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HomeMy WebLinkAbout12622 �. �'..`, ,,, !� CITY OF DIAMOND BAR E~ DEPARTMENT OF COMMUNITY 8c DEVELOPMENT SERVICES � �� _ 21660 E.Copley Drive Suite 190 (909)8G0-3195 Fax(909)861-3117 PRESS ����9f"" BUILDING PERMIT APPLICATION FIRMLY � JOBSITE Z`I'�J�� ``.�'yL'�� �'t`-E-'� �� APPLICATION PERMI� Z�n /C o ADDRESS 'E741�i'-'IUt�{'b 'r3LVI�� C:1� �(��Gf�j DATE � I • � ' ���NUMB `�' �� c� ISSUE TYPE OCC APN LOT TRACT_ DATE CONST GROUP p OWNE�C�-'i—�JR 17r-c°11�C.,t-�Y �` ADDRESS '^5.�1� ZONING SETBACKS w FRONT _ RW U gCITY ZIP TEL. — APPUCANT t["Tt�c�47�C'-±�-�(1-1-^J TEL'?��(��C.`e�G� REAR fl � SIDElSIDE STREET RW i J . CONTRACTOR SIDE I�_._..__ p� ADDRESS PROPOSED USE ` '�C�C�� ��ed,d"7� o CITY ZIP _ TEL. ��''f��' ( NL'�C-�1.�-�/t�'t��T t�.i ARCHIENG/ �T���r,;ty�l h[C",� �6.�M�.7.,�►.....�� � ADDRESS NO.DWEL., NO. NO. � � CIIY ZIP TEL. UNITS STORIES BEDROOMS � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION u� Q OWNER-BUILDER DECLARATION SFR/ADD/REM O p I HEREBY AFFIRM UNDER PENALTV OF PERJURY THAT I AU EXEMPT FqOM THE CONTRACTORS LI� Ge�d98/C01pOff W CENSEUWFORTHEFOLLOWINGREASON(SEC.�0.i1.5BUSINE55AN�PflOFE5510N5GODE:ANYCIT'OR (n U COUNTVNhiICHREd1IHESAGERIARTOCONSTRUC7,ALYER,IMPROVE,�EMOLISM,ORPEPAIRANVSTRUC- W pyti0/DBCk Z TURE.VRIOR TO ITS ISSUMICE,RL50 FIEWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIONED �L� STATEMENT THAT HE OR SHE IS LICENSED PURSUMIT TO THE VROVISIONS OF THE CONTRAC70RS LI. W � CENSE UW(CHAPTER e(COMMENCINa WITM SECTION 7000)OF�IVISION 3 0F THE BUSINESS AND PRO� u' Pool/Spa FESSION6CODE)ORTHA7HEORSHEISEX[MP77HEREFROMANOiHE8ASI5FOR7HEALtEGEDEXEMP� (� � � TION.ANYVIOLATIDNOFSECTION7031.SBYANYAPPLICMITFOR�PEFMITSU&IECTSTHEAPPI.ICPNTTO Z Re-Roof � � ACIVILPENALTYOFNOTMORETHFNFIVEHUNDREDDOLIARS(SSoo).j: O ❑I,ASOWNEROFTHEPROPERTY,ORMYEMPIOYEESWITHWqGE5A57MEIFi50LECOMPENSATIDN, � Commercial � WILI 00 THE WORK,Ml�THE STRUCTUflE IS NOT INTENDED OR OFFERED FOR SALE(SEC,7044,8U51- J � NE55 AVD 7ROFESSION3 CODE:THE CONTfiACTOHS LICENSE LAW OOES NOTAPPLY TD AN OWNEA OF � PROPERTY WFIO BUILDS OR iMPHOVES THEREON,AND WHO DDES SUCH WORK HIMSELf OR HERSEIFOR � THqOUGHHiSORNEROWNEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTENDEDOR m QOFFEFFDFOR8ALEIF.HOWEVER,THEBUII�INGOflIMPROVEMENTI550lDWRHINONEYEAROFCOMPLE� Z TIOPI,THE OWNER$UILOEN WILL NAVE THE BUROEN OF PROVIYG THAT HE OR SHE�IO NOT 8WlO OR = IMPROYEFOR7HEPURPoSEOFSALE). W ❑I,ASONMEROFTHEPqOPERTV,AMEXCLUSNELVCONTMCTINGWfTHLICENSEDCOMRACTOFS �.. , � TO CONSTRUCT TME PR6IECT(SEC.70�1,9USINE55 AND PROFESSIONS CODE:THE CONTRACTORS U� VeI118U0I1 _�f__ ADJ.AREA . W CENSELAWOOESNOTAPPLVTOPNOWNEROFAPROPERTYWHOBl11L�SORIMPFOVE57HEREON,ANO � YMiOGONTRACiSFORSUCHPRQIECTSWIiMAfANTRPCTOR(S�LICENSEDPUftSUANTTOTHECONTRAC� QUANTITY DESCRIPTION FEE � TORS LIC6NSE UW.). QCi1,1MEXEMPTUNDERSEC. 8.4P.C.FOR7HISRrASON � 3 — -- � � DATE� � :�''�_OWNER""_ . U Z W � I_ICENSED CONTRACTORS DECLARATION W � I HEREBYAFFlflM UN�ER PENALN Of�ERIUHV THAT IAM LiCENSE�UNDER PROVISIONS OF CHAPTER � � 9(COMMENCINO W17H SECTION 7000)OF OIYISION�OF THE 9USMESS AND PFOFESSIONS CODE,AND Z ��� MY LIGENSE IS IN NLL FORCEAND EFfECT. � � � � LICENSE CLASS� LIC.NO.____„___.,..__- J U DATE CONTRACTOR ._.."_____ a- � W � WORKERS'COMPENSATIOM DECLARATION Q � 1HEREBYAFFIRMUNOERPENALTVOFPEfiIURVONEOPTHF.FOLIAWINGDECLIRATIONS: U f/'1 Z Q 0 _�IHAVEANOWILLMAINTAINACERTIFICATEOFCONSENTiOSELF-INSUREFORWORKERS' 2 � COMPENSA710N.ASPROVIDEDBYSEC710N37ooOFTHELA80RCODE,FORTHEPEFF017MAhCE W OF THE WOflK FOR WHICH THIS PF.FMIT I&155UED. � � W _.I HAVE AN�WILL MAINTAIN WOAKERS'COMPENSATION INSURP�CE,AS RE�UIRED BV 9EC'ION . __ Q 370o OF TNE 1A90R CODE,FORTHE PERFORMANCE OF THE WORN FOR WNICHTHIS PEFMIT IS ,. �, 0 ISSUED.MYWORKERS'COMPEN5ATIONINSURANCECAFPIERPNDPOLICYNUMBERARE: CONSTRUCTION __.. _..___._.. ..__.,.______.—.—__.__ ¢� _ PLAN REVIEW ---'------- ----- ' CARRIER'__'_'_"_ -...._,...'_""""_ � ro�ICYNUMBER___.____ ---.- ELECTRIC _____ � (RilS6CCfqNNE�ND70E�1F'�E�EOOFil1EPEiUMISfORONEkNhURED0011l37SIS�OJ)OAL[SS} PLl1MBING .._ __._. Z I CERTIFY TMAT IN THE PERFORMANCE OF THF.WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL � �______„._. (3 SHAILNOTEMPLOVANYPERSONINANVlAANN[RSOASTOB[GOMF.SUOJECTTOiHE � y WORKERS'GOMPENSATION LAWS OF CALIPOPNIA,AND AdREE THAT IF 1 SHOULO BECOldE �NSPECTION FEE __ � _'_—_' _' S SUBJECTTOTHEWORKERS'COMPFNSATIONPFOVISIONSOFSECTION97000(THELABON V CODE,ISNALIFOFTHWIR7COMPLVWITHTHOSEPROVI510N5. �SSUANCE , „ ' ' "'-""_-'_''_—_"'"' � SMIP � ....-'- '-'------- '---- p OATE:_..'_ .' APPLI . _____.____. _—'_' J ENEHGY P/C ...--- WARNING FAILU(i[TO SECURE WORKERS'COMPENSATION CAVER�6E IS UNLAWFUL,AND SHALL 9E A� �y SU&IECTANEMPLOYEATOCRIMINALPENALi1E5ANOCIVILFINESUP700NEHUNDRE�TMOl15MD ENERGYPENMI �������"'�^ _ �OLLARS(5100,000),14 ADDITION TO THE COST OF CAMPENSATION,DAM0.GE5 AS PROVI�ED FOR IN �+p - � SECTION37080FTNELABORCODE.INTEREST.AN�ATTORNCY'SFEES. RETENTIONFE : ����A1�GTY __ � CONSTRUCTIONLENDINGAGENCY PRE•ALTFEE: ___.__._.__ ________..._._._ � IHEREBVAFFIitAllINDERP[NILLiYOFPEFJURYTMATTHEREISACONSTRUCTIONLENUINOAOENCY _, � FORTHEPERFOPMANCEOFTHEWORKFORWHICHhIISPERMITI515511EO(SEC.30W.CIVCJ. � ������ ����� ZW ___.__ —.___._._'____-_ ____.� � LENDER'SNAME ____-._.-- !- LENOEWSAD�7RES5 —.___.—"-- ---"'...._.__ ' wICEflTIFYTHATIHAYEREADTHISAPPLICATIONANDSTATETHATTHEPBOVEINFORMATIONISCARRECi TOTAL FEES rz � I AGREE TO CAMPLV WITHPLL CITY ANO COUNTY OFlDINANCES ANU STNT[lAWS RELA7ING TO BUILDING CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF 7V{IS COUNTY TO ENTEfl UPON THE ZA60VE•MEMIONEDPPOPEHTYFORINSPECTIONPUflPOSES. COMMENTS ___.__.__._._....___ _._ � ���?T"� V S.�S�`�l.g��'—__ -- —__-'____._. __, m PEPMITTE"f1AME RINn -------'--- �, �-`■�` 7 � ,�.�. f� � �q� --- �_ � SION�A7U EO�ERMI'17EE �P �� � �A7E � --- � REGPT.NO. , PAID BY � VAUDATION_ WHITE-Depertment Copy,YELLOW-Finence Copy,PINK-Assessor Copy,GOLDENROD-file Copy,aREEN-Applicant's Copy �: � i . . . . -. __. , ._. __ . _, - - ��� , - ; , , , �� � � � � , � ; , �._ . 6 �� i j i . i i i � i � � . . . � ; ; ; i € � I I t i . : _ ��' �� , ( . . ' i � ( � ' I ', I � ' � I - I I � � � 1 I - �� � � q �i � i I � � � � � � � . I I � � � I � � � '� ' . � �� � ` ' � , . I . � ' , . � ��jt � � � � i , � � , � j ! � � , t� , ,, �r" � � f " ^._ ._. .,.� . . . . i . � � � t r i � i I ' .i-.... I ' ... _;._ 1._ � j 3 5 I � � I i ��� � ' � ' I ' I � � i � � ; � , � , S'��, , _.�. . -G-� , � I � � � � ' �- ��� j j i � � i , 1 I a i , , , ; i { t ; , � I � � � ! I i i � �'���, � f i � � � ' � I . 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