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HomeMy WebLinkAbout15036 � � � CITY OF DIAMOND BAR -- �� --J�---�; DEPARTMENT OF COMMUNITY&DEVELOPMENT SER\�ICES f� '; �� 21660 E.Copley Drive Suite 190 /�-; � (909)86Q3195 Fax(909)861-3117 � PRESS �����'� � BUILDING PERMTT APPLICATION FIRMLY � JOBSITE t f „p APPLICATION PERMIT �� P/C j� o ADDRESS^� �U.�I/4i(��/"._f�)C"Y'� DATE �E�'7� �' -NUMBER1��.ti.1� # �v ' �� � APN LOT TRACT �SSUE /��� TYPE OCC —y�— DATE I � V_CONST. GROUP p OWNER C�`17f�. a , 0 ADDRESS • �_ 4� � t.e�dr-��'a% ! (z;� ZONING 5ETBACKS W C�Ty �si.?f?UAI,, ���zIP TEL. FRONT RW ❑ � RPPUCANT TEL. REAR ❑ � SIDE/SIQE STREET RW ❑ � CONTRACTOR �� � � SIDE ❑ gADDRE '��.,of �' � . r � � CITY �O r'/r'/i/�_ ZIP �r'/�// TEL. PROPOSED USE_' a i}1 � 0 ARCH/ENG/ z DESIGNER NO.DWEL. P�O. NO. Sf' ADDRESS �S ClTY ZIP TEL. UNITS :>TORIES BEDROOMS v� �n DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER•BUILDER DECLARATION SFR/ADDlREM O I HEREBY AFFlRM UNDER PENALTY OF PER7URV THAT I AM E%EMPT iROM THE CONTRACTOpS LI- Gefa9B/C81p0(I t�SJ CENSEUWFORTNEFd.IAWINGRFASON�5EC.709f.5BUSWESSANDOROFESSIONSCO�EANYCITVOR (/� COUNTYWHICHREOUIpESAPERMITTOCONSTRUC7,ALIER,IMPROVE,DEMOLJSH,ORREPA6IANYSTRUC• W P0tiO1D6Ck TURE,PHIOq TO ITS ISSUANCE.ALSO REWIRES THE APPLICANT WR SUCN PERMIT TO FILE A SIGNED W STATEGENT THAT HE OR SHE IS UCENSED PURSUANf TO THE PROVISIONS OF THE CONTRACTORS ll- w ) `P � CENSE U1W�CHAPTER 9(COMMENCIN�WITH SECTION 7000)OF OIVISION J OF THE BIISINESSAN�PRO� � POOVSp8 (�r� �: FESRqNSOODE)ORTHATHEORSHEISIXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEDE%EMP- � V TqN.ANYVqLATI0NOF5ECTION7031.5BYANYAPPLIC7INTFORAPERMIT5UBJECTSTMEAPPLICANTTD Z Re-Root � A CML PENALTY OF NOT MORE 7HAN FNE HUNDRED DOLLARS(i500)J: � ❑1,/SOWNEROFTHEPpOPEflTY.ORMYEMPLOYEESWI7HWA0E5AS7HEIR50LECAMPENSATIOPI, Q CofflfflBrCial � WILL DO THE WORK,AND THE S7RUCTURE IS NOT INTENDED OR OFFERED FOq SALE(SEC.7040.BUSI- J � NE55 NID PqpFE5510N5 CODE:THE CONTRACTORS LICENSE UW DOES NOT APPLV TO AN OWNER OF PROPERTYWFiOBURDSORIMPpOVESTHEREON,ANOWHO�0E55UCHWORKHIMSEIFOqHERSELFOR � CL THROUGHHISOHHEROWN@APLOYEES,PROVIDE�TFUTSUp11MPROVEMENTSARENOTINTENDEDOR m � OFFEREDiORSALEIF,HOWEVERTNE8UILDINGORIMPpOYEMENTISSOLOWITMINONEYEAROFCpMPLE- z TION.THE OWNER$UILDER WILL HAVE THE BURDEN OF PROVINO THpT HE OR SHE OIO NOT 9UILD OR = IMPROYEWR7HEPURPOSEOFSALE�. ❑I.AS�WNER QF THE PqOPEFTfY.AfA EXCLUSNEI.YCANTRACTIkO WYTH LICENSFD CONI RACTOFYS � TO CONSTHUCT THE PRQIECT(SEC.ioH,BUSINE55 ANO PROFESSIONS CODE:TNE GONTRAC70RS ll- Velu2ti017 Y,��_ADJ.AREA W CENSEUWOOESNO7MPlV70ANOWNEHOFAPHOPERTYWHOBUIl0.SORIMPROVESTHEHEON,AND ' ._ � VYFqGONTRpCT5FOR5UqiPpQ1ECTSWITIACONiflACTOR(5)LiCENSEDPlJRBUANTTOTHECONTRAC• QUANTITY DESCRIPTIOi� FEE � iOR5l10EN6EUW.). O I A/A EXEMPY UWDEFl SEG B.8 P.Q FOR TH!5 qEA504 J U � � � DATE OWNER_ U � LICENSEO CONTFACTORS DECLARATION W J � I HEREBY RFFIflM UN�ER PENALiY OF PERJVpY THAT i AM LICENSEO UNDER PROVISIONS OF CHAPTER � ' � Y�COMMENCIN(i WITH SECTqN 700a�OF DIVISION 30FT4E BUSINESS ANO PFOFESSIONS CODE,AND Z � __ MY LICEN9E IS N FULL FORCE pND EFF:CT. G� liJ .e` � �s yy /� 0] 0 L!CENSE C�IIA.�S'�S y���v LIC.NO, 7 / f �K' � ^-/�J � V DATE v I/ -� CONTRACTOR<SGtI����g[_S � 1�� W � � WORKERS'COMPENSATION DECLARATION -� �� � ¢ NI HEREBV AFFIRM UN�ER PENALTY OF PERNRY ONE OFTHE FOLLOWING DECLAFATIOIrS: Z Q __IMAVEANOWIL!MAIN'fAINACERTIFICATEOFCONSENTTOSELF�INSUREFORWORNEFS' Z � � G]MP�NSATION,AS PFIONiDED BY SECTION 3'/aoOF T31E LABOR CODE,FOR 7ME PERFORMANCE �U OF?HE WOH1C FOR WHICH THIS PERMIT IS ISSUED. � � � _I HAVE AND W!LL MAINTAIN WOPKERS'COMP'eNSATION INSUMNCE,AS RE�IiIRED BV SECTION Q 77000FTHElABOPCODE,FORTHEVERPoRMANCEOFTH'cYlOR%FOpWHICHTHISPERMITIS � ISSUED.MYW�O�RS'COM.P�ENSA_TIONINSUflANCECRN�'paRIERANbPO)LICYNUId�ER RE:' CONSTRUCTION .r �I� j CARRIER "' ��!� `' �)��� ,//�!�. ' '*��,� PLAN REVIEW �y � � POIICYPNMBER s��3�J'"}��/ � ' � � ELECTHIC `��'+r g (MSSECfICNNE�NOTBEODMPLEfEDOF7IEPEPlNii6fYJROhEtAx�Di1EUWLLARSR�aO;ORLESS\ PLUM8ING .J"�•��Lta:� � _ ' ,` `' � I CERTIFY THAT INTHE PERFOFMANCE OFTHE WORK FOFl WHICH THIS PERMIT IS ISSIiED,l MECHANICAL _ _ �`-7-�C! �°$ SHALL NOT EMPLOV ANV PERSIXJ IN ANV MANNER SO AS TO BECO SU&IECTTO THE � �� ��g �"�'i a i �T— � WORKERS'COMPENSAiKKJLAW50Fpq�IFORNIA,ANOAGREE FISHOULDBECOME INSPECTIONFEE �:��,. �.}� '�G� � SU&JECTTOTHEMK7RKERS'CAMPENSATbNPROVI510N50F T 370oOFTHEIABOR :y�d•;yd � '� CODE,I SHALL FOflTHWITH fAMPL WITH TH0.SE P 5 ISSUANCE ':�:. �-y Y . `�`��'s'if-::.. ,.�4sa � /�i/ � { SMIP �,.��C L �.;i'a,Ai..-.... '�-r.r"F,i � p OATE�L� APPLICAM:— — f i�r > 0.i u,,, ;M«..��'ti.��:°.:..-�- � ENERGYP/C M:c .8y.€-�;.`•::" WARNPIG FAILUflE TO SLCUflE YVORKERS COMPENSATiON COVER0.GE IS UNLAWFUL,IWO SH/�L BE �y SUBJECTAN EMPLOVEF TO CRIMINAL PENALTIES AN�CIVIL FINES UP TOONE NUNDRED THOUSAND ENERGY PERMIT — ^�l_— } OOLLARS({100,000),IN AO�IT�ON TO THE COST OF COMPENSAT�ON,DAMAGES AS PROVIDED FOR IN — �/I� J SECTION 37oe OF 7HE L480iY CODE,INTEREST,ANO ATTOFlNEI"S FEES. � � V � RETENTION FEE: ry+�" � CONSTRUCTION LENDING AGENCY pRE-ALT FEE: [l� - O 4 I HEREBY�FFIRM UNDER P ENALTY OF PERJURY THAT THERE IS A CONSTRUCTION IENDING 0.G�NCV FORTHE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMR IS ISSIiED(SEC.3097,CIV.C.). a�� Z'' d'-- W � LENDER'S NAME _ F— LENDER'SADDRE55 � TOTAL FEE �� D w ICENTIFYTHATIHAVEREAOTHISAPPLICATIONIWOSTATE7NATTHEABOVEMFORMATKKJISCqRqECT. � I AGflEETO COMPLV W1THlLLL CITY ANO COUNf'/ORDiNANCES AND STATE lAWS RELATMG TO BUILDING ^ ///��� CIXJSTRUCTION,ANDHEREBVAUTHORIZEREPRESENTATIVESOFhi15COl1NTVTOBJTERUPONTHE �/� /�! rs9�` �'i]�}/� r �"�I�.�� ��' z E-{+IENTIONED PROPEflTY FOR INSPECTION PURPQSES. i t�i/7 K- ��r-/-�' o�-(/�' o � �� � ✓r� COMMENTS � � y -- ¢ PER I ENPME�P31N `' ) /�) � cn �L� � _�i' -t!�, Q — � 51 ATURE OF PERM EE DATE Z RECPT.NO. 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