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HomeMy WebLinkAbout11698 �� ��_ CITY OF DIAMOND BAR "—' � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES j' w 21660 E.Copley Drive Suite 190 C.•�� pR ESS � � - - (909)8G0-3195 Fax(909)861-3117 �:'. ���9�°�.' BUILDING PERMIT APPLICATION FIRMLY o�° JOBSITE +7 ���� �j�/�,�� /�i,�� ��P A�APEICATION ` �� �� NUMBER� #/C ~� � ADDRESS ��" _Z)��r•/s' C�fi c� ISSUE TYPE OCC APN LOT TR CT �� DATE � � CONST. GROUP � OWNER O " ADDRESS��' � "` G�.. ZONING SETSACKS z CITYC'�� c.�7� C'A/ZIP� TEI. � °' � REART RW C�-1 g APPLICANT � TEL.--���- SIDE/SIDE STREET RW Cl _ � CONTRACTOR SIDE f_7 � ADDRESS � / �' CITY r ZIP TEL Ca PROPOSED USE�i�� ��C 1�/�G- � w ARCH/ENG/ .S G•.rS� � DESIGNER � A r/ •� G—' NO.DWEL. N0. NO. a ADDRESS Cw � UNITS _ STORIES _________BEDROOMS � CITY rZIP��� TE v �� �' DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION R OWNER-BUILDER DECLARATION SFRlADD/REM O p I HEREBY AFFlRM UNDEfl PENALTY OF PERJURY THA7 I AM EXEMP7 fROM THE CANTRACTORS LI- Gaf8Q0/CBfrJOfl W CENSELAWFORTHEFOILOWINCREA50N(3EC.7n31.5BU51NE5SANOPROFE5510�5CODE:ANYCITVOR (n U COUNTYWHICHREWIflESpPERMRTOCONSTflUCT,ALTER,IMPROVE,DEMOLISH,OfiREPAIflANVSTRUC- � W pyIiOlDeCk � WNRE,PRIOH TO ITS 19SUANCE,ALSO REWIRES THE APPl1CANT FOF SUCH PERMIT 70 FILE!SIGNEO • � STATEIAENT THAT NE Oq SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI� � CEN9E LAW(CHAPTER9(COMMENCINO WITH SECTION 7000)OF DIVISION 30F THE B1151NES5 AND PRO- u' PooUSpe y FESSqNSCO�E)ORi11ATHEORSHEISEXEMPTTFiEREFflOMANDTHE8ASI5FORTHEALIEGEDE%EMP• (�} F TION.ANVV10UT10NOFSECTION�03t.58YANVAPDLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO z Re-Raof � � ACINLPENALT'OFNOTMORETWWFIVEHUNDREDOOLLARS�SSOD)): ❑I,ASOWNEflOFTHEPROPERTY,ORMYEMPLOYEESWITHWA6ESA5THEIRSOLECOMPENSATION. C� Commercial � WILL�O THE WORK,AND THE S7qUC�URE IS NOT INTENOED OR OFFERFD FOR SALE(SEC.7044,BUSI� J _ � � NESS ANU PHOFESSIONS CODE:THE CONTRACTOR6 LICEN6E LAW DDES NOT APPLY TO AN OWNER OF ? PROPERiY'MK1BUttD50flNAPROVE5TIEREON,ANDWFIODOESSUCHWORKHIMSELFOFHEF5ELFOq ' �' THPd1GNHISOHHEROWNEMPLOYEES,PROVI�E�THATSUCHIMPROVEMENTSARENOTIN7ENDEDOFI ' m Q ,OFFEREOFORB�LE.IFHOWEVEi1,iHEBUILDIN60RIMPROVEMEN715501DWITHINONEVEAROFCOMVLE- � Z TION,7ME OWNER�BUILUER WILL 17AYE TME BURDEN OF PflOVING THAT HE OR SHE DID NOT BUILD OR = WPqDVEFOHTHEPl1RPO5EOFSALE). ❑1,AS OWNEH OF 7HE PROPERTV,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS Q TO CONS7RUCf THE PFWEC7(SEC.7osa,BUSINESS AND PROFESSIONS CODE:THE CON7RACTORS ll- V31ua�101t ADJ.AREA W CENSEUWDOE3NOTMPLYTOANOWNEHOFAPHOPEflTYWHOBUIL�50RIMPR04E5THEREON,AN� F VhqCONTRACTSFORSUCHPRO.IECTSWITHACOtJTRACTOR�S�LICENSEDPURSUANTTOTHECONTRAG qUANTITY DESCRIPTION FEE �j TORS 110EN5E UW). � ❑I AM EXEMPT UNDER SEC.___--- B.8 P.G FOR 7HI5 REASON Q � U � ¢ LL �ATE OWNER "_--__'_'"'....."'"_ U . � LICENSEO CONTRACTORS DECLARATION W � I HEFlEBY AFFIRM UNDER PENALTY OF PERJUHV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTEH � d .9(COiAYENCIMOWI7HSECTiON7000)OFDIVISION30F7HEBUSINESSANDPROFESSIO�SCO�E,AYD Z MY UCENSE�S IN FULL FORCE AND EFFECT. -y m � LICENSE CLASS LIC.ND���?�—�S�.��!_L � N . V DATE y � S GONTMCTOR�.�_�4+9 a 6dJ � WORKERS'COMi'ENSATION DECLAFiATfON Q � I HEREBYAFFIRM UNDER PENJLLTV OF PENURV ONE Of 1HE FOLLOWING DGCLARATIONS: U � Z � _IHAVEANDWILlMA1NTAINACER'T�FICATEOFWNSENTTOSELF-INSUREFORY/ORKERS' 2 COMPF.NSATION,ASPROVIDEDDYSECTION37000FTHElA80RC00[,FORTHEPcflFOflMANCE IU „ OF iHE WORK FON WHICH iHIS PF.RMIT IS ISSUED. � 0 ' . _.I HAVE/WU WILL MAIMAIN WOflKERS'COMPENSATION INSURANCF.,AS REOLIIRED BY SECTION � 37000FTHE LABOR CODE.FOHTHE PERFORMANCE OF THE WONK FOR WHICH iHIS PERMIT IS � � 2 IS5UED.MY WORKERS'COMPENSATKKJ INS ANCE CA^qRIER AyN;D f?�OLICV NUMBEHARE'. CONSTRUCTION a� { _ __ " "'_— _ Q y�'�'� ' - u � CARRIEfl��/ � �$•��x✓ •.�yy__S_.�[Q?f.?�A_ PLAN REVIEW l ----�_. �. + �...'...._.._..._ � - -' --...• . . - --------------------------- � � POLICYNUMBER ' ' > -'^ ^ _ ELECTHIC ` ��-�'_" ' '"— � � (fF16SECiqNNE�NOTBE,� ' DOFTF�PEfiMITAiWRONEHUDAREUo`~o��ts�Siaa�ora�ess� PLUMBING _..------------------....------------ -_ � W � ICERTIFYTHATINTHEPERFORMANCEOFTHEWOPHFORWHICHiHISPERMITISISSUED,1 MECHANICAL ____________._.____..._____ -_____._ - (f SHALLNOTEMPLOYPNYPER5(MINANVMANNERSOASTOBECOMESUBJECTTOTf1E � Uj WOflKERS'COMPENSAYIONLRWSOFCALIFOPNIA,ANOAGHEETHATIFISHOULOBECAME INSPECTIONFEE __ _—_ SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 370o OF THE LA80R = CODE,ISHALLFORTHWIiFiCOMPLYWITHTHOSEPROVI510N5. ISSUANCE �S'�— d p DATE�.__ APPLICANT. _ SMIP � .� ..... ... _I_• _._ W ENERGY P/C J WARNING:FAILURETOSECUREWORKERS'COMPENSA710NCOVERAGEISUNLAWFUL,ANDSHpLLUE -- "---'-' -'-' " '-'-"--' ' -'--'--- '--' — � 5UBIECTANEMPLOYEflTOCRIMINAIPENALTIESANDCIVILFIYESUP700NEHUNDflEDTHOUSAND ENERGYPEHM�T ' � ' DOLLARS(5100.OW�.INADOITIONTOTHECOSTOFCAMP[YSATION,DPIIAGESASPROYIDE�FDHIN "' --"""-'-"" '-'-' ----' '--' -- � SECTION97oeOFTHF.LABOROJDE.I.YlEREST,ANDATTORNENSFEES RETENlIONFEE: __.__._ — OCONSTRUCTION LENDING AGENCY PHE-ALT FEE: _..... ,r;.•, � I HEREBY AFFIRM UNDER PENALTY OF PERJURY?HAT 7HEFiE IS ACANSTRUCTION LENDING AGENCY E'.:'��� ti tlb ,5 FOFIHE PERFOflMANGE OF THE WOflK FOR VhIICH THIS PERMIT IS ISSUED(SEC.3087,CIV.C.). —������� ������ ' Z __' -"-' __'__'_—'_______—" W � LENDER'SNAME_ ..---- ------ � LENDER'S.40DRE55___ ._._-. ---.---- �� WICERTIFYTHATIHAVEREADTHISAPPLiCATIONPNDSTATETHATTHEABOVEINFORMATIONiSCORflECT. TO IAL FCES t3 y - � I AGREE TO CAMPLY WITH ALI.CINANU COUNTV ORDINANCES AND STATE L4W5 RELATMG TO BUILDING CANSTRUCTION,M�HEREBY AUTHORIZE REPRESF:NTATIYES OF TNIS CW NTV TO ENTER UPON THE ZABOYE-�ENTIONF�PROPERTY FOR INSPECTION PURPOSES. COMMENTS ____. __ _____.— Q �, /��y �'" _ �� � f G��`�'"` — _. "'_ --_ _— ___ m PEflMITTEE P ) / -""' ' -----'-'---- � sior+= E���� � �""'��� � REC.PT.�� PAID BY __ � VALIDATIO _ ~ WHITE—Depattment Copy,YELLOW�inance Copy,PINK—Assessor Copy,GOLDENROD—Fila Copy,GRE N—ApplicanPs Copy � � g � ._, .............. .. . .........x ......., .. ,...,._. _.<... _ ...... ., _... _ ..... .. _....... ... ''_ ____ _ ..._... .......,_ .�. ,.. 3 ' 'j_' . . � . . _ ,_ . .., _ _.. 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