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HomeMy WebLinkAbout10710 `� - - CITY OF DIAMOND BAR ,�` 1 COMMUNITY DEVELOPMENT DEPARTMENT �' •.,,.,� . 21660 E.Copley Drive Suite 190 i�, / PR ESS (909)860-3195 Fax(909)861-3117 ; � / '""" BUILDING PERMIT APPLICATION %" FIRMLY � } JOBSITE ^� � y�d � ..� p �� � �,p APPLICATION _. ,,� l?-� PERMIT f��/CI P/C o ADDRESS �1i���!'9 �l��/��d,.,,. ,�, ,F b DATE � NUMBER # � c� ISSUE NPE OCC APN LOT TRACT_ DATE CONST. GROUP � OWNER �d)'"r`; ' �r � �i7.sr: "i 'qtt : /�r.� �e�' i� ' � o ADDRESS�°�,���'-�' �:� i�/.�� �'�'`�` ZONING SETBACKS Z CITY� "f�t 'ri� ZIP 1 �1''�'�TEL.��i�p"�•./'N� FRONT RW I.I � A REAR f_1 o APPL CANT '" �- TEL. ���9 _M , "� :�7't-.�'�' SIDE/SIDE STREEi RW ❑_ m CONTRACTOR SIDE ❑ � � ADDRESS PROPOSED USE ��'��"` �� � CITY ZIP TEL. , � ��� oARCWENG/ � � z DESIGNER NO.DWEL. O. . ' a ADDRESS UNITS STOR�ES BEDROOMS � CITY ZIP__ TEL. � N DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � p� OWNER•BI:ILDER DECLARATION SFRIA�D/REM O 0 I HEREBY AFFIqM UNDEF PENALTV OF PER�URV THAT 1 AM EXEMPT FROM THE CANTRACTORS LI- G8f898IC8fpOfl W CEN5ELAWFOHTHE�OLLOWMGREASON(SEC.7031.SBUSINESSAN�PROFESSIONSCADE:ANYCITYOR (n U CWNTYWHICtiflEOUIRESAPERMITTOCANSTRUCT,ALTER,IMPflOVE,�EMOLI6H2ORREPAIfl�STRUC- W P8}IO/OBCk w TUHE.PRIOR TO ITS ISSUANCE,AL50 REWIflES THE APPLICANT FOR SUCH PEHMIT TO FILE/151GNE0 W � STATEMENT 7MqT HE OR SHL IS UCENSED PURSUANi TO THE PROVISIONS OF THE CONTMCTOR6lJ- � CENSE LAW(CHAPTER e(COMMENCING Wlhl SECTION 7000)OF�IVISION 3 OF THE BLISME35 ANU PN0. u' POOVSpO Q FESSIONSCODE)ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEQEDE%EMP- V TION.ANYVIOLAiIONOFSECTION7031.5BYpNYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO Re-Roof ,� � � R CI`�IL�NALTY OF NOT MOflE iHAN FIVE HUNDflED DOLLARS(SSOD),): � ��(SONMEROFTHEPROPEHTV.ORMYEMPLOYEESWITHWAGESASTHE�R50LECOMPENSATION, � COI11111BtCIaI Z Wlll/00 THE WORK.AND iHE STPUCTURE IS NOT IN7ENDE0 OR OFFEFED FOft SALE(SEC.701i,BUSI- J NESS AND PROFESSIONS CO�E THE CONTRACTORS UCENSE UW OOES NOT APPLY TO AN OWNER OF i � PRODERTYYMOBIlILD50flIMPROVESTNEREON,ANDYMObOE55UCHWOqKHIMSELFORHEHSELFOR m � � TMqOU6HH190RHEROWNEMPLOYEE3,PROVIOEDTHATSUCHIMPflOVEMENTSARENOTINTENDEDOR L1J OFFEHEDFORSALE.IF,HOWEVER,iHEBIJILOINGORIMPqOVEMENTISSOLDWITMINONEYEpROFCOMPLE- I Z TIDN,THE OWNER-BUILDER WILL HAVE THE BUflDEN OF PROVING THAT HE OR SHE DID NOT BUItD OR � IMPROVEFORTHEPUfiPOSEOFSALE). f�I,AS OWNER OF TME PROPEATY.AM E%CLUSIYELY CONTRACTING WITH ULENSED CONTRACTORS � TO CONSTRUCT THE PROJECT(SEC.70aa,BUSWE55 ANO PROFESSIONS CODE:THE CONTRACTOqS LI- V211181i011 � ADJ.AREA,_ W� CENSEIAWDOESNOTAPPLYTOANOWNEHOFAPFOPEHNWHOBUILOSORIMPFOVESTMEPEON,AND — F WHOCONTpACTSFORSUCH7ROJECTSWITHACONTRACTOR(S)LICENSEOPURSI1MlTTOTNECANTRAP QUANTITY DESCRIPTION FEE Y TOflS UCENSE LAW.). � J � ❑i AM EXEMPT UNDER SEC._________..._____.—__ B.8 P.Q FOfl THIS REASON U � �_— Q � �ATE ` OWNER_ �.�_ ,.,�—�S„�'��� V Z W � LICENSED CONTRACTORS DECLARATION �j ' � I HEAEBY AI'FIAA1 UNDER 9ENALTV OF DENURY TiiAT 1 AM LICEYSEO L'NDER PROVISIOh50FCMAPTER V. �� 9(COMMENqN6 WITH SECTION 7000)OF OIVI310N 30F THE BUSINESS 0.ND PflOFESSIONS CODE,AND z AIV I�CENSE IS IN Fl1ll FORC[AND EFfGCi. m V.1 �� LICENSE CUSS LIC.NO. � V DATE____�_..._,�_—_—_ GONiRACTOP a W � WORKERS'COMPENSATION DECLARATION Q � y U N I HEHEBY AfFIflM UN�ER PENALTY OF PERJURV ONE OF THE WLLOWING�ECLAFATIONS: Z Q � � _IHAVEANOWILLMAINTAINACEFTIFICATEOFGONSENTTO5ELF�INSUFEFORWORKERS' _ � 7-d- COMPENSATION,AS PflOVIDED BY SECTION 3)OOOF THE LABOR CODE,FOP THE PERFOIUAANCE W OF THE WORK FOR WHICH THIS PERAIIT IS ISSUED. � W ' I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSUMNCE,AS REOUIflEO 8Y SECTION .y ,�y Q �a�o00F THE LABOR CODE,FOR THE PERFORAIANCE OF 7HE WORK fOR WNICH THIS PERMIT IS �cr....l4' — "f��/ / � ' lSSUE�.AIY WDRKEPS'COMPENSATION INSURANCE CARRIEfl AND POLIGY NUMBEP ARE: ONST _�7 / � j CAFlRIER PLAN REVIEW _._ t ZraICYNUMBER______ — ELECTRIC _, � �iHISSECfIdJNE�NOTBE�TF110FTFEPERMRISFIXi�NEMY�DPED�OLIARS(5100)OFiLE5S1 PLUMBING 0 Z I CERTIFY THAT IN TF1E PERFORMANCE OF THE WOFK FOR WHICH iH15 PERMIT I6 ISSl/ED,1 MECHANICAL (,�J SNpLL NOT EM7LOY ANY 7ERSON IN ANY MANNER SOAS TO BECAME SUBJECT i0 THE - � WORKERS'GOMPENSATIONLAWSOFCRL�FOPNIA,ANDAGREETHATIFISki0ULO8ECOME �NSPECTIONFEE _ 9 � SUBJECT TO THE WORKENS'COIAPENSATION PROVISIONS OF SECTION 3100 OF THE 1A80fi �SS , • �, • � � CD�E,I SHALL FOF7lHWITH COMPLV WITH THOSE PROVISIONS. O �P n � , p DATE: .�_"_'_ APPUCANT: _.,______'�'--_"— — ' — w ENERGY P/C __,�•� p `� J WqRNING FAILURE 10 SECURE N'ORKEflS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALlBE y - �y SUBJECTANEMPLOYENTOCRIMINALPENALTIE5ANDGVILFINE5UPTDONEHUNOREDTHOIISPND ENERQYPERMIT � _ ODLLAFi5�5700.OW),INAODITIONTOTHECOSiOFCOMPENSATION,DAMROESA3PROVIDEDFOflIN -�— — �' SECibN37oeOFTHELABOqCODE,M1iEREST,ANDATfORNEV'SFEES. RETENTIONFEE: ___ d CONSTFUCTION LENDING AGENCY PqEALT FEE: k.�.� B'1 L� �Q�( 0 w .. aR .f �s:• � 1 HEPEBV AFFIRM UN�ER PENALTV OF PERJURY THAT TNERE IS ACONSTFlUCTION IENDING AGENCY FOR T11E PEFFOFMpNCEOF THE WORK FOR WHICN TH�S PERMIT IS ISSUED(SEC.3087,CIV.C.). Z W � LENDEH'SNAME —_� — __ F LENDER'SADOHE&S - w ICEHTiFVTHATIHAVEREAD7HI5APPLICA710NANOSTATETHA7THEABOVEINFORMATIONISCORRECT. TOTAL FEES ��� � d IFGflEETOCOMPLVWITi1ALlC17YANDCOUNTVORDINANCESANDSTATEUWSREUTINGTOBUNAING � CONSTRUCTION,AND HEREBYAUTHORIZE HEPRESEMATIVES OF THIS CWNTY TO EMEfi UPON TME Z ABOVE-MENTIONED PROPERTY FON INSPECTION PURPOSES. COMMENTS � i:� . ,�,�� p _ :°�� _ � • "n -" � PERMITTE�E�F�NT� � � 6 G � � .� �� I A. p_. = SIONA EOFPERIAIITEE DATE RECPT.NO. �PAID 8Y�'' �'� VALIDATION �^" ~ WHITE—De arlment Co YELLOW—Finance C py.GOLDENROD--File Copy,GREEN— p py, opy,PINK—Assessor Co Applicant's Copy .�, _�_._... �_ .__. -- �__�.....-. _ ._ , - � I i -__,..! � ._. _. 1 �- _____�.. � �_..__.�.�.'.�.� �_�_ �. .i' E. � uz c�i � g; { ��;-n•-n���-� �a en v� � c-�m,�n i� � � a -n 4�l g l-;I crx 71 m � .n �II �.�'it^.71 a � f I z�z!� � slm m r�ri�� rr�a Xi� �IOkG� Qi7o {'j� ItiS I�p��-' ry7 . :PYI"6� ,! � � - � I D�AiDID��d, fn ,T3 �� :�r -I�;J�C�CjC.�OiD ��� ��bfol'"1 G$i-i .. �-1� I ��� :i � � il ri Iri. �Df'� �� m � �� �-���GiI�C� -t � ��m v�ml � r;. . 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