HomeMy WebLinkAbout15137 (1094) �'� J,� CITY OF DIAMOND BAR �
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES ��
� . 21660 E.Copley Drive Saim 190 �/�
(909)860-3193 Fax(909)861-3117 ';l PRE$$
''"" BUII.DING PERMIT APPLICATION FIRMLY
� ODRIESS ` J1������ �����'! APPLICATION� � � PERMIT �X�/3� p ,�Q�q
G DATE NUMBER' � It �'�p` �
$ ISSUE 7yPE pCC
APN LOT TRACT DATE CONST. GROUP
p OWNER �� "'
p ADDRESS �S� � � LLC i''� ZONING SETBACKS
� CITY ZIP TEL. �OM RW ❑
APPLICANT TEL. REAR p
� � SIDE/51UE STREET RW ❑
CON7RACT0 --LL' SIDE p
ADDRES �a � ` � �.�
g CITY G✓L-. ZIP TE��v��� PROPOS�D�E
� ARCHJENC�/ �
DESIGNER � `�
ADDRESS NO.DWEL NO. � NO.
� CITY ZIP TEL. UNITS STORIES BEDRO�MS
� DESCRIPTION SQ.Fr FACTdR PSF ADJ.AREANALUATION
Q OWNER-BUILDER DECLARATION SFRlADD/FIEM
O
I NEREBY AFFlRM INJDER PENALTY OF PERJURV 7HAT 1 AM E%EMPT FROM THE CONTMC70RS ll- GHfeyB/CAIpDR
C@15EUWFORT}IEFOLL0IMNOREA60N(SEC.7ua1.6BU5INESSANOPROFE55KKV5CODE:ANYCITVOR (n
OOUNiYY11FYCHAEC�JWE3APERMIT7000N5TpUGT,ALTER,IMPROVE,OEYlO1J5H2ORREPAIRANYSTRUC- W P8110/DBCIC
IURE.►RIOR T01T5 159UM10E.pL30 REW IRES iNE MPUCANT FOR SUqi PERMIT TO FILE A SIONm W
BTA7E4EN7 TXIIT HE OR&1E IS t10EN5ED PURSUAHT TO 7HE VROVISIpJ3 OF 7FIE CONTFUCTORS U•
C�JSE UW(Qf0.PTER 0(COMMENCq1O YfIiH SECTION 7000)OF DINSION 9 OF THE BlI3INES5 ANO PRO- �'i' PDOI/Spe
FESSIONSCODqOR7XATHEORSHEISE%EMP7TIEREFROMANDIMEBASISFORTHEILLLEGE�6xEMP- �
TION.MIY VIOLA710N Of SECTION 7031.6 BV ANYAPPIICANT FOR A OERMIT SUBJECTB TNE MPLICANT TD Z Re-Rooi
� AqVIL VEN/LTV OF NO7 AAORE TU1N FNE NUNDRED DOLLARB(=500�.):
D4A.^OWt1EROFTHEPROPEHTY,ORMVQ.IOLOYEESWITHWAOESA5T/EIR80LECOMPEN5AT10N, (,`pmmBICiOI
WILL DO THE MfOH1C,ANO iHE BiRUCTVRE IS NOT IMENDED OR OFFERED FOR SALE(9EC.7w6,Bu51- �
y NESSAND iilOFE5510Nb OODE:7NE CONiMC70R5 LICENSE LAW OOES NOT�PP�'!TO AN OWNER OF �
PRDPER7Y Wl10 BUILOS OR IMPROVES 7NEREON,ANO MM110 DOES SUCH WOpK HIMSfLF Oq HEHSEIFOR
� TMf10UfiMNI50RNERONM�APLOYEES,PROVIDEU7WITSUCMWPROYEMENT3ARENOiINTENDE00p IL�
OFFERED POit S1VLE tFliOWFVER11�E8UIl.01N00R IMPHOVEMINT IS SOLDV/11HIN ONE YEAqOFCOMPLE-
TION.T1E OWNER�BURDER N1LL HAVE TXE&1RDEN OF PRONNO iHAT ME OR SHE DIDlpT BUItD OR
W PROVE FOR THE PURPQSE OF 9ALE�.
W OI.AlOWNEROFTFIEPROPERiY,AME%CLUSNEIYCONTMCTINOWRFiUCENSEDCONTMCTOR$
' (� 1000NSTRUCTT1ff VRQIECT(BEC.70M,BUSINESSAND VFIOFESSIONS CODE:7HE LONTRAC70h5 LL 9Wi[I011 ADJ.AREA
�i� CENSEUWDOE8NOTAPPLYTOANOWNEROFAPROPERTYWFIDBUILDSORIMPRDVESTHEflEON,AND
Z WFIOCONfMGT6FORSUCHPROJECT3WIT1111fqNfRACTOR(S�LICENSED%1qSUANTTOTME00NTRAG OUANTITV DESCAIPTION \ FEE
� TORSl10EN5EUW.�. •
J /'
❑I AM EXEMPT UNDER BEC. B.i V.C.fOR THiS REASON U �
�= DAiE OriNER F�
� U
q LICENSED CONTRACTORS DECLARATION W
2 IHEREBYAFFIMIUNDEflPEN.LLTYOFPE0.IURYTHATIAMLICENSEDUN�ERPROVISIONSOFCNAV7ER �
S ��COMMENCWON7THSECTION7000)OF�NISION�OFTHEBUSINESSANDPNOFESSIONSCODE,AND Z
7[ W LICENSE IS rl FULL FORCE AND EFFECT. /']
� LICENSE/Cj'A 55 C��! LIC.N0. �a� ` .�,��,r-� �
DATE r'/ � C �'d� CONTRACTOR G ti � a
WORKERS'COMPENSATION DECLARATION ,�
� IHEREBYAFFIRMUNDERPENALTYOFPERAIRYONEOFTHEPoLIOWINODECLMAi 5. ��r z
� __IWWEANDWILLMAINTAINACEIffIFlCATE�CONSENTTOSEIF-M1511REFORWORKERS' _
OOIAPENSATIDN,A9 PNOHbED 8Y 6ECTION 3700 OF TFIE LABOp'(.O�E.FOq THE PERFqRMAN W
Q OFTHEWORKFORWHICHTHISPERMIT1915SUE0. �
� �IFUVEANOWILLMAIIirA1NWORKERS'COMPENSATI�NINSUfUNGE,A5REQ11RE�8V5ECTION
Q 37000FiNElABORO00E,FOR7HEGEH�ORMANCEOFTHEWORKFORWHICHTHISPERMRIS
� ISSUED.NY WOq'K`r�B7�yCO NSAT�INS j�PNCE CARRI ANO POLiCY NUMBER ARE: CONSTRUCTION / -�
�j GRAIER "/ ' � PLAN qEVIEW .. .
� vaLCYNuueER '�' ECECTRIC
� (MssECIpNNE�NOTBEC�LE�oF7HEPEwAiBWRa�EM1WREODcuNL9(f� on PLUMBING
� IC6RTFV 1}IAT NJ TME PERFORM/NCE OFTHE WORK FOR WHICM THiS PERMIT IS ISSUEO,I MECHANICAL
SIiALL NOT EMPIAV ANV OERSON IN ANY MANNER SOAS TO BECOME SUBJECT TO TNE
� WORKER9'COMPENSATIONUWSOFCALIFOi1NIA,ANDA EET IFIS BECOME INSPECTIONFEE
SSUBJE p70 EIMORKERS'COMPENSA OF OOFTNELA90R -
-�L J�i�rnca.+a�r ISSUANCE
� � l Q� ��✓^ .�r.�.��,..:i.��
p DATE: APPL�CAN7: SMIP
� ENERGY P/C
WARNING:FNLURE TO SECURE WOflKER5 COMPEN511TION COVEFAGE IS UNUMIFUL,AND SHALL BE
�y, SUBJEGTNJEMPLOYER70CRiAiNNLVENALTIESNVOCNI�FMIESUPTOONEMUNDREDTFiOV$ANO ENERGYPERMIT ( ��
¢ OOLURS(i700,000),IN PDDI710N 70 TXE C0.ST OF COMPENSATqN,DW AC,ES AS VHOVIDEO FOR IN
SECTqN 7iW OF THE LABOH OODE.IN7EREST.ANDATOHNEV'S FEES. F7ETENTION fFEE: J �''
nW. CONSTRUCTIONIENDINOAOENCY PRE-ALTFEE:����'�Jl' �jl�•x`:r�'�i� �:.�Z�
� IHERE9YAFFIRMUNDERPENALTYOFPERJURYTHATTHEREISACONSTRUCTIONLENDINGAUENCY l"�'�} AT'��� G'1;;;:'"
Z FOR 7NE PERFORMANCE OFTHE WORK FOR WHICH 7HIb PERMR IS ISSUED(SEC.70o7,CN.C.�. !'-71����E��`3 � "�`� 1�
W ��,n�
� LENDERS NAME
� IENDER'SADDRESS
� ICERTIFY7HA71HAVEfiEADTHISMVLIG.TqNANDSTA7EhIATTHEA60VEINFORMATI0NI5CORPECT, TOTAL FEES /' '�
d 1 AOREE TO CddPLY WITH ALL CRY AND COUNTY OROINANCES AND STATE lAWS NELA7N6 TO BU0.DING 4 (.7
� CONSTHUCTION,ANOHEAEBVAUhIORIZEREPRESEMATNE50FTHI5Cd1NTVTOENTERUPONTHE r � / �
ABOVE.MEMIDNED iROOERTY FOR INSPECTIDN VURG06E3. v
a ���� �^���, �� co MENTS
4 P EE E I �! �+ � r
J
� I� E 1 E DA
� RECPT.NO. PAID BY VALIDATION
WHITE��Oertment COpy.YELLOW—Finence Copy,PINK—Asnessor Capy,GOLDENROD—Flle Copy,GREEN—Applicant s Copy