HomeMy WebLinkAbout12-1785 r � ��
�,��_ CITY OF DIAMOND BAR
� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21810 Copley Drive,Diamond Bar,CA 91765
(909)839-7020 Fax(909)861-3117 Building Inspection Hotline(909)839-7027 PRESS
��''"'. BUII,DING PERMIT APPLICATION FIRMLY
� JOBSITE C��5 0(I r' ) r� I L ` ,1jP/C
>- APPLICATION PERMIT i
o ADDRESS � � �N DATE � NUMBEd #
`� APN LOT TRACT ISSUE TYPE pCC
DATE �� CONST. � GROUP
p OWNER 2_ -
� ADDRESS � � ' ZONING SETBACKS
0
Z CITY ��-w✓ ZIP �/Z 65 TEL. � FRONT Ryy �
� APPLICANT TEL. REAR p
�� SIDE/S�DE STREET RW ❑
CONTRACTOR SIDE �
ADDRESS
� CITY ,�r:U.�ink.��r iq-ZIP yn7l�/ TEL 6 g PROPOSED USE
w ARCWENG/
z DESIGNER �~'
a ADDRESS NO.DWEL. NO. NO.
� CITY ZIP TEL UNITS STORIES BEDROOMS
�
� DESCAIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION
� OWNER-BUILDER DECIAAATION SFR/ADD/REM
O
p 1 HEREBY AFFlRM UNDER PENAL7Y OF PE0.)URV THAT 1 AA/E7(EMPT FROM THE CONTRACTORS LI- G8t3gBlCafpOR
W CENSEUWFORTHEFOLLOWMOREASON(SEC.7031.6BI15P7ESSANOPROFESSIONSCAOEANYGTYOR (n
U COUHiVWHIp1RE0UIqE5APERlAITTOCONSTRUCT.ALTEA,tlAPROVE,DEAqU51{.ORREVNRANYSTRUG W Patio/Dedc
� NRE,PRIOR TD RS ISSUMICE AL50 REOUIHES THE APPLICANT FOR$UCH pERMR TO FlLE A&ONED W
� STATEMENT THAT HE OR SHE IS LICENSED PURSUAHT TO 7HE PROVLSIONS OF THE CONTqACTORS LL
� CEN3E LAW(4UPTER Y(COIIMENpN6 WITH SECTION]000)pF OMSbN 7 OF THE BUSINESS ANO PR6 � POOUSPB
FESSIONSCAD�ORi}IATHEORSHEISE%EMPTTiEREFROMANDTHEBA515FOR7HEALLEOEDE%EMP- (� e
V T10N.ANYVIOLATIONOFSECTION7o31.5BYANYAPPLICJ�I�/TFpqAPERMITSU&lECT37HEAPPLICANTTO Z Re-Roof
� ACML PENALTV OF NO7 MORE THAN FNE HUNDFED DOlURS(35oo),r
� ❑4�SOWNEROFhIEPROCERTY,ORMVEMPLOVEESWI7HWAGE5A5THEIR50LECOMPENSATION, � Commercial �
Z WILL DO THE WORI(AND TiE STFiUCTURE L4 NOT IMEllDED OR OFFEAED FOR SALE(sEC.70a1,BU51- J �
� NESS MID PROFE5510NS CODE:THE CON7RACTOR4 UCENSE LAW DOES NO7 APPLY TO AN OWNER OF �
PROPFFTY YV/i0 BUILOS OR IMPROVES THEREON,AND NMO DOES$UCH WORK H W SELF OR HERSELF OR
� W THROUGHHISORHEHOWNEMPLOYEES,PROVtDEDTHA75Uq/IMPROVEMEM73ARENO7PRENDEUOR m
Q OFFERmFORSALEIF,HOWEVEiL7HEBUlDW(30RIMFROVEMENTISSp�pW�7WNONEYEAROFCOMPLE-
Z TON.THE OWNERAUILDER WILL HAVE THE BUi1�EN OF PROVP!(i THAT HE OR SHE DfD NOT BUIID Oq
� PIPROVE FOR THE PURP0.SE OF SALE�
W ❑1�.40WNEROF7HEPROPEHTY,AMIXQUSiVELYCANTMC7PJ4WITHLICENSEDCOMTMCTORS
Q TO CONSTAUCT T}IE PRQIECT(SEC.)O11,BUSINE55 ANO PROFESSIONS CODE:TFIE CONTRACTOHS LI- V81U8II0(1 ` qp,�,qpEq � �
W CENSE LAW OOES NOTAPPLY TOAH OWNER OFA VROPEAiY VMp gUIlDS 0R IMPROVES THEREON,M!D
� NIIiOCONRUCTSFORSUCHPRO,IECfSWfh1ACOHfRA(,TOR(5)LICFNSEDPURSUAMTOTHECONTiUG Q�J/�T�r( DESCRIPTION '
TORS UCENSE UW.y �E .
0 ❑I AA1 El(EMPT UNDER SEC. B.8 P.C.FOR THIS REASON Q .
� U
� DATE _„_ ONMER H
O � U _�,.
�Q, LICENSED CONTRACTORS DECIARATION w � -..,f -
CL 1 MEREBY AFFlAM UNDER PENAL7Y OF PERJURY THA7IAM LICENSEA UNDER PRON510N5 OF CMAVTER � - ,q d;:. -
d o I���CWO WfTF1 SEGTION 700U)OF DMSION]OF THE 9USINESS M!D PROFESSIONS OODE,M1D Z
� MY LICENSE IS IH FULL FOFCE AND EFFECL . m . - �, _
� UCENSE C � O LIC.NO. � � .�.'v.c.. :�.0� �r.. ��
~ DATE COMRACTOR 1 d �>�.p . �y� . �
w :u-o.� ,d,�.
� � WORKERS'COMPENSATION DECLARATION Q � � ,y� ;,
� I HERFBY AFFIRM UNDER PENALTY OF VER1UqY ONE OF THE FOL�OW WO DEClARA710N5: U
� Za
� _IHAVEANDWILLMAINTMNAGERTIFICATEOFCONSENTTOSELF�INSUREFORWORKERS $
Q COMPENSA710N,�14 GROVIDED BY SECTION�700OF THE UBOR CODE,FOR THE PERFORMANCE U�
OF THE WORN FOq WHlqi THI$pERMiT IS ISSUED. W
0 �/ �
w J6�I HAVE AND WILL AWMNN WORKERS'COMPENSATION MSUqANL'E,lS REOUIRED BY SECf10N /�/
Q ��J7000F TME LABOR COOE,FOR TNE PERFORMANCE OF THE WOPo(FOR NRilpl iH15 PERMR IS �/�.(J�
65UED.MV WOPoCEp$'COMPENSATON INS�ANCE CAAAIER AND PO�ICy NUMBER ME CONSTRUCTION %
j cww�q � 7�7 t G ��6�n PLAN REVIEW
�z POLICY NUMBER ����� —�� ELECTRIC
Q '
p (�s�c��+r�mwTe�ao�rIDa�n�a�u*�swacr+EFu�or�0ouuts(s+oMar�tEssl PLUMBING �
w
z I CERTIFV THAT P17HE PERFOf1MANCE OF THE WORK FOR WMICN THIS PERMIT IS ISSUED,I MECHANICAL
C3 SHALL NOT EMROYANY PERSON W ANV MANNER SOAS TO BECAME SU&1ECT TO THE
Cn WORKERS'COM7ENSATqNLAW50FCAlIFORNItiAF1DA(3REE7HA71FISHOULDBECAME INSPECTIONFEE
= SU6IECT TO THE WORKERS'COMPENSA7IDN P�o IONS OF SECT OF THE UBOR
caoE. 5 warriwirM coua�r win�naS" aov�s�s. ISSUANCE
O
' p DA7E: I� APPL�cnN7: / � �SMIP __ � �
W
J WARNIN0.FAdURE TO SEGURE WORKERS'COM SATqN COVEMGE IS UNUWFUL,PND SHALL BE ENERGY P/C
J
�y, SU&IECT AN EMVLOYER TO CRIMINAL 7ENALTIES ANO C7VIL FINES UP TO ONE HUN�RED 7i%]USAND ENERGY PERMIT
DOLUR.4(1100.000�W�DDI710N TO THE CAST OF COMPQdSA710N,DAMAGES A9 PROVIDED FOR IN
J 6ECTION 37oE OF THE LABOR CODE,WTEREST.AND ATTORNEYS FEES. � 'O f7��
� w - RETENTION FEE: CJ
O CONSTRUCTION LENDING AGENCY PRE•ALT FEE
Q t HEREBYAFFlRM UNDER PENAL770F PERJURY THA7 THERE IS ACONS7RUCTqN LENDINO AGEHCY
� FOR TME PERFORMANCE OF 7HE WORK FOR WHICH 7}{I9 PERNIT IS LSSUED(SEC.30W,C1V.G�.
Z �
W
� LENDERStUME . .
� LENDERSADORE55 �
w ICEHTIFY HAVEREADTViI3APPLICATIONANDSTATE7HATTiEABOVEPlFORMATIONISWH/iECT. TOTAL FEES �?/'���
p. I AGREE TO Y YATH ALL CIiV AND COUNTy OROWANCES AND STATE LAWS RELATINO TO BUY.DiHO 6
� CONST N)AND HEREBY AUTViOR1ZE REPRESENTATNES Of 7HI5 COUNTY TO EMER UPON THE
Z ABOVEM ED PROPERT'FOR I crarr vuarosEs. COMMENTS
0
J
�
m PERM NAMEID � .
Q _ /
U�
y SIONA7URE OF PE E ATE �
� RECPT.NO. PA1D BY ��VAUDATION
WHITE—DepaAment Copy,YELLOW--Flnence Copy.PINK—Assessor Copy,GOLDENROa-File Copy,GREEI�AppllcanYs Copy
• ,
�$`�'�'` �� [�@f��C3�D �,��
�N����l'1��49 �6��C3�R�3
.f� �Lw�ot V .�� h,� '�M .��. b ,� `� }' .'.4;_ � �� .`� D �
.. �°�' � �.� . �e
;ET Bp�k I h FLOOR JOIST ----------
----- ----- ----- - -— — -- -- -- ------ -- — ---
FTGS/fOkMS/STEEL j� fHA REO�vtTS
----------------- - - - -- -- --------- --- - -- ---------
�LFiTRIC GROU�JD C i_ IJN�ER FLOOR QUCT
GROUi`dD FLUNIBING r UNDER FLOOR CONC�UIT
SLAB GRADE ` _ _ � FIRFPLArE FOUl�OATI��N _
TEti1P POGl1ER _ � FIREPLACE 80��Q BEAM
WATER SERVICE fvtlD HT.BOf�lD BEAM
RaOF SHEATHIfJG � �/ I 8 FT.BOND BEAM
FRAMI(VGIVENTILATION __ _____ �FINAL BOND BEAfvI__ ____ _
ROOF COVER PRE-GRADING _ _ _
ROUGH HEATING �BENCH�NG __ _ _____
ROUGH ELECTRIC � � I ROUGH GRADING
ROUGI-I PLUMaIP1G FINISH GRAOING
SHOWER/TUBTEST POOL ELECTRIC
EiCT.LATH;SIDING I POOL FENCING
WALL INSULATION POOL FINAL
CEILING I�dSULATION OFF SITE IP.�1P5.
DRl'�VALL NAILING --�� DEDICATIONS
SEWER FINAL ENG.
SEPTICTANK LANDSCAPE/IRRIG. __ __ __
SEEP PIT/L.L. OM SITE IMPS.
GAS AIR TEST FINAL ZONING
FINAL.CONST. `` S'"�', ,;;, ,,, FIRE DEPT.FINAL
<,.,,.,,r, � ,.,
FINAL HEATING 'r;.:�„q;, ,�, " 9;..,,•}.;�..., HEALTH DEPT.FINAL
FINAL ELECTRIC " �:�°�,c'��,�i_ ,��'W�'�'�'.r�;,,'• •�:�.��.,;'+��., DEV.FEES PAID
FINAL PLUMBfNG ,`"``+':'�`t"'' ''`�:' '�i.y �� ENERGY
��.v ''�y. �!Y� '�ir'Y':�,
FINAL PLANING ;;a,; • -:�r3c �� ' `3 ';t;�;� .,,,r, ------
FINAL ENGINEERING _ _ °��'�"�,;.: ;�;,�'�w h — - ° g e — — --
- -- � -�v,�y
COMMENTS ..__ _ -.- _--- --
SEPTICTANK SIZE _
SEEP PIT/U SIZE
�"�', ' , i
'���--
��.' Attachment A
• Form for Non-Franchise Haulers for Constrnction and Demolition Debris
Company and Project Info:
Name of licensed demolition contractor hauler or self hauling company -i UCT�0�' �
Address of Company �� � ��J �r r���r C- ��1� Cih's� )�►(FLO(k)�n- � ' �
Zip CodeT� �� Phone Number 3`� �- c�— G 7 8
Address and Name of Project Site .
`��— 5��1 0�-3 5 0 6 r�u io� � �e�,;uc. �.� .— �
Type of ycleable material or waste material to be transported for this project
� � �N - �AC -
Report Information:
Please submit this information prior to final building inspection.
A report reflecting the following information:
• The estimated volume or weight of construction and demolition debris,listed for each
material;
• The estimated volume or weight of consh-uction and demolition debris that can be .
diverted listed for each material; �
• The estimated volume or weight of construction and demolition debris that will be
landfilled as waste; and
v . Identification of the vendor or facility that will collect or receive the construction or
demolition debris.
AB 939 Fee Payment: �
Pay AB939 fee of$12.00 per bin and$50 per roll off for all non- franchise hauler containers
Type of Container � number of container
Paid date(office use only) (revenue code CD Waste)
Agreement and Signature:
The property owner agrees to submit documentation to demonstrate compliance with the 50%diversion
requirement for construction debris and shall indemnify and hold harn�less the City for damage and
liabili , including any financial liability, fines and penalties, associated with using a non-City
fran . ised hauler failing to satisfy iversion requirements.
. . . ' c�r� v� 0 � �
op O er Si e P ' � ame Date
C/�/l v��Z d�
Sel auler Signa e Print Name Date '
Last updated June 26,2008
? ,