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HomeMy WebLinkAbout11546 '-�``�--- CITY OF DIAMOND BAR I I 1 � COMNIUNIT`!DEVELOPA4ENT DEPARTMENT �� 21660 L.Copley Drive Suite 190 / �'�E.�� (909)8G0-3195 Fax(9Q9)861-3117 ��/ ` ��'"�� BUILDING PERMIT APPLICATION V J'� FIRMLY o DDR'ESS !�L� _�_ DATE CATION L/������ NUMBER � '�/ ( � ISSUE TYPE OCC APN LOT TRACT � DATE _CONST. GROUP � OWNER � "� O ADDRE /` � ZONING SETBACKS w r' �'' FRONT RW,__ --' z CIIY ' L�� ZIP TEL. ' t � - -- o APPLICANT _ TEL. �I REAR [______ Z SIDFJSIDESTREET RlN L___. a SlDE L.__.___ m¢ CONTRACTOR u� �_ ADDRES � � CITY � ZIP L �+� TEL.I��/,7��9 PROPOSED USE � ARCH/ENG/ - - iz DESIGNER NO.DWEL. NO. NO. a ADDRESS --- UNITS STORIES BEDRO�MS � CITY ZIP TEL._ � � DESCRIPTION � SQ.FT FACTOR PSF ADJ.AREANALUATION � OOWNER-BCILDER DECLARATION SFRIA�O;REM � p I HERE3V AFFI4M.U�vDE�7 PENALTV OF P�_RJ'.:RV i HAT I AA1 c%E.'AP'=ROM T'r.F CONTRACTORS LI- � � Garage/Carport � W CENScU'6VFORTHEFOLLOV.'MGREASON'SEC.7C51.SBUSINESSA\DPROFESSIONSCODe:ANVqTVOR U COUNTYVti,�CHREQUReSA�c�iM!TTOCOASTRUCT,R:7ER,IMPP.OVE,DEMOU5�,09R'cPAIRANYSTRUC- I W patio/Deck Z TURE,PR:OR'O ff�!SSUAI:CE,ALSO RECUIRES Tr:E APPUC�N'FOR SUCH PERh11T i0 FlLE A S:GNED w w STATEM1'EN�THAYHe Oa SHE IS LICEfvSED PURSUAN i-0 Tr'F�70V'S10�5 OF TME CONTRAC?OFS:I- � CENSe LAW(CHA?TER 9(COMMEYCI�G YJV7H SEC:IOY 70C9;OF D:V:SION 3 Of THE BUSINE55 AIV�P90- I �I Poo!/Spa I �'eSSIONSCODE)ORTFUITHEORSF.EISE%EMPTTHEREFROMANDTH"e6ASI5FORTH'cALLEGECEXE1dP- (�� I 0 710�.ANYVIOLATIONOr'S�CTION7o315BVANYAPPLiCA\TF09APERM�"SUBJECTS'H'eAPPJCAN7�0 � �I RB-R001 i A C:VIL PENALTV OF h'OT P.10PE THA�L'IVE HU\�,iE�DOLL49S(550C;.j. I i 0 Li,A50WNEROFTF:E�FOPERTY,CRMYEMPLOVEESWITHWAGESASTHEIRSOLECO.'dPENSATION, 0 Commercial � ` WILL�O THE WORK,AND THE STRUCTURE IS VOT INTENDED OP.OFF_RE�FOR SA:.'c;SEC.7onn BUSI- i J -- NE55 AtiD P.70Fc5510�'S COJ[:THe CO'.'THACTORS L'CENSE LAW OOES YCT APPLY'O AN OWNER OF � � PROPEFiTYWHOBUILD50R1�1!r70VEST'r.EREON.AN�WHOAES6tY'HN!OPKHIMSEIFORHEftSELFOR I � CC THROUGHHISORHEFiOVrTlEMPLOYEES.PROVI�EDiHATSUCnIMPROVc'MENTSAR'eNOTIN7ENDE00R m I LL OFFEaEDFCRS/LE.7F,HOWNcR,THE6:11LDIhGOP.I!APROV'c61ENT1550_DWITHI.L'ChEYEAROFCOMPLE- � i 0 T:ON,THE OVJNER-BUILDER WILL!-'AVE Tr!E BUiDEN OF PROVIYG THAT HE OR SHE 01'J NOT BuliD OR �-- Z IMPROVEF09'HE?;1RPOSEOFSALE). � _ _IASONMEROFTHEPROPERTV.AMc%CLUSNELYCON7RACTING\VITHL'CENS'eDCOVTRACTORS W Q TO GONSTRUCT THE PRW ECT(SEC.�t44,B;151NE55 A�D PROF'cS3'�ONS CODE:THE CONiFACTORS!I V8IUeflOn ADJ.AREA W CENSELAWDOESNOTAPPLYTORNOWNEROFAPRO�E9TVWHDBUILD50RSA�ROVESTHEPEON,M1ND '— , � WHOCO�iRACTSFORSUCH�50JECT5WI�HACONTRACTOR�S)LIC^vSED�URSUAYTTOT'r.ECONTRAF ! 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' � I J O �I AM EXEMPi UM1DER SEC. ___ __B.fi P.C.FOR THIS R'eA50N � Q � - --- _ U z ..AT` ___ OIYM1ER _—____'_'-- f U� � W � LICENSED CONTRACTORS DECLARATION i w. 2 IHEFiEEYAFFI��NUNDERPENA'=YOFPERJURVTr:ATIAMLICEVSEDUNDER?ROVISIONSOFCHAPTER � � ✓� � � 9�COMMENqKGW1THSECT'ON7oW)OFDNIS:ON30FTHEBUSINESSAN7PR0°E55'ONSCODE,AND I z r X MY UGENSE IS IN FULL FORCC AN^v EFFEGT. .�7 m � LICENSE SS LIC.NO._ f� `'y _ I �i F�— UDATE�� GON7RACTOR ____ a W � � WORKERS'COMPENSATION DECLARATION U i � � I HEREBV A:FIRM UNDER PENA�TV OF Pr.q��qy ONEOFTHE FOLLOWIYG OEC;ARATIONS: � Z Q � I Y.AV'c ANJ WILL MA�N.-AIN A CERiiFIGATc OF CONSE�'T TO SELF�INSURE�OR WORKERS' _� COMPENSAT:ON.ASPROVIDEDBYSECTION37ooOF7HELA30RCODE,FDflTV'EPERFORMANCE U ¢ F THE WORK FOR bVHICH TH�S PER�AIT IS ISSUED. � � � W IriAVEANDW�LLR7A'NTqNN'ORRERS'CO�IPENSATIONIM1SURA�CE.ASREa'JWEDBYSFCTION Q 37oCOFhiELA309CODE,FORTHEPERFORMANCEOFTHEWORK'ORYJiICHTHISPERMITIS ISSUEC.MYV/Oii{E�'COMP-�U ONINSU�A�'CEC�RRIERAIIDPOLICYYUMBERARE: ! CONSTAUCTION ___,____ _ _ ___ 7 CARfI'ER_ _ I PLANREVIEW ___ _ ___ Q �/`� .y„ % N � POLICYNUMBER � � ELECTRIC Z w _—_ Q � (fHISSECTKNJNEmNOTeECONPE7"cDOFTFEPERMfTISFOFONEF0.1NDfiEDD01l.ARS(S10DIORLESSI. PLUMBING .___ W Z I CERTIFYTHAT IN Tl:E PERFOPMANCE OF THE WORK FOR 1V�ICH 1HI5 P=RMIT 1S ISSUED,I i MECHANICAL _____ _ _ (J SHALLNOTEMP�OYANYPe950tiINANYMAV\ERSOAST03ECOMESUBJECTTOTHE ...,y5 •;,:, '+' � WORKERS'COMPE�'SATIONLAWSOFCALIFCftNIA,pNOAGFEcTHAT1=15HOULD3cCOME � INSPECTIONFEE __ � = SU3JE�TO'H"cWORKERS'COMPEKSAT:O'r'PROVISIONSOFSEC'ION37aoOFTHELA60R � ! CO'JE,I SHALL FORTHWIT4 CONPLY W;TH'HO E PROVI� ISSUANCE :. � y SMIP p DATe:�c�8_ APPLICANT: � — � JENERGY P/C ]►f1i1 �, "����+ WARNING�FAILURETOSEC�JfiEWORKERS'COR!PENSATIONCOVERAGEISUNLAWWL.AN75HA'_LBE �e5 aa' � SUBJECTANEMP�OYERTOCRIM.INAL?ENALT:'cSANDCIVILFIN'eSU?TOONE4UNDREDTHOUSAND ENERGYPERMIT j�r��� �' � �OLLARS(5100,o0oJ,IN ADDITION TO THE COSTOF COIA�ENSATION,DAMAGES AS CROVIDED FOR IN ------� -�--- J SeGTION37GeOFTHElA90RC0'JE,INTERES'.ANDA:TORNEYSFEcS. � RETENTIONFEE: � __ a CONSTRUCTION LENDING AGENCY PRE-ALT FEE: p —�---'— --- -- � IHERE°YAFFIR!.AUNDcriPENALTYOFPERJUrIYTHAT?HcRE15ACO.tiSTFlUCTIONL[N�INGAGr-NCY � FOR TnE�cRFORMANCE OF-HE WORK FOR WHIGH'H:S PERM1IIT IS ISSUE��SEC.3C3],CIV C.) 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