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HomeMy WebLinkAbout17164 (1113) CITY aF DIAMOND BAR --�--�---� DE�'E1FtTMENT OF COP��i7NI1'Y&DEVELOPMENT SERVICES _ � - 21825 E.Copley Drive ' (909)�60-3195Fazr(909)861-3117 PRESS "��'-v��` B�JJILDINGPE18ft�IITAPPLICATION FIR LY o DDRESS � � t�� r `�l�`�j'o � / DATE CATION� '°�"� �� NUMB R � #f C e�� s � lSSUE � I+°� I TYPE � OCC APN LOT� 7RACT DATE p� p OWNER .. 'i ( � CONST. GROUP `�` ADDRESSt�"P `a^� "''"�� Pr+ ! ZONING SETBACKS Z CITY ,�������/��LIP���TEL:�:� ,�� ��� FRONT RW ❑ o APPLICANT i TE�.�'����'�'s�a'��Z� REAR ❑ Z i� SIDE/SIDE STREET RW ❑ ¢ CONTRACTOR I SIDE � o CDDRESS i ZIP TEL. PROPOSED USE a � ° o ARCH/ENG< a "DESIGNER w , NO.DWEL. NO. NO, n. A�DRESS cn , UNITS STORIES BEDROOMS � ' CITY ZIP TEL. `�n DESCRIP710N SQ.FT. FACTOR PSF ADJ.AREANALUATION �, 0� NER-BUILDER DECLARATION SFR/ADD/REM � O '�,' I HEHEBY AFFIFiM UN�ER P NALTV OF PERJUFiY THAT I AM EXEMPT FfiOM THE CONTRACTORS LI- Gfl�O J0/C2fP01[ '� � W.. 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W.:,'�. ❑I,ASOWN,EROFiHEPROP'iEtiiY,AME%CLUSNELYCONiRACTINGWI7HLICENSE�CONTRACTORS [L�� TO CONSTRUC7 THE RROJECT�,�S�C,7044,BUSINESS ANO PROPESSIONS CADE:THE CON7RACTORS ll- ValUatlon ADJ.AREA W:'�, CENSELqWDOE$t�OTAPPLYTO NOWNEROFAPROPERTYWHOBUILDSOFlIMPROVESTfiEREON,AND ��'� '�WHOCONTRACTSFQRSUCHPROECTSIMTHACONiRACTOR(5)LICENSEOPURSUANTiOTHECONTRAF QUANTITY DESCRIPTION FEE .��, TORSLICENS�LAW.�. i, Q,;'� C{�AM;EXEMP'f�UNDERSEC.��i B.&P.C.FORTH FEASON Q � ��., , . . �i U r LL' . 'fE '.'"'�_S� �I OWNER��: :.�A°, k � �' � '� ..,.- , W ���� .� . LICENb�ED CONTRACTORS DECLARATION W ��,�. 1 HEfiEBYAFFIRM UNDER PENALT�`OF PERJURYTHAT I AM LICE�SEO UN�ER PROVISIONS OF CHAPTER � ;d',�� 9(COMMENCINGWITHS�CTION7GOOJOFDIVISION30FTHEBUSINESSANDPflOFESSIONSCODE,AND z �,`X�,'�. MY LICENSE 15 M PULL FORCE ANp EFFECL m � � LICENSECLASS I LJC.NO. � ,'��' DATE � CONTRACTOR __ d W a�i WORK�IRS'COMPENSATION DECLARATION � � �� IHERE6YAFFIqMt1NDEFPENALI�'OFPERJURYONEOFTHEFOLLOWINGDECLARATIONS: z � _IHAVEAfJOWILLMAINTAI ACERTIFICATEOFCONSENT705ELF-INSUREFORWORKERS' 2 .¢ ' COMPENSAYION,AS PRO I�ED BY SECTION 3]0o OF THE LABOR CODE,FOR 7HE PEPFORMANCE U OF THE WOPK FOR WHIC THIS PERMIT IS ISSUED. w � � QW ' _IHAVEANDWILLMAINTAI WOFKERS'COMPENSATIONINSURANCE,ASflEQUIREDBY5ECT10N - ' 37000FTHELABORCOD FORTHEPEFFORMA4CEOFiHEWORKFORWHICHTHISPERMITIS �'� ISSUED.MV VJORKEFS'C�MPENSATION INSUqANCE CAPRIER AND PDLICY NUMBER ARE: CONSTRUCTION > cARRiER � ! PLAN REVIEW 'Z POUCV N�MBER i ELECTRIC _._. Q � (MISSECTIONNEmNOiBqCOt�APLEI'EDOFTHEPERMffISFOPIXJEHl1NDREGWLLARS(§100)ORLESS). PLUMBING Z ICERTIFVTHATINTHEPE�iFORMANCEOFTHEVIORKFORWHICHTHISPEFMITI5155UED,1 MECHANICAL ('3 SHAILNOTEMPLOYANYFy`E�ftSONINANYMANNER50A5TOBECOMESUBJECTTOTHE (n WORKERS'COMPENSATIOryLAW50FCALIFORNIA,ANOAGREETHATIFISHOULDBECOME INSPECTIONFEE SUBJECT�iO THE WORKEf#5'COMPENSATION PROVISIONS OF SECTION 37o0OF THE LABOR � � CODE,ISHALLFORTHWITHCOMPLYWITHiHOSEPROVISIONS. ISSUANCE q � p DATE: A�'PLICANT: SMIP �,� � WARNING:FAILUF3E i0 SECURE WPflKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALL BE ENEFIGY P/C � � . SUBJECiANEMPLOYERTOCRIMI�JALPENALTIESAN�CMLFINESUGTOONEHUNDFE�THOUSAND ENERGYPERMIT �OLLARS(51oo,odJ),INAO�ITION OTHECOSTOFCOMPENSATION,DAMAGESASPFOVIOEDFORIN � SECTION3]beOFTH�LABORCO E,INTEREST,At�ATTORNEV'SFEES. RETENTIONFEE: O � CO STRUCTION LENDING AGENCY PRE-ALT FEE: ,'',,� IHEREBtlAFFIfiM,UNOERPENAL�OFPERJURVTHATTHEREISACONSTRUCTIONLEN�INGAGENCY ,� FOR THE PERFORMAtJCE OF THE�ORK FOR WHICH THIS PERMIT IS ISSVED(SEC.3091,CIV.C.j. --- �W . � ___'___— '.� LENDER'SNAME ' ';1-- LENDER'SADDRESS � '� ICERTIFYTHATIHA�EPEADTHIS'qPPLICATIONANDSTATE7HATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES � JO Y "�,� . IAGREETOCOMpL`�WITHALLCITYANDCOUMYORDINANCESANDSTATELAWSRELATINGT06UILDING ��� '�,� CONSTRUCTION,pNpHEREBYAUtHORIZEREPRESENTATIVE50FTHI5COUNTYTOENTERUPONTHE �� ABOVE-AAEM'IONEDPROPERTYFdftINSPECTIONPUflPOSES. COMMENTS Q ��������"''C.& r`� �(�,Q � � — � . P�MJ7��NAMEIP NTJ ��� � �� � � � .�'z� � � �1 �yj $IGNATUREO PERMITTEE i, DATE ° � �� � RECPT.k0. PAID BY VALIDATION WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanYs Copy� ,.. _... __ ,. _.. , _.. >,.;;_ . , ,.._. _..w. .. .. . . .-: . ,. . ... 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