWIL�IiOVEMEMSARENOiINTENDE�oR m �
7�� ,',OFF6iWWN3AtEIF,FIOWEV�iHEBUlLpIN00RIMPEiOVEMfNtI550tDWITHlIONEVEAqOFCaMpIb ' Y �' .
� "fION.SHE OVYAIFhgUIIDER YnLL HAV�THE BUFiDEN OF PROVINa 7HA7 HE ON SHE DW NOT WRD OR
.� *IMPFIOYE�FOH7HEPUPPOSE�SAL�� . .
❑L A501NNBiOFTiE PROPEHIY.At1IXClU5NELY'CONfRACTINOIMTH 11cEN5E0 COIJTFACTORS
I Cr ,;f0 CON&TR�ICTSHE PRQ�ECT I5EG 7w4.B1191NE98 PND PROFE9SION3 COOE:hIE CDNiNACfOpS LJ• VHI118[i011 DJ.AREA -
Ill �CBi6EtAWDO6SNOTMPLYTOANOVtlNERAFAP,fPopEAiYWHO&1NDSOHIMPHOVE37HEHEDN,AND '
�MIO CONTAACTS FORSUCN PAdJECfS WRHACONTAIICTOR(�UCB�ISED PURSUANTTOT.IE WNTAAG
� ,tt3Asuca+sEuw.} �UANTfiY DESCRIPTION FEE �� ,
c
i D111MfXEMPTUNDERSEC. B.BP.C.FORTHISREA;ON Q . � j�„ �i. � ��
�� ' V' !
r�r�
� UATE ONNER 1'�' �� � '•; i
� UCENSED CONTFt4C'�ORS DECLAAATION � � �� a �
.L� i1HEFi�YAFFIRMlA�OEFiPENALTYOFPERIUpYhiAT1l�7.1t10ENSmLW�EflPROVISbN50FCHAPTER � �' _
' O_? G(QDMMBdCWQ WRH SEC710N 7ooD)OF UIVI&ION b OF THE BLISINESSAND PRDFESBIONS CODE.AND z Q . - .
�X� W UCENSE IS W FIAl FORCE AND EFFECL n
W% � . . r
���
br'�wENSE cu ; uc.rio.. � ` � y. ".
v o�'rE�` carrgncrort a _"�
, lJJ� .
�_ �� WORI�RS'COMPENSATION DECLAfaAT10N � � � ��
N,' IHErIEBYAFFIRNUl�ERPEWV.7YOFPERM1IRYONEOFTXEFOLLOWMGDECLAMTIONS Z ' �� , .`'`�'
��• �_I HAVE AND N7LL MAMT�q1 A CERTIFlCATE OF CpNSENTTO SELF.{µSURE FOR NApKEpS' SQQ ) ` f V
� GLYARENSATION�ASPRDYIDWBYSECTIa!l370oOF1HELABORCODEFOP�FiEPENFORMIWCE �U { QT�'" � �
. OF 1HE WORK FOR WHICH TTp4 PERMIT 6 ISSUED.
�: �
C __I FUVE AND N7LL MAIKTAIN 1YORKEA5 GOMPENSA7IDN INSURANGE,AS REi7UIHED BY SECiION ���,��
37000FTHELABOHCADE,FORTHEPERFORMANCEOFTHEWORKWAWHICH7HISPEHMfTIS
� 159UEQ MY KEFLSF rPF19AT�t INSU9�GRflR1ER MID P NUMBER E CONSTRUCTION [�
j• � cMPoEH T P PLAN REVIEW �J
� �•� vt�ant66����, � • ELECTRIC �
�': 6�j
r�rqrsEabsr.�maFtr�e�rr�sFa+cNEm�ronEaoouaRs(s�oqor+�ss1 PLUMBING _� ��
��� i cEar�v�et�1 m ttiE Pe
St1ALLNOTEMPLOYM'YPE�SONAINIINYNANN9i80A5TOe�CECOMEsue�Ec�rTon+��� MECHANICAL �y��
� NbRKEFlS'COMPENSA710NIAWSOfCAUFOAN1AvANDAGREE7HATIFISHpriDBECOME INSPE�T�ONFEE k
� SU&tECTTOTHEW6Fll�fi3'COMPENSATIONPROVISIONSOFSECTIIX7a7ooOfTHEtJ�BOfi
� �E.i '�wRrHvmii cor�+�x rnni rno e ramns ISSUANCE �g Q � �
�: �Y�--��- 3-�—�JE��� SMIP y� p �
p:.'OATE: APRiCANi: '"1 1.�W\/ �
w,r; ' ENERGY P/C � ; �
,J,.,WAfltUNG;FRILUJiE TO SECIiRF YiOAICE55 COA1P�15ATqN COVEHAOE IS UNIAWR)L AND SHALL BE r
SU6IECTAN EMPLOYER TO CRINIWIL PENALTIES AN�CNR FINES L1P TO Ot�HUNOREO 7HOlJSAIID
�-• ENERGYPERMIT C�� r'r
J •bOIURSjf1 ao,o0o�,Ml ADDRIQ�I TO THE COST Of COMPENSATION.DMAAOE6 AS PHOVIDEU FOfI IN
,.�y r SECTIOOV 37ot DF iNE LSBOR CO�E,INTEREST,PND ATYdHNEYS FEES " ��
, ��. . RETENTION FEE:� e
��� PRE-ALT FEE: '�
� CONS'fAUCriON LENDIN�AGENCY •
���IHEREBYAFFIRMU�AERPENAL7YOFPERIURYiTIhT7HEfiE15ACONSTqUC710NLENDMlGAOENCY `a � '
�.'.FORTiffPERFOFtMANCEOFTHEWORKF9qWHICH7T115PERyMyRI5155U�(SEG30B7,QV.G). r � �� ,s
,L';t i.�r,oExs wv�e.�tF1 1-i�—C►�L��'��k I f��-�'���----- —G � � ` . '',..• , , �
i:�noerrsnoon�ss . � ' o
C�� ' ��{y �
��''ICERi1FYTHATIHAVEREADiMSAPPUCAT101JAND5TATR,'TiIATTHEABOVEINF-0RMATIONISCORpECL TOTAL FEES � � � �1,, � ��
p�yIAOREETOCOA1p4YyYITHALLCII'YPNDCOLNTYORDiW11(CESANDSTATEUWSflEIATNGTOfiUIlA1N6 <3 1•,•'.�,.
���`C�NS7RUCTION,ANDNEflEBYpUTHOR�ZEREpqESE11TATNE50F'RiiSCOUN7YTOQrTERUPONTHE .
I���ENTION�PROPERTY FqR INSPEC7qN PUFiPOS�S. • ''i
�•'t COMMENTS - ^i" , �
:�.�,��1C'rl� �'�1t�� �
�:'� A , ;..
� r'. k
�::PEFWRTEENAMEIP __ ^ � ��
i�.-1= �
�i .�ry � ��
{n SIQNA7UflEOFPFAMfTTEE DATE ��, ,.,I
� RECPT.N0. PAI�BY_ VALIDA7ION
���'�� �t�.����a������ ������
� � � �����=.�'°����� �`��°�`�� .
. . � R .��4',i�. ^ .., . . ' ' . .
'y'.� '�t`::`c � .s;^ ^,+�,';."��,`,:`?'c`v�,"'=+',s'�'�;�'��i'�,'��¢'�"� ��„�.4�, i:
.^.i� '�'s_„�,.x�.�i :tir' � " �,�� !' t; �:u • i•w. .:��''�, i•t:.�, �' ,�� .i �
a�:�7.�;•- .4•�'r��.k: - ''•��'�rii... - �y.i�et':£2i.� `,�y�•k, ;e.S:��y..,,- •.* :a iM;�i'�`5.,�.y a+Y 9� d `�e"��. .Y� :ry��.
ti1:a..��.r:.� .?��r,'r�,... .. ..�j'i��..t�S .""�i,r:�'a,rs.�e�"dt'ns.ti w.�;'�..`l�'��'1�.:`....ia'f`���rTi'.i rrt'�s�ltriF:i�vy;+i.:�?=.R: , i+•• 2:': ri r�.b_j•• "'�''' '' �" ��
:'id.,7:r"a' r�^s`^»:��a�� ti•i=�i+ra�:ii::`�Ci�`�f.
"Y �;�'... .� � � . "'•_,J.�.��� .�.:�a:
���,�,,��(� / �^�g� .,...__„�,� _— - � �.....���. ._ .. - ..;_ J�I±� . . A�^�- . . •
"�,�i-?S:C�.ti"✓Y'!:Y��1cY`.`�Y`f;�.. S . � ��!1� t'"1..�',i��uF.M1+fll��v ' '� •_ .. � .. . i . . .. �.
E'� ��C�T�i?�'�=aFt�v�f��. , �_._��� ��+.i!`:�C3C�i F�.t`}{J;=i�Dt.+��f' � � ` �'�
P� �
�Fd�Ut`�L=ri_4.;PVia�P1G. ��2���^-. - t.}tu� :C.��R�LC���'C�.f�!G�;i1' I • ' , �
�
S!�.i'a�F�+�I:��. _._____ _{� �!?=i�F4..�,��:�Jt3i��ia.i ij�P�1 �_~_����� � _�
� ��A.�€�'F'Ctl«�'�� ...,.�. ' � .,.._:��_._ �L.t�"i�-�i�P��;�"v�•�'.+aJ"di.`�..�?�.t�,C4� i -`----- - ^ �
w "iN:�:i"�n����°�IR�:,c _____��{--- : ' � �,I i�!�i���d�J��.�� l , . ,
��C;F SHti,K�i�#t�l�:. . �t��.'"�":.... ..,���'z'.��"{�:��5�4�� ' . ;"_ }
; < :• '� '�'� �''�;�dj ; �; F��!�€..�u?�����:A��1 "V;�__� 1" . . g
�.....i ._���..:4..+' ' ' • �" y ' ' �_� ���_�1�i11.�`'..+�:4��`w^ � __.,_T.._—_____e.. ��
�����E�;€-4Et�'�"4F1Ca_' ____��-__�__� �r._____� i ��!ti1��.}�`�.. .. �`�� , �� - � '--�-----�
.+'�'. • , ' .__...� s !�'�iS�x1-!t��l��l�vC� ti i. . , • �
:; , . , . �� . . _ � � ` s=fi�a����ra€�;r�:� ; `�
��; _ � '', � � � - • , �'C��tL�LE�T�i� � j ._�����
��.7C1:L:t�l`#7r`.�1C�al�cx� � �_ �f�? •t" i t3t��r��'�Cifi�lG 1 ' � � � .� a
�y�3�s'�+L'n?��J't•�;�it�t�,�- ---�-�.� � r�'��.#3'�;�,4g_ ' �...,.._�
��v�'�3�i;i�S4,9'„�.�:t`t�t��� i _ _.___ Gr�S�'€'�i�itr"''S. ; � - • �
�t�'���'�k:�a�.t�.��ir�iCs i?�1�< �,C} �^ ��,,,��p��iC�1'��; "E ----�----�_ �`�
'� � � --�------•--. _ '
�F����? - - , " ..�l�,dA�k.��#�.=s. �T� 1 ' �
�,s�r������:�i� .- -� --� _ � �J�ha���:��'�IIP�41G. �� . ,, _.,,.�..
�,���P_�:�'��.�.. i i . '_-�-�-..___i Oi`1�1 i�?i��'�. ' -_.—_.�,._.�._._.......__.. �
;U��!�T'E y'$` � � _..._.__._..l� "'3T�1:�i.:t°+��!°�C T " ' f• �
�,_.a n�,�-;' , `_ ''��'"'"'�`�'�, < µ��Y��^r�cC UE��i'� ��iy�I,��, __.�..� �p
-,6-� �.��`���. . .`^� ' . __ ' { I �P
. � . `\,�� n 'rf•�,,.:�^ 4,�;e,�,;, .. � ; i'fi��������. 5'#�ar'�t�.. ....._........y'...,.._,,,_ � . � ' '
. . .. . i `� .E . � �)��r`.t'���'•'r�,4E'� j """'""`t"'..__._
. *T� ' ' ��
!`i.']ia'!i_��.�.:��'Gi�t.? � _' • : " `s,j i.:������f ��_-__...__._. �-....�. _�....
+.E._�....-- L� �.�.w,�..��_� -,._ ....- � .
�� .. . . „-- � , ~ , ^�-'-^--{} ' ;�a. �..�.. � t
_Y..�..�,�.�---.. � � _-�--�-----;---�- , :� � ,� �`h ------------�-- �.�
I:c:— , � _ -- � - �----__ _.- ,.________ _, _ - . . . . � --.J. f
. �,f � , !' i . . ;
�!�.�e��t�������__..__._�. _ , '. Y�.' . � -._. _ � �
� �.�.'a, �� � t . �
c ;,:'.;``"r.�.__„ -... . - • .' _._ "!
+ - - - — - ._..._�... � _...._i..::._.F
. � � I
�,_._� _ _.._....� ` ...._-�. �___._;.�-�
e. . . ' _ � . . J. , , � �� t
¢-�-.. ,r _ ...,..���_ —�.�_._��.. �.,—�, .�-�....{
�� ` _�� ...'.�._�_-....—_ . . . .�... --.-,-r,-..._ _... '"`""' , �
� , i{ _... _�.. �.-.�--..�.�..-..r--...W...+.......� � ' .. ��
��
��..,...�. � i - ._..� _� -' ...,._...,-�,..�-....—..._.-..,4.�._.._. ��—..,,--_....�--.«�.,..� -..,.....,. '}'__S
��,��s�"f,.��.��=�.F�E�i�%?� _ ' i �
�'�;�:_E��,�s-�ir�.�'��:'_'�;.____.._....._.__. _'""""'..�_ : .�.. ..._.__ _.._._ .___ __.___.._ __ ._. _;�_�
,
���.. ;� f. �; . • ,�:•.,.:�� � '�: .______ —. .� _..�� �..�._..�_..., �.,,�,....____....___.._,_.�._..._._._______.._._._._._ _�
� '�,�,;wy..'�{:�.�:��'`�,�.��s;.., *,�V..`'¢y • . .:!�~ � ' ' ` �� ;
5 � 4'." �+�.;.•� ti• .,_.i_....,.J
�;.r�c:. r � .�.'y ti.�, ���. _� -�.-..,.. , .. _- . _._.. .-..�.,__...�,._�..�.,.._,..,,,_,...,,._
, 7 •j,�s��.},^�,n.:1.'e•�,• .'.:..i: •'��'' ! , � �
i �h�'iu'''�r. ,:F`l�:�i'.�fi;'s'.. . �� .�..... __�_ � --_-_._•__---�..�_.....-.-,�.__.. f
� :.r,.�: ' ..{,,.,;'; .;;....`,4 t !
',s'' :o.t�;:'�:':"LI: . -..i'.i ; �.� �.. _.._ I � i
• '.5, ' r: .�t�•�'•'� . • •'�. - _.._ _ ._._.� ...__�..—..�
. c'.:; yh ': ',i••y'r .i+i. •.y�1''. i r --9
..A}5 ����, '.?' ._� -_.._ ,
� .•i'*§'.t'i:� �,;, 'f,.ry}+��i•,}M�-.�' . _.-.�..._.,..__... _�,.�, ....w_,.._._e._, ......_..._ _..... ' . ._....._.�...�..--•--..�.--.i...y�
'A:�•';,r �_�,�+ ..r. +e �� µi' ----^ -- - ,._._____.____••. _ �_�` _._.,.._� ._.�_..�.`...._.�_.__�__..��....�....._ i ��
f i�": ..��, -..� �'a�. , .. . . „ ,. _____�.._._-_•• „ . ._._...._ .--, _�__�...�..,,--.- ._.,... .,.....—......__,._._.. ...._..-...._,...��.--_�
BIAMOXII BAR
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21660E. Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117 •e 14551 CS2,3a3K
PRESS
BUILDING PERMIT APPLICA
, _ . . . _
LIS . . ,
JOBSITE k i ev*k,..,,
ADDRESS kol\SV-4/j l lnt'D TiaNt t)
9
X
�
LL-c,
III
K ,
I APN LOT RACT 2,2A.177
ec
C)
a
a
z
&
co
ip . Ir.-Atip-Ir
OWNER illA i kir
ADDRESSrzavianctirckw----7a4 a
CITY Ite: ZIP I ' TELPIEntr ' P
APPUCANT "killtamtr-- TEL-wea-
CONTRACTOR
ADDRESS
CITY P
ARCHING/
DESIG 'O1, a
N:LER IL 4
•AIDDRE ArgilliKiiiMUTtiaWifirifaiP .1. --
CITYiiiraiiri ,•A A 'P._L,i^TEL-iriZMW'e,2.
- g -
en
cc
0
0
LLI
...m
9
hi
Z
44).
,EC
,LU
CI
X
EU
.CC
:LU
ci• ..
"AI
1=
c,
17•C',
0
J-LJ.
GI'.
cs.
W.
Q
.>'• '
ca.,
•".:
.a •
V.�J'
rri
1- 7
ILI
34-
13.174'
CL.
9.:
---_,-
..- 1
= 1 - OWNER-BUILDER DECLARATION
1-j:'.. I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS U-
C,1 co4SE LAW FORME FOLLOW11.44 REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
• ,COUNTY WHICH REOUIRESA PERMITTOCONSTRUCZALTEROMPROVE,DEMOUSH.OR REPAIR ANY STRUC,-
'TUBE. PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS UCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS U.
CENSE LAW(CHAPTER it(COMMENC)NSWITESECTICI0000)OF DIVISION 3 OF THE BUSINESS AND PRO-
'..FEstioNs CODE)OR MATHS ORSHE IS EXEMPTTHEREFROM AND THE BASIS FOR THE AU_EGED EXEMP-
,T10- N.ANY VIOUWION OF SECTION MHZ BY ANY APPLICANT FORA PERMIT SUBJECTS THE APPLICANT TO
A CIVIL; PENALTY OF NOT MORE THAN Prim HUNDRED pou.Ans($500).):
.- 0 L AS OWNER OFfHE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
:WILL DOME WORK,AND THE STRUCTURE IS NOVINTENDED OR OFFERED FOR SALE(SEC,7044, BUSI-
NESS AND PROFESSIONS CODE;THE CONTRACTORS UCENSE LAW DOES NOT APPLY TO AN OWNER OF
'PROPERTY WHO BUILDS OR IMAROVES.THEREON.AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS oR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
:,0)FFERED Foil EALE IF,HowEvER,THE MALMO ORIMPEOVEMENT ISSOLD WITHN oNE YEAR OF coMPLE-
• TION.THE OWNER-BUILDER WILL HAVE THE BORDEN OF PROVING THAT HE OR SHE DID NOT Butt)OR
IMPROVEFOR THE PURPOSE OF SALE).
' 0 I.As OWNER OF THE PROPERTY.AIA EXCLUSIVELYCONTRACTlNG WITH UCENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044. BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS U.
.CENSE LAVl DOES NOTAPPLY TO AN OWNEROFAP.FIOPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO 03NTRACTS FORSUCH PROJECTS WITH ACONTRACTOR(S)LICENSED PURSUANTTO THE CONTRAC-
TORS UCENSE LAW.).
' . . .
CI I Abl EXEMPT LANDER SEC. B.&P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEEEEW AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
0 (COMMENCING WITH SECTION Mc)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
' MY LICENSE IS IN FULL FORCE AND EFFECT.
. Mtge,
moue ctAq LIC. NO..
DATE coNTI3ticroct
55(-41 WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PEFUURY ONE OF THE FOLLOWING DECLARATIONS
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENTED SELF4NSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OS THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTMN WORKERS COMPENSATION INSURANCE,AS REQUIRED BY SECTlON
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT iS
ISSUED. MY k,ERS .•PENSA•..INSURANCF C.ARRIER AND P• NUMBER• E
PO j .1 •II/Pi 4:4 it- *Ii 0 #
CARRIER AI.A. . en
Y NUMBER •A 97 .A )2 ..-
t
NOTRE COWLETEDOFll-EPERMIT IS FOR CNE HUNDREDDOLLARS($10:00RLESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I
SHALI..NOT EMPLOY ANY PERSON IN ANY MANNER SOAS TO BECOME SUBJECT TO THE
WORKERS COMPENSATION LAWS OF CALIFORNIA-AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE.I FORTHWITH COMPLY WITH THOSER4 Cilrbine
DATE: APPLICANT: R.4.t 1,3
WARNING; FAILURE TO SECURE WORKERS COMPENSATION COVERAGE IS UNLAWRIL AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
• DOLLARS WI 00.000),SI ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN
SECTION 3700 OF THE LABOR CODE. INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
,I HEREBY AFFIRM UNDER PENALTY OF PEPLUM,THAT THERE IS A CONSTRUCTION LENDING AGENCY
•. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS pERMIT IS ISSUED(SEC. 307.CIV.C.).
•. LENDERS NAME Nont-(.plAii-t 1-1-orno)
J LENDER'S ADDRESS
iCERTIFY
y,,,.', „ TIFY THAT IHAVE READ THIS APPLICATIoN AND sTATETHAT THE ABOVE INFORMATION IS CORRECT.
_,. AGREE TO comply WITH ALL CT(AND COUNTY coloiNAItCES AND STATE LAWS RELATING TO BUILDING
..07:1 r CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATWES OF THIS COUNTY TO ENTER UPON THE
.... ABOVE-MENTIONED PROPERTY FQR INSPECTION PURPOSES.
kr, ...
1 3ocr Ai-am
.1. pEruarrEE NAME(P
SIGNATURE OF PERMITTEE DATE
.l..x.l FIIiMLY
APPLICATION 0 1 PERMIT it.4 OCC
DATE a-a- NUMBER I V„63 7-0/--(2-0--
c
ISSUE
DATE
/1_4' 4_,:/1.11-0 CON ST. GROUP
FRONT SEfBACKS
ZONING REAR -
SIDE/SIDE .. - RW 0
0
STREET
SIDE RW 0
. 0
• , PROPOSED
N0. 'UNITS USE N-SVL. „ .
DWEL.
N0. N0. -
STORIES BEDROOMS
• FT . ..
m . ADJ:AR. ALUATION
W Garage/Carport szammeimmei Ir10-91P;4
tu A. �
Li- DESCRIPTION SQ.
0
Z
E5 VI 111LWIrMinarBaril
-I ACTOR PSF
m
SFR/ADD/REM IarigThl
Patio/Deck
Pool/Spa . . - , .
Re-Roof . .-
Commercial --•
ValuationQeM DIAREA
FEE
QUANTITY DESCRIPTION IIIMKUNI,
%
--$
<
C.�
E
1,-
§ riir al ; (--
LU IIMMI M111.111111111
MEM e*a ..
IIMOVIMMIIIIIIIIIIIII II I,
IIREMMINIIIIIIIIII -
0
z
3-
Q_���
IMMUNE."...
Ile MIIIZZSIAINIINIIIIIIIIIIIIItiI L4.. 111
MOM
0
2
<
x
0
u.i
m ."-k) 4
I J7 1 t.00
i ialV
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SNIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FE E: . s'.\ PIO
OA•
11/935111A11.111111M- Slat li
, .OAIIIIIIWVPIMt;-vitIP N
Id 1111 f 111
1ST'S. s
•Y�
i-114C5I,OQA'
9111-10
)r-..Oik.ALI
aS.0 fQ.
W-114'31:
9 10_,
t_oTh4.3�.. no\ ..
TOTAL FEES
COMMENTS
RECPT N0. 14(, PAID BY )en. 1 t n VAI IDATICIM ,
- . 1 ..- .. .
,UNDER ' . .
FHA RECNITS . .
I • ... , . . '1 _ — .
- . I... UNDER FLOOR DUCT, 0 ' ...
E
FLOOR CONDUIT • I -1
LL_FTGS/FORNISiSTE-.EL _ - . ,
I FI EOTRIC GROUND 1
----7 . • i
GROUND PLUMBING
-21.-OC
1 .. ..
Si ABGPADP . F I RE PLACE :FOUNDATION- • .. . •
r ,,..-4If —
, 1 FIREPLAOE.-BOND BEAM .
F --- — 1
TMP POT2R
, EMiD HT. BOND BEAM • "
SERVICE . .. r- '
t_N_AT_E_R ... i /2"--74-bt
. 8 FT. BOND BEAM . J.- , . .
I ROOF SHEATHING t C . - . „ . ,
..i,... / .
'(.1.•:. 7 i ':' I *'. —_ FINAL BOND BE 1 , --,_:_
1 1 PRE-GRADING,---,--.
, _l. . 1 , I BENCH.IM"..*, .. • v
r--------,-,- ROUGH GRADING ...,,—.--..---1—::—.—,.......11
AQUI:Z*114tY111,4G -; . . , . '
I
i �„•��� • .
. .. , . • , I. .
. • .." • . 1
. . i FINK-3H GRADING, 1
t • I ,
IQ .
; .-- I POOL ELECTRI.O , . . .
fi,,*At ' 1
it
FICope—_,A1010*1�---- - POOL FENCING . . .
VEXT. LATH/SIDING
. . - .
-1
P00!...P+NAL . . , _i . -
,_•;
. . k
ONALL. INSULATIONL.L._
—ow '
........AM, ---- OFF SITE IMPS.
111,
S
'OF-ICING INSULATION
• —.. ..i. ..H
....1��� . . �
EQICATIONS . ,
1.0 'w
:DRYWALL?-4AILING "is,/pp
S
FINAL ENG. • i
rSEWER .
LANDSCAPEARRIG. . . .
• SEPTIC TANK
LiSEE—P.,ETlL.L. ON SITE IMPS. '
t ipAS.A4R IiEgif . ,
I FINAL ZONNG . '
12.,1_FE DEPT,FINAL 1
1 . 1 'cIrEALTH DEPT FINAL I
1 g.....r1E-E.Nr.. ,:): .. . . : . . ...,.......
„ � �
. . . . .. . , . ..
. . 11
i 0 I,• ' - . --.
1 • ; I
1
DEV. FEES PAD • I
.- • I
ENEP,GY i
.4.....
ivzINN PLI.-2MBING
1 *
I I 4 • .. 1 . I
. MilirMettill* .I'X; _ 1
't----- -----
��.-
1
• i
-,7;At.ENT8
SEPTic'TANK s17E SIZE
I "
ss
,
';•'s