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HomeMy WebLinkAbout11825 � CITY OF DIAMOND BAR �,�;j -�---���' --- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES - ��/ 21660 E.Copley Drive Suite 190 �� PRESS (909)860-3195 Fax(909)861-3117 �� �'�•�� � BUILDING PERMIT APPLICATION FIRMLY � JOBSITE APPLICATION PERMIT J P/ �(�' o ADDRESS � �� � � � � DATE � NUMBER ! � # L {� y A ISSUE TYPE OCC � APN 7_�_.����LOT "�� TRACT�,1 I t3�"� DATE CONST. GROUP p OWNER ��Cs <+t ADDRESS �_'S�l�b r�'�'�lZi�.u(J_ I��__ ZONING SETBACKS � CITY�11�in'��"��� '$��ZIP�:S TEL.W�'] �Li-17'4? FRONT , RW rl � APPIICANT TEL. REAR ❑ � SIDE/SIDE STREET RW �7 d� CONTRACTaR�L�1�.�.� ������ SIDE u_ ADDRESS � �l1�!'1�f7 i�I�,(S i�k-��V �'� � 'pROPOSED IJSE t�'A1 N:? ��v��i � CITY C'hertz. 4ii�_ ZIPC�[ tJ'c TEL�'•1 � 2 OS w ARCWENG/ � WDESIGNER �AW�� NO.DWEL. NO. N0. a ADDRESS UNITS STORIES eEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION O� OWNER-BUILDERDECLARATION d�'�f SFR/ADDlREM p I BY AFFlpM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FHOM THE RACTOqS LI- Gaf0g8/Cerpod W CENSEU 1NEFOLI.OWINaflEASON(SEC.7C31.68USINE53ANOPFOFESSION L:ANYCRYOR U COUMYNMICFI IqESAPEfiM1TTOCONSTRUCT,ALTER.IMPROVE.�EMOL15 (iEVAIRANY5lRUG Pati DaC 1 W. 7URE.PRIOR TO IT UANCE,AL50 REWIRES THE APPLICANT FOR SUG RMIT TO FILE A SIGNED STATEMENf THAT HE O E IS LICEN5ED PURSUANT TO THE PROYISI OF THE CONiFlAC70R9 LI� � CENSE LAW(CFUP7Efl B( EkCWO WiTH SECTION 7000)OF DIYIS 9 OFTHE BUSINESS AND PR0- � POOVSPe " FESSIONSCOOE)OflTHATHEO HEI9EXEMPTTHEFEFHOMAND BASISFORTHEALLEG[DE%EMP- 'iION,ANYVIOLATIONOFSEC710N 1.SBVAHVAPPLICAN7FOqA°P[RMITSU&IECTS7HEAPPLICANTTO Z R8-ROOf r ACMIPENALiYOFNOTMORE11�M1 EHUNDREDDOLLARq(5500).): ❑I,ASOWNEROFTHEPROPERTY, MYEMPLOYEE,$iCqTHWAGE5A5TMEIR50L`cCOMFENSNTIOtJ, 0 CO(fIR18fClfi� �: VALLDO THE WORI(AND 7l1E STRl1CTUR NOT I FiDED OR OFFEflED FOF SALE(SEG.7040.9U51- J NE55 AND PROFESSION3 GODE:TNE COM LICENSE UW DOES NO7APPlYTO AN OWNF.R OF � DROpENTYWMOBUlD50flIMPROVESTHEHE DYMODOESSUCHWOfiKHIMSELFORHEFSELFpR ' � 7Hq0UGHH190RHEflOYMEMPLOVEES,P DED ATSUCHIMPROVEMENTSARENOTIN7ENDEOOR m L�7 ,UFFEAEbWNSl1LEIF.FIOWEVER7NE8 INOORIMP VEMENTISSOIDWITHINONEVEAROFCOMPIE- �i iqN,THE OWNER$U�LDER WILL H HE BURDEN OF OVING THAT H6 Oq SHE DID NOT BURD OH Z� IMPROVEFORTMEPURPOSEOF ). C71,1150WNEROFTHEP ERT',AMEXCLUSIVELYCONT TINGWIYHLIGENSEDCOhlfRACTORS �� TO CLJNSTRl1CT TH[PR0.1 (SEC.7aH,BUSINE55 M1D PROFE NS CODE:THE CONTflACTOflS LI� V8Iu8fI0f1 .�I�9C`!��" _ADJ.AREA___________ __ W CENSELAWDOESNOT LYTOANOWNEflOFAPFOPERTYNRiOBU SORIMPROVESTHEREON,AND � �HM1IOCONTMCTSF UCHPflOJECTSWITHACONTRACTOH�6�LICEN3 URSUANTTOTHECONTRAP QUANTITY DESCRIPTION FEE NRS LICENSE ! �� ❑� 6MPT UNDEfi SEC. __8.8 P.. THIS REASON U � p �` — — — pC li' E ,OWNEA _� __._..�� V Z W .� Q' LICENSEDCONTRACTORSDECLARATION W � 1 HEPEBV AFFIlOJ UNOEH PENALTYOF PERJUflY THA71 AM LICENSED UNDEfl PfiOVISIONSOF CHAPTEfl � �� B(COMMENCWOWITMSECTIONN00)OFDIYISION30FThIEBUSMESSANDPROFE5510NSC0�E,AN� Z _„ __� X', MYIICENSE IS IN FULL FORCEAND EFFECI m 0 UCENSE CUISS �� LIC.NO. �_I�`�✓�� _._.,y � 1-+ `y� W�� OATE la ___ CONiRACTOfl..-L���LL' G...C0�41 0. � WORKERS'COMPENSRTIONOECLARATION Qrc�X ¢ �; � � V �. IHEREBYqFfIRMUNDEHPENALTVOFPERIURYONEOFTHEFOLLOWINCOEClARA710NS: Qz � �'� IHAVEANDWILLMAINTAINACEflTIFlCATEOFCONSENTTOSELF-iNSL1RFGORWORKERS' S �� �COMPENSATION.ASPROVIDEOBYSEC710N77000FiHELABOqCODEFORTHEPERFORMANCE W OFTHE WOPK FOR WHICH'MIS PEflMI71S ISSUED. � W 4 ��/ IHAYERNDYfiLLMAIYfAINWOflKERS'COMVENSATIONINSUqANCF.,ASfiEWIREDBYSECtlO� 'I � } d aloa OF h1E LABOR CODE,FOR TF1E PERFOHMMICE Of THE WORK FOR WHICH THIS PERMI7IS ,` ���— 0' ISSUED.MYWORKERS'COMPENSATIONINSURANCECARPIERANUPOLICYNUMBERARE: CONSTRUCTION ,�J� C� Pl.AN REVIEW �,_���__.. �--- � CAflRIEFl���^- f � ---- ---- � POLICV NUMBER��q. � �- � — - ��� - ELEC7RIC , ___. , ._ ..._._ � p �TH44sEc'rnNNEmNJrBEmM°LefEUOFrriEaEf�M71SfoHHaJerarot7EooalAFls�$too)aaLEssp PLUMBING . ----- ------- .-- --- ZI CERTIFY THAT M THE PERFOFMANCE OF THE WORK FOA WHICH THIS PERMIT IS ISSUF.D,I MECHANICAL .,_, �__._,_,._ ._.__. _._ (,�J SMALLNOTEMPLOYANVPEflSONINANYMANNEflSOASTOBECOME�IBJECTiO7HE y WOHKERS'COMPEN9ATION IAWS Of CAL�FORNIA,PN[7 AGHEE 7HA71�I SHOULD BEGNl.E INSPECTION FE[ _,_ __.... ..___ ___ L__ 3U&IECTTO THE WOflKERS'COMPENSATION PflOVISIONS OF SECTION 370o OF TM[UBOR j COD 15 FOFiTHWITHCOMPLYWITHTHOSEPROVI51ON5. ISSUANCE _ � -'_PA�""_..-_. � � 4�S ' iv�n ,�°��tiC�:� L SMIP p DATE:�_ APPLICANT. ._'_ _" _—___' -.�_. w ENEFiGY P/C —������ � WARNING FAILURE TO SECURE WORKERS'LOMPENSATION COVERAGE�S UNLAWFUL,pYD SHALL BE � -���� --' --' — �, SUBJECTANEMPLOYER70CRIMINALPENPLTIESANDCIVILFINESUPTOONEHUNDFiE�TMOUSIWD ENERGYPERMIT ''� ���{J /� � DOLLARS({700,000),IN ADDITION TO TNE COST OF COMPENSATION.DAMAGES AS PROVIOED FOR IN ��"++—'—'---"-'"'---+-fy—�--J�f�(� J� SECTION370BOFTfIF.LA90RCODE,INTEREST,AfdOATTORNEY'SFEES. RETENTIONF(E�E: ! •'� -�_ OCONSTRUCTION LENDING AGENCY pRE-ALT FEE`�'I��} —_—__ -. ��. IHEREBVAFFIRMUNDEHPENALTYOFPERJUHVTHATiHEflEISACONSTFLICTIDNI.ENDINGAGENCY BU�+D _ __ FOR THE PER W PMANCE OF THE WORK FOR WHIGH THIS PERMIT IS ISSUEO(SEC.3087,CIV C.). Z _ "' — '_' — W � IENDEN'&NAME...___.-- _'—'_ .—'— -."_„ __' ' '_ F- LENDER'SAOORESS __—_ ----- -- � TOTALFEES � 1 CERTIFYiHAT I HAVE flF.AD THIS APPUCATIONAND STATE THAT THEABOVE INFORMATION IS CORRECi ' � W IAOREETOCOMPLVWITHALLqNA1JDCOUNTVORDINANCESANDSTATELAWSRELA71NGT08UILDING � �'iSTAUC^:�r',WdD'n'en'euVnUTlwn7�Z'enE'rFeSEnTATIVESUiTnIJWUNYYTOENTEflUPONTHE Zv VE�MENTIONF.�VFOPEPTY FOR INSPECTION PURP0.4ES. 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