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HomeMy WebLinkAbout14049 �'"'^� CITY OF DIAMOND BAR � -�"--�� "-�" DEPARTMEIVT OF COMMUNITY&DEVELOPMENT SERVICES � 21660 E.Copley Drive Suite 190 (909)860-3195 Faz(909)861-3117 PRE$$ �����'� BUILDING PERMTT APPLICATION FIRMLY Q ADDRESS � 2� ����� DATE " ��� � '� NUMBER� � # / /��IS >- APPLICATION ��c � PERMIT P/C � ISSUE TYPE OCC � APN LOT �TRACT DATE_ CONST. GROUP p OWNER o ADDRESS lti ZONING SETBACKS w CITY ZIP TEL . FRONT _ RW C � APPLICANT Ir' TE �J � REAR ❑ � — r SIDE/SIDE STREET RW ❑ � CONTRACTOR (SY) SIDE ❑ ADDRESS � CITY ZI ,TEL� PROPOSED USE �l7�/U I� �L Cj o ARCH/ENG/ � � ADDRE SR _ • NO.DWEL. NO. ��. NO. CITY ZIP TEL. UNITS STORIES BEDROOMS� � u� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-SUILDER DECLARATION SFR/AD�/REM O I HEREBV AFFIRM UNDER PENALTY OF PEFi1JPV TNAT I AM ExEMPT FROM THE COYTRACTORS LI� � GaragelCarport � CENSELRWFORTHEFOILOWINGREASON�SEG.7aa1.58U51NESSANOPROFE5510N5C0'JE:ANYpNOR (n CWHTYWHICNHEWIRESAPEAMITTOCONSTHUCT,RLTER,IMPPOVE.DEMO!!SH,ORflEPAIRANVSTRUC� W patio/Dack W TURE,PRIOR TO ITS ISSUANCE.ALuO REOUIRES THE APPLICANT FOR SUCH PERM�T TO FILE A SIGNED w STATEMENi THFT HE OR SHE IS LICENSED PURSUANT TO h1E PRONISIONS OF THE CANTRACTORS LI� � i .SE UW 1CHAPTER B(COMMENCINO W�TH SECTION 7000)OF DIVISION 3 OF THE BLISMESS ANO PRO- LL' PDOUSp2 FESSIONSCODE)ORTHATHEORSHEISEXEWPTTHEPEFROMANDTNEBASISFORTMEALLCG[DE%EMP� (� TqN.ANVVKK.ATIONOF5ECT10N7o31,6BVANVAPPUCANTFORAPERMITSU0.IECTS7HEAPPLICANT70 Z Re-Rocf '„� ACML PENIV.TY OF NOT MORETHAN FNE HUNDREOOOLLARS(SSao).): � CI,A501M1EROFTHEPROPERN,ORMYEMPLOYEFSWITHWAGESASTMEIfi50lEGUMPENSATION, COfIlI11BfCIflI V/ILL 00 THE WOAK,AN�iHE 5TRUCNflE IS NOT IN7ENOE0 Ofl OFFERED FOR SALE(SEC.7014,BU51- �J I � NE55 ANU Pr70FES510N5 CADE:THF CONTHACiORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF � PROPERf`(YVIiO BUIlDS OR IMPROVES THEFEON,M1D WHO DOES SUCH WORKHIRLSELF OR HERSF F OR CL 7HROUGHHISORNEROMMEMPLOYEES,PROVIOE�THATSUCHIAIPROVEMENTSARENOTIN?EN�EOOR m L�1 OFFEREDFOR SILLE IF,NOWEYE0.7F1E BUILDING OR IMPROVEMENT�S SOID WITHIN OIdEYEAR OF COAIPLE- V TION,THE OWNER-BUIIDEH WILL HAVE THE BUFDEN OF PROVING 74AT HE OR SHE CID NOT BNID OR � IMPROVEFORTHEPURPOSEOFSALE). W ^I,ASOWNEHOFTHEPROPERTY,NAJ(CWSiVEIYCONTRAGTINGWITHUCEYSECCONTRACTORS — (,� TO GONSTRUC7 P.iE PflQIECT(SEC.7oba,AUSINESS AND PflOFE5510N5 CCDE:THE CONTRAc:TORS LI- VSIIid�iOfl ADJ.AREA_ W CENSEUW�OESNOTAPpLI'TOANOWNERDFAPROPERTYWFI06UILOSOFIMPHOVESPiEREON,AND -- � YrtqCOMRACT5FOR5UCH7ROJEC?SWIr,�q�pp;7qq�OR(S1�ICENSEOPUHSl1ANTT0?HECONTRAC- QUANT:IY SCRIPTION FEE � TORS 110EN5E LAW.1. _ - L 0 ❑I AM EXEMPT UkDER SEC._______B.L P.C.FOR INIS REA501. Q� �T �- S ' � 3 v Z " 4'�7L a c � --- ---- - ..- ¢ �e' ► DATE OWNER_„_,____ F" a --- w� 5 .� cs� C'.e: 1 �. F4 LiCEiVSED CONTRACTORS GcCLARATION W� CC 1 HEREBVAFFIRM UNDER AENA�TV OF PERJl1RV THAT I AM L:Ce45ED UN�EP.PROVIS.ONS OF Ci{qp7ER Z� '� J p� Y(COMMENCINO WITH SECTION�000�OF DIVIS�ON 3 OF THF BUSINF.SS AND PRD�ESSIONS CO[:E.AND - ! ��� X MY UCEN3:15 W FULL FORC D EFFEC7. w a �o m � "��6'e'�"�:_ � LICENSE CLASS�_ LIC.NO.�� 6 � !+ $' �,�r�r � W DATE � ��"�/ _ CDNTRACTOR `J J � ���� `� -- ,� � WCRKERS'COMPENSATIONDECLARATIDN � 2ji U C,4/ �X � C-�G _ «/� -��- '' � I HEREBY AFF!RM UNDER PENALTV OF PERIURY ONE CF ThE FCLLOWING D'eCi.ARATIONS:� Z ���, _��� P /1 a ld � !I-1AVEAYUWII.LMAINTAINACEfiT:FICATEOFCANSENTTOSELF-WSUAEFORWORKERS' _ � COMPENSATION,AS PROVIDED BY SEC710N s�ooOF THE LA�OR COOE,FOA THE PERFORMANCE W OFTHE WORK FGR 4VHICH TNIS VFRMIT IS ISSUED. � , O ' W __IIiAVEMlOWILLiAAINTAIN\YORKEHS'CAMPF:YSA'.ION!NSURANCE.ASFEOU!REDBVSECTION � � ` ' Q 3�a0 OF THE LABOR CODE,FOR 7iiE PER-'ORMANCE O.'-''c WORN FOR WHiCH THIS PERMIT IS �� �Q ISSUED.MYWORKER 'CAMP SATIONi/N'5�11�R/�M10ECA IEaANDPOLICVNUMBEAARF, CONSTRUCTION _ _ � _ jCARRIER ��- '�-"t�v _ —_� � PLAN REVIEW _��� �` � POLICYNUM9Ffl �ti� � ELECTRIC ✓ � '_- ---____ )!� � fn+ss[c�arareE:nnarsecor.wEre�oFr.��wwr�s�a�E!iunoraFo�B+aaloatEssF PLUMBING _ ! V d � w � ICER7IFVTHATIN?HEPERFORMANCEUFTr.EM10fiKFOqWhI:CHTH15?EHMI7151SSJEO,i MECHAh;ICAL ___.._ ., _ t_ I � C7 SHALLNOTEMPLOYANYPERSONINANYMANNERSOASTOBECCMES::B.'ECT'O7HE � WORKF.FlS'CDMFENSATIONLAWSOFCAUFOP�IA,ANDAGaEETHATIFISHWLDBECOME INSPECTIONFEE S SUB:ECTTOTHEWORKERS'COIAPENSATIONFROV!5!ONSOFSECTIOv3]COOF?f+'eV.BOR __ -_ — y CODE,I SHAIA,FORTHWITH COMPLY WITH THOSE PROVISIONS, �SSUANCE gr O �ATE: APPLiCANT: SMIP �f. �'•�� 1 � — ----_ �'z^ .•• � ENERGY P/C s r.._.. � WARNING:FAILURE TO SECURE WORKERS'COA4PENSATION COVERAGE IS UNLAWFUL,AN�SHALL BE ----- LL SU&IECTANEMPLOYERTOCRIMiN/LLPENALTIESANOCPJILFINESVPTOONEHUNDREDTHOL'SAND ENERGYPERMIT � � DOLLARS(i700,o00�,14 ADDIT!ON TOTHE COST OF COMPENSATION,ORMAGES AS PqOVIDED FOR IN +� J SECTION37090FTHELABOflCDOE,INTEPEST.ANDAT70RNE`"SFEES. RETENTIONFEE: °✓y+-�W x� �� �'-�' Q _"_'__"'_ . . O CONSTRUCTION LENDI.'JG AGENCY � , .--.�.,e _-�_� PRE-ALT FEE: f�Y�"t��!'°�=.-��...,:.va v.. .a .. � IHERE9YAFFIRMUNDERPE�ALTYOFPERJURYTHATTHER'cISAC045'fFll,'CTIONL'cNDINOAGENCY _,L�'��TY"1'1r3.;a-'• f.=yr+-n .� � FORTNEPERFORMANCEOFTHENfORKFGRWHtGHTHISiFFMITISISSUED�S[C.309J,CIV.C.�. '------� -'G�•�-�-`�.w�a:S.i..'�•d-1:;_,.. .< Z W -- � LENDER'SNAME_'___ '_____' __—"""'___ . _ F- LENDER'SA�DRESS__, �,/}--� � ICERTIiYTHATIHAYEFEADTHISAPPLICATIONANOSTA7ETHATTM'cABOYEINFORMATIONISCORRECT. TOTAL FEES ✓ [ /•S� � � W I AGREe TO COMPLV WITH qLLCITV AN�COUNTY ORDINANCES AYD STATE LAWS RELATING TO 6UILOING � CONSTqUCTIIXJ.ANDHEREBVAU7HORIZEREPFESENTATIVr50FTHI5COUNTVTOEMERUPON7H'c ZA60VE-MENTbN D PROPEHT/Y�OR INSP CTION PURPOS� COMMENTS O ��v��.^l'�'1/ --- � �i — QPERMITTEE NPM y� _ Cn / � NATUfiED P ITTEE DATE = RECPT.NO. � PAID BY VALIDATION_ ~ WHITE—Department Copy,YELLOW—Finance CoDY.PINK—Asussor Copy,GOLDENROD---File Copy,GREEN—Applicant's Copy .. . . . ,.... � .�. . ��� ... , ..,.; .. , / �. .. ' . # .., ' ., ..� . • . .`Y;_ F•. r ' ' . , <�}� <. �.� .. '!'_ 'r`��.` .. .. .� . -,a<......�,.t.::r�"� .'. �•r.. :.�,. . :s•w. - . . '_' .;.t.,...�.., _'__ ._ ���a6,�A��4� �1 � � �. ° �iX . „ �t � uF3� 71.. '�k.��Yr�r � ��„ � . , ,rw%'Yr�� ,�i�: ..... .. � . ... , � , . , , . , . . ,_, � . , . � . . . , , . , . � ... , ' . i j. 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