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HomeMy WebLinkAbout12748 _ �� _ CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DBVELOPMENT SERVICES ��� w 21660 E.Copley llrive Suite 190 �'�� PRESS (909)860-3195 Fax(909)861-3117 ��YM'� BUILDING PERMIT APPLICATION �- FIRMLY o ADDRiESS � �J f �J�L.V��i' [�7L��,v '�� OATEICATION r'� L.�•_."�/ NUMBE� � #/C � E" o� - ISSUE TYPE OCC APN _ LOT TRACT DATE CONST. GROUP � OWNER � SC.'.. IV ..Y� O � ADDRESS �'�= I 5j" (6�.'�d� " G�ivt'T"�� ZONING SETBACKS z C�TY d�As�7dad� � ZIP`3!��,:"' TE ! ' i`S� FRONT _ RW _ Cl o APPLICANT �r i C i�4�11 L.-�+%a� TEL i� REAR J __ z SIDE/SI�E STREET RW f.l � CONTRACTOR ,�►91�.,� �1�C1•t1� SIDE Ll__.__ � ADDRESS � � .4cJ• p CITY('!sLil�� ZIP a�3'L TE " �c7 ��� PROPOSEDUSE �A�°7r=d' �/�F7�Ls2 G1�l4����U�-'7' _ o ARCHIENG! ���� ` _ �z DESIGNER - NO.DWEL. NO. NO. a ADpRE55 UNITS _ STORIES BEDROOMS � CITY ZIP TEL. � u� DESCR.IPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILOER DECLARATION SFRlADD/REM d � 1 HEREBV AFFIRM UNDER PENALTY OF PEfiJURY THAT i AM E%EMPT FROM THE CONTRACTORS LI- GefeCJ9/CalPOff W CENSEUW(-0RhIEFOLI.OWINGHEA50N(SEC.70315BI1SINESSANDPROFESSIONSCA�E:ANYCITYOR (n U COUNTYriHICHRE(N/1flESAVEflMITTOCONSTRUCT,AL1'Efl,IMPROVE,DEMOLISH,ORREPAIRANY57RUP W {�gli0/DeCk � Z T1RE,PFlIOR TO ITS ISSUANCE,PLSO REOUIRES THE APPLICAM FOR SUCH PERMIT TO FlLE A SIGNEO w BTpTEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTDRS LI� w � CEN5E LAW(CHADTER B(COAIMENCING WITN SECTION 7000)�F DIVISION 30F THE BUSIMESS ANO�R0- V' POOVSpB � PESSIONSCODE)OHTHATHEOflSHEISE%EMP7THEflEFROMANDTHEBA515FORTHEALLEGEUEXFMP- (� — V M1N.ANYVIOL4TIONOFSECTION7037.SBYANYADPLICANTGORAPERMITSU&IECTSTHEAPPLICANTTO � Z Re-Roof �_ ACIVILPENALttOFNOTMORETHANFIVFMUNORED00LLqR5(5500).): UI,ASOWNEHOFTHEPROPERTV,ORMVEMPLOYEESWITHWAGCSASYHEIRSOLECAM7ENSATIDN, � COfIIrtIBfGI�I �/. WILL DO THE WORK,AND TME STRUCTURE IS NOT INTENDED OR OFFERE�FOR SALF(SEC.7044,BL1S1- J NESS AND PROFESSI045 CODE:71{E CONTfiAC70R5 LICENSE LAW�OES NOT APPLY TO AN OWNF:R OF � PROPERTYWHOBUItASORIMPROYESTHEREON,ANOWMO�0E55UCHWORKHIMSELFORNEqSELFOR � �['. THROUCaF1HISOqHEqOWNEMPIAVEES,PROV10[OTHATSUCNIMIPRO�EMENTSAHEhOiINTENDEDOR m QOFFEREDFORSALEIF,H04YEVER7HE9UILDI4GORIMPROYEMEYTISSOLDWITh11NO�EYEAROFCOMPLE Z TKKJ,'fl{E OVlNEN$UILDER WILL HAVE THE BURDEN 6F PROViNG THAT HF.OR SHE DID NO7 BUILD OR � � IMPqOYEFORTHEPURVO5EOF5ALE). U 1,AS OWNER OF THE DROPEl�T1:AF,1 E%CW SIVELY COMRACTING W ITH LICENSED CANTRACTORS Q 70 CANSTqUCT 7ME PRQIECT(SEC.�040,B�SINE55 AND PROFES510N5 CODE:THE CONTRACTORS U- V81118�1Of1 ADJ.AREA W CENSElAW00ESNOTAPPLY70ANOWNEROFAPROPEHTYWHOBUILDSORIAIPPOVESTHEREON.MD � � ��� � � �' �'�� ��-��� _` NTIqCONTRACTSFORSUCFIPROJECTSWITMAGONTRACTOR(5)LICENSF.UPURSUANTTO7HECONTRAG QUANTITY �ESCF7IPTION FEE i � 70R6t10ENCELAW.). Y �' ❑IAM EXEMPT UN�ER SEC.,^_ __B.&P.C.FOATHIS REASDN J �. "'_'-" B �� _--_ "'--'_- � � — _ � DATE, OWNER._ "'__.... V �� W �Q LICENSED CpP1TRACTORS DECLARATIUN �� � � • I� f.0 1 MERE9V AFFIPM UND'cR PE1!ALNOF PERJURY TMAT IRAS UC54SCD UNDF:Vi Pf,DVI510N5 OF CHAPTER � y �/ J �� 8(COMMENCINOWITHSECT�OY7000)OFDIVISIUN30FTHEBUSINI:SSPNDPROFE`u5:CN5CODF,ANO Z C LJI+�� , � ]C, MV LICENSE IS IN NLL FORCEAND EFFECi. m 4U /- nI �• LICENSE CLASS ��l c�!� IIC.NO.�.!__ _� : j � V�� DAiE_'_1�•(�.�� —CONTRACTOH _ __-.- �s 7 d � Q" f '1 � WORKERS'COMPENSRTION DECLARATION �,��,5��1� Q �� U �' IHEREDYAFFIHMUNDERPENALTYOFGERlURYONEOFTHEFOLLUWING�ECLAflATIONS: � � __ C] tMAVEANDWILL7AAINTA1NpCERPIFlCATEOFCANSEN7705ELF-!NSUREFORWO(iKF.RS' _ � � CAMPENSATiON,ASPROVIDEDBYSECf10N3]o00FTNElA130RCODE.FORTHEPEIi�OqlAANCF iU Of THE WORK FOR WHICH THIS PERMIT IS ISSUEO. , � � _ w �t NAVEAND WILL MAIMAIN WORNEqS'CAAIOENSATION INSURANCE,AS REOt11RE�HV SFCTI04 Q 97000FTHE LABOR CO�E,fOR THE P[RFORMANGE OFTHE WORiC FOR WHICH THIS PERMIT IS IS5UED.MYWORKEflS'COMPENSATIO4INSUFANCECARRIERPNDPOLICYNUMBERARG: CONSTRUCTION _, _. ___,___ _ , _. _.,____,_ j CAFfiiEH.,_� ����� � PIAN HEVIEW ,�/ __.".'-'_'- -..._ . '-_' ' "__' .-.—.� ZPOLICYNUMBER " � '� C?___—_ '� "' ELECTAIC _,--..--, —.-. .- ¢ —. 0 [IHISSF.CTIONNEEDI�76E07P.1PLEiEDOFTEPERA4TISFORONFHUWfiI;DWUMS(SIW)ORLES6�. PLUMBING _...-.--,. -----. ----�-,-- �._.. Z I CEfliIFV THAT IN TME PEflFORMANGE OF THE WORN FOfl WHICH TF715 PERMIT IS ISSIIFD,I MECHANICAL __._.__ _ _____..."-' ' (,�j SHALI.NOfEMPLOYANYPERSONWM1NVIAANNF.RSOASiOBFGOMF5l1UlECTTOTHE (} f� �(�yyJ: ��. WORKERS'COMPENSATIONLAWSOFCALIFORNIA,AN�AGREETHATIFISHOULO[iFCOM[ INSPECTIONFEE ,��.�_��� ,___. � SL�BJECTTOTHEWORKERS'COMPFNSATIONPRO NS F ECTIU�a7ooOFTNEL4BOR ISSUANCE __J d� � CO�F,I SHA FOFlTHWITH COMPLY WITHTHO I . - �..—. . �'ITY��DI A,M _..--- -- �� � SMIP QND��_. [1ATE:�� _ APPLICANT: - :.._..'.'__ .'.._._ ��` . t�m(. .'—__.__.'__— W• ' ENERGYP/C "-""''"�•NG r�1qL%JAFE`T .— J WARNING FAILIIH[TO SECURE WORKERS'COMPF.NSATION COVE AGE IS UNLAWFUL,AND SHALLBE �---- - �y SU�JC-CTAN EMPIOYER T0 CRIMI4AL PENALilES AN�CIVR FlNES UV TO�NE HUNDRED THOUSAN� ENERGY PENMIT DOLLAflS(5100.000),INA�DITIONTOTHECOSTOFCOMPENSATIO4,UAMAGESASPROYIDEDFORIN - -� ---� -- �-�---�-----��— J� SF.CTION37080FTHELABORCODE,INTEflEST,ANDATTORNEV'SFFES. RETENTIONFEE: __ ¢'. _ '__ '-_' '_" ' '_"" � CONSTRUCTIONLENDINGAGENCY PRE-ALTPEE: _.._.---. ..__—_.. _..__ _. O �: IHEREBYAFFIRMUNDERPENALTYOFPERJUfiYTiATTNEREISACONSTFUCTIONL[NDINGAOENCY _ __ ________ FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3�97,CIV.C.). � __ _ _ __—__- '�' �� LENDER'SNAME -..____-'..._. '_' _'__ _'__ '_ F_- LENDEfl'SADOR[SS_'_'_' —__'_'-_ "--'-' W ICENTIFYTHATIHAVEREADTHISAPPIICATIONANDSTATETHATTHEABOVEINFONMATIONISCORRECT. TOTf\L FEES 2 d IAGREETOCAMPI�W�THqLLGITYANDCIXINTYOFlDINANCE5ANU5TATELAWSFELATINGTOBUILpING �]�l � CqNSTRUCTION,AND FIEREBVAUTHOHI'LE RFPRESENTATIVES OF THIS COIINTV TD ENTEF UPON T11E � Z AE30VE�MENTIONEDPROPEflTYFOHINSPECTIONPURPOSFS. COMMENTS __ ____,._. __ � �l GN-+4-�� J< JJJL.�Lt✓t� --- _._. _.-. ._ - � m PENAITTEEN FINT •� ' _'—--' . .. ..Cn; � J 9 '!� �;J _ _-„_-_-�' '__'_" }_ " _'_-'-__ � 4 G%+ �p SIGNATUP.OFPER DATE ' '—" � RECPT.NO.___ � PAID BY __.�__—VALIDA710N,___ WI11TE—Departmont Copy,YELLOW—Finence Copy,PINK—Assessor Copy,GOLDENRO�File Copy,GREEN—Applicant's Copy .t 1 1 :. ., . !3 „ . .. ....`,... . . , ..._.. .t. I . , f ., I _ , ' , ,,,,I ��� . ��* ' ' I.. .�' V t 1-: i � �" . . F "5 v C =� 4 Q� � �. I"; :� : � � s : _ � l �,,� � � �{ i 'i i ; � in $ t �dqs } � . . : � .. ��: �i y .. ' ._i r � �r (��� ..� ' . ; . , � ' i } ' � 4 r I ` 'Kx �� , , �� � _ � I � " j � �, ;' � . �.. , , 1..�,� i-�_ . � S'� ..� , . � .'' , . ( � j . 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