HomeMy WebLinkAbout11699 r:_,,•
CITY OF DIAMOND BAR '��'
--�-1�--- DEPARTMENT OF COMMUNITY 8c DEVELOPMENT SERVICES � � �`
21660 E.Copley Drive 5uite 190 �,�'
(909)860-3195 Fax(909)861-3117 PRESS
' ���fl�°�� BUILDIIVG PERMIT APPLICATION FIRMLY
oN" JOBSITE + /' �/� APPLICATION � ' � a'� NUMBER�� #/ ��I � J
ADDRESS ����� �G•�A/� ��G/V ECf�,c DATE
c� ISSUE TYPE OCC
APN LOT TRACT B�,,,,, DATE � CONST. GROUP
p, OWNE�/f11t9Q�i[��/ ��t-�S l�J� r�,�
ADDR S Lt,� '!rl? Ei ZONING SETBACKS
z' CITY P�I�/`! TEI.. FRONT RW ❑
g APPLICANT TEL._ _ ?' REAR ❑
� SIDE/SIDE STREET RW ❑_
� CONTRACTOR SIDE _ ❑
� ADDR SS � � - PROPOSED USE----y� �C ���fr r.-v�Le�
� cirr ziP�:'��'2'iTEL.
o ARCH/ENG/
� DESIGNER �' G �£ G" �N NO.DWEL. NO. NO.
d ADDRESS � ' � UNITS_______ STORIES .___._.—__—_ BEDROOMS_
N' CITY ZIP� TEL.
N DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION �
� OWNER-BUILDER DECLARATION SFR/ADDIFIEM
�, i HEREBV AFFlRM UNDER PENALTY OF PERNHY THFT I AM E%EMVT FflOM THE CONTRACTORS ll- G8f39B/CBfPOfI (f
W CENSELAWFOiiTHEFOLLOWINCREASON(SEC.7037.SBUSINESSAN�PROFESSIONSCODE:ANVCITYOR (/� C�
� COUN7YNMIpiflEQUIRESAPERMITTOCONSTRUCT,AL7ER,IMPROVE,�EMOUS4,ORflEPA1RANYSTfiUG ,�J,J pyii0/DBCk
W TUflE.PRIOR TO ITS ISSUANCE,AL50 flEW IqES THE APPLICANT FdR SIICH VERMIT TO FIIE A SIGNED W
�. STATEMENY THA7 HE Oq SHE IS LICENSED PURSUANT TO THE 7ROVISIONS OF 7HE COYTRAClORS LI�
CEN9E LAW(CHAPTER B(COMMENCINO WITH SECTION�000)OF DIVISION 3 OFTHE BUSMESS AND PRO- LL POOVSPB
FESStONS�E)OR THATHE OR SHE IS EXEMPT THEREFROM AND THE 6F515 FOR TNEAILCGED EXEMP-
710N,ANYVqLFTqNOFSECTION7031.5BVANYAPPLICANTFOFAPERAlITSU&IECTSTHEAPPLICANTTO Z Re-Root
, F ACMLPENALT'OFNOTMORETIWJFIVEHUNDREDDOLURS(f5a0).)�
� ❑1,1150WNEROFTHEPROPERTY,OHM'fEMPLOYEESWITHWA0E5A5ThiEIF50LECOMPENSATION, � CommBfC�al
� N7LL DO TNE WORK NN�THE STRl1CTURE IS NOT INTEN�ED OR OFFERED FOfl SALE(SEC.7044,BUSI- J �
� NESE AND PROFESSIONS WDE:hIE COMRACTOR6 LICENSE lAW OOF.S NOT APPLY 10 AN QWNER OF �
PROPERTY YR10 BUILDS OR IMVHOVES THEREON,AND VA10 DOES SUCH WORK HIMSELF OH HERSELF Oq
p[ THiWl1GHHI50HHEROWNEMPLOYEES.PROVIDEDTHATSUCHIMPROVEMENTSARENO71N7EN�F.�OR m
QOFFEREDFORSAIEIF,HOWEVERTNEBUIL�INOORIMPROVEMENT1550LDWI7HINONEVEAROFCAMPLE-
Z TION,TME OWNER�BUI�DER WILL HAVE THE Bl1qDEN OF PROVMG TiAT HE OR SHE DID NOT BUIID OR F�
� NAPi�VE FOR THE PURPOSE OF SALq. '\ Y
❑I,AS OYMEHOF THE PROPERN,AM EXCLUSIVELYCONTMCTING WIiH LICENSEDCONTRACTOHS
� TOCONS7RUCTTNE PRQIECT(SEC.lo19,BUSINESSAND PROFESSIONS COOE:THE COMMC70RS ll- Valuati0fl ADJ.AREA
W CENSELAWDOESNOTAPPLYTOANOYVNEROFAPflOPEflTYWMOBUIL�50RIMPRWE57HEflEON,FNO
� WNOODNYMCTSFORSUCHPRQIECTSWITiACONiRACTOR(S)IICEN5WPI1R5UANTTOTHECONTRAG QUANTITY DESCRIPTION FEE
Y roRsucenseuw.�. -
� ❑I AM EXEAIPT UNDER SEQ__ - B.A P.0 FOR 7HI5 REASON U
Q
� DATE OYYNER __"_____"_'....'"_""_ U •
W
� LICENSED CONTRACTORS DECLARATION W
� I MEREBYAFFIRM UNDEfl PENAL7Y OF PERIURY iHAT 10.M LICENSED UNDER PROVISIONS OF CHAPTER � r
� 9(C01.IMENCINO Wfi}i SECTION 7000)OF DIV�SION 3OF THE BU51NE55 AND PROFESSIONS CADE AN� Z R
?G MY UCF.NSE IS IN Fl1LL FORCE AND EFFECT. m
IJ.I `y� �/ `� �
o LICENSE CLASS_� LIC.NOkpS4���..l i��+�.1. � J
� DATE��'=�GONTRACTO� �-
W
� WORKERS'COMPENSATION DECLARATION Q ¢
� I HEREBY AFFIRM UN�ER PFNALT!OF PEFiIURY ONE OF THF.FOLLOWIN6 Df:CLARATIONS: U
y Z
Q
0 __IHAVEANDWILLMAINTAINACERTIFICATEOFCANSENTTOSELF.INSIJREFOFWORKEflS' S
� COMPEN5ATION.AS PROVIDED BY SECTION 37000F TME LAdOH CODE,FOR THE PEflFOflMPNCE `U
OF TXE WORK FOR WHICN THIS PF.RMIT IS ISSl1ED. �
� - k
W �I HAVE AND WILL MAIMAIN WOFiKEHS'COMPENSPTION INSl1RANCE,AS FEOUIRED BY SECTION f
Q 37000FTHE UBOR COOE.FnR hIE PERFORMANCE OF THE WORK FON WHICH THIS PFRMIT IS • ! _ ---
ISSUED.MY WORKEHS'CO�MPENSATION IN�RANCE CPRRIER A OLICY NUMBE�� i� COPISTRUCTION � ' +�'3' � �
j CARRIER-��y= �-�6,`'�a � ..�" ' .�V— PLAN REVIEW G---.- � � �'
' ---�- p
__ --- -------- - ---------------------
� POLICYNUMOEH���_.�..�� ����--r��')�� ELECTFIC S
' d i3 _�.-��7 —�----....---------...--- ---- --
� °
Q ITFiS5ECi1CiJNE�NOTBEOJNVLEfEDOFiHEPEWrYTISFORONEFM�I%iEDDOLLAPS(Sioo)IXiLESS} PLUMBING �
—......,._.,..""'--_'__________'___"_--".._"'_-- �
Z� I CERTIFYTHAT IN THE PERFOflMRNCE OF THE WORK FOR WHICH THIS P[RMIT IS ISSUEU,1 MECHANICAL
_._..."'__"'___ — _ '___'-__'_
(} SHALLNOTEMPLOYANYPERSINiINANYMANNF,RSOASTOBECOMESUBJEG�TUTNE
N WORNERS'WA7PENSATIONLAWSOFCALIFORNIA,AN�AGNEETHATIFISHOULDBECOME INSPECTIONFEE ,,,___.__.._.___________ �� Cf
S SU&IECTTO THE WORKERS'COMPENSATION PROVISIONS OF SECTION�7000f-THE LABON ISSUANCE _ ' " �'� -�� _ �
CADE,1 SHALL FORTMWITH COMPLY WITH THOSE PROVISIONS �i�'"
O. SMIP �'��� . L . 3� _
p DATE____ APPUCANT. _.__-_'. ,r � . •
w ENERGY P/C ____ws;'�,._ �
J WARNINGFAILURETOSEGUREWONKERS'COMPENSATIONCAVF.RAGEISUNIAWFUL,ANDSHALLBE
" ' _'___ '____._..._..._ ...—___"-_"—
SU&IECT AN EMPLOYER TO CRIMINAL PENNLTIES ANO CIYIL FINES UP TO ONE HUNURED TMOUSAND �
tJ'i ENERGY PERMIT `"' '
DOLLARS(f100.0001.�NA0DIT�ONTOTHECOSTOFCOMPF.NSATION,DAMAGESASPROVIDEDfORIN —'--------' '-'-'-' --""-- '-""'-"—'
J SECTION 370B OF THE LABOF CODE,INTEREST,AND ATTORNEI"S FEES. RETENTION FEE: _.__.-._— "'�'
� . _ -_____'--'��-_"__
OCONSTRUCTION LENOING AGEPICY PHE-AL7 FEE: _.`����_ -
� IHEREBYAFFIRMUN�ERPF:NALT'OFPERJURYTHATTHEREISACONSTRUCTIONLEN�MGAGENCY ______,_,_,________ ';,�`x _
FOR THE PERFORMANCE OF TME WORK FOR WHICH THIS PEfiMIT IS ISSUED(SEC.3097,CIV.C.�.
Z -
W
� LENDER'S NAME._. "-- --'----- '_'_ ' _"'... _
H LEN�EN'SADORE55___ ------ - G/
wICERTIFVTHATIHAVEREADTHISAPPL�CATIONANDSTATETHR7THEA90VEINFORMATIONISCAHRECT. TOTAL FEES � � 1 "��
� I AGREE TO COMPLY WITH ALL CITY AN�COUNTV OMINANCFS AND STATE L4WS REUTING TO BUILDING
CANSTHUCTION,AND HERE9Y AUTHOFRE REPRESENTATIVES OF THIS COVNTY TO ENTEH UPON THE
A80VE�MENTIONED VROPERTY FOR INSPEC ION PURPOSES.
Z �� � �, COMMENTS___.__.__—____
n — ���
= F � _..__-_"__ _' '�-
m PERMITfE��l�Hl Q/ (�' '— --
� °���� ��N�• �L__-
(n -- _"_ _"_'
� swe EOF ERMiiI°EE� OATE O pAIDBY � VALIDATION
= RECPT.NO. __ _
~ WHITE-0epartment Copy,YELLOW—Finence Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanYs Copy
:
_ � �� _. _.. _. _.. . _�_
�� I I _ ..,__ ._._..._ , .
t �� � ; � ; I` �,
, �
� I I j . , ' I � � , i �
� �*��� I � I � � ' � ! i �� , . I i i � I I ' � � I i i
" ,, #�,�,��� , I � : _ � � . . . � . � � � �
� ��r�� � � , ; � : � � ° a � � � � ; � 3
- �,�,�Sm ! ' � i � I � ' � ' ( j ' ! ( i
�� j i i i ' 1 i ( � i , I � i � � f 1
.
I i ( ; � � , I 1 ; F
( , I ;
� , � � � I , � , �
: �F"� 7----I- 1..:.,: � ;.,....� i � . . ,i_ �. ---i- - ' - ; i - � = � 1 .
- ( � � ( �i I . :' � , � ,, _ ' ., I � f I � 1
ai�i 4 ... :I i .I. i . , f . _ i _ � � i . . i i ,' . i ! ' i � � ' . i .�� f
. ; �
. �J � � � i � � i . . . . � I . . ! . • I
.. � rA� - I t � ' j � ' � � .
I ; '
I i
:. �. A- �. ......� i , �... i... 7 .-,_...,- ,. .,.. .. �.__ ..�j�J ' ,! . i � .
- . . ' I E I �� I � i � � � ( ' I ' ; 1 �
� ' � � K S, , � ; I � � . � � I � ' � I (�', I I , 1
�, „.�,t; _ � i� 1 � i i . � :, , � . i � ���. . .' .y i � j �, s ,
- � "� ��{}� � i 7. '' � � '�5 z i I � 'I I ' 3� � i � I � � � ' � 1 �
F� C ! , . : : � , � ' . , i
. t-`.^ ��}9�� I �. � C -. r i� � , � � � . ax�� ( � i : �' , _ i � l
�4 � �� � i .
� q � � . (, �' � �''�� �''Sf�^, -� � iii� C �����.j i � �t� ' i � � •.�, I � �� � i � � 3
G t ', �I ! �
M�P �`.' ��b�. i �� .�i .a� Cr �� f �� •�� ,`: ' �f ; ; ` � �� � "
.� �"_ � � i._ i i i�-i �t � �:� I r � � � i t 1�fi Y ; ' i i � t
,� t . ; .. �. 4 1. .j .� ,_I . (._.t,1E, � ' , � . . � j ' 3 .. §
+ r
�� Va 6 . � d '- i - _... ' , ' " -.__ ..�._ _ _' ' i i . , � �
,,.`. y _._.�..�
�� ' . �. t I �� i . ! . � .
� �, a � ( , I i � ,
,. ���, - f ; , � : I � i i ! ; � ; '
� fi� ��< � � � � � � . � ; � ; I � ; ,
�s, � ��: � � � . I ; j ; � -�
��. v�t� C � � i � � � � j � � � � �
. i � �
. �x � , I � � � � � i � �
¢';fi � � � � � � , � ; �\; i � � ; � ; � � �
� }�'' � � � � � I � i �� ' � � i ,� , _ � � ; � ; � � � !
���� � � , � � ; v i i � ; I j i
s�b�� }._ � ,-- - --- � i - - . ' -, —,-- � i I I i �,
r � � ' I � I ,� �, , i � � I •. . , ;
,
i ' .
�: 1 { . I � � I . ' I : I ... - � , � � I � . ' � ' I ' lE
.. I E
' ��t^� . � � `._ � �_ � . _ __. �." _� �`�.." � � �. ; s _ :�'e.i
, ... ' __ ., �
�� i � �. ,
. ��.�w I , � � � . ' . I ��� . . . i � . � i �� �,
s.�f ' �' ; ' � ( ' � i { � � ��� �
� i
� > � �� . '. � � � a � � F � b4 b �
., k� ( 1 L' �� I � �b _ : I t � (�F , ' ' I _ � 1 i x �
. � s , _ ! i � i � E �_��\ i � � „ I y�'.� � �
v �� i w ° � � ,� � I � i .i � f- . � �'��; ° ,'i �
E I - ) � � . � t q, .y�p
- �� y � 1 � I i � � �� ��� �
� ,�' I ; r' � '", � � � , , � I �' ��'�{�'�� ,' y,
�. ` '
.. ' F73 � . � �, l / � . ., ".'�; . � I�' 1.., �.��
' �. I . I fi I " ,C� � } F {
-. .!��n. I _.�,�, L � I 4 �f .._L� �., . . ' i . 4 , .
..�. ,. $ � ��
..._..�.... ..................... :�. .,....1,......... , . �..�:....�< . '.... . ..,.....,.a. . . .. . ....� .........�. ._... ._._,,._..� ....._ . .__��..._..�._.�.._.. ..