HomeMy WebLinkAbout1191 A ^~. '"� CITY 4F DIAMOND BAR ��PRE�� ���
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��, ^ DEF�ARTMENT OF BUILDING AND SAFETY
�^^ BUILDING PERMIT FIRML,Y
JOBSITE ���° �a._...._ APPUCATION PERiuiIT US�—
ADDRESS;�.L1 � �� '�- r � r ' DATE NUMBER CODE
� ISBUE ^,TYPE C.
6 APN _� OT TRACT DATE ' � �ONST. GROUP
� CROSS ST ET SETBACKS ���
°^ OWNER �"�' ` ce., ZONING FRONT RW ❑
o ADDRES � �� - -" ' `� � REAR ❑
o I APPLICANT '�z ZIP ,—L TEL..� J`� � SIDE/SIDE STF�EET RW ❑
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a CONTRACTOR 7 ��� , �
o ADDRESS ' SEWAGE ❑ PUBLIC PMT�
DISPOSAL ❑ pRiVATE SQ.FT./100 GAL
W CITY_ ZIP TEL. __�
z STATE GRADING � CU.YDS.EXC. CU YDS FILL
a LIC.NUMBER
y ARCH/ENG/ Vy X�YPE SQ F7 FAGTOI� PS . �ApJ. REANALUAT'iON
`=' DESIGNER W �
p l�DDRESS � 2
= CITY ZIP TEL. � � 3
� PROPOSED U5E - �'� a z �
� f�' � � 6ARAGE
o NO.uWEL. NO. NO. m pORCH
y UNITS STORIES BEDROOPAS
s LOT DIMENSIONS VALIJATION ADJ.AREA
o NO.OF BLDGS HOW QUAN'f'ITY DESCRiPTION �E�
W ONLOT USED Q
� —
W ❑ �
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~ LCENSEC CONTR�L?ORS OECLARATION:I Aeie�y afFirm Uial I am hcensetl unAer Omvisions af Chapter 9�commencing I^
� rvr.n 5 tior.1�001�f Dr�ision 3 cf!he 8us�nes5 and P:afessions CoAe.and my license�s in fuN lo¢e and ellett �
3 �
YhF.R�RUILDER DECLAFA710N�i hereLy a16im that 1 am e xmpt from�he Camrac�a's Lrtense law foi the iollowinq
Z reasor jSec 7031 5,3us:ness and Pmlessions Codr Any city ar county wh;ch requires n permit to cunslruct (}
o altei imFinve,de.:nrnnh m repau any stmcWre pnor m ns issua�e also:equires Ihe apphcant tar such permil Z —
Qlo:ile a signed statemert Ihxt he�s hcer.sed pursuant to the Omrisions ul ihe Controttor's L¢ense Law IChapter �j
p� ��cummenang�mth Seclmn'000�ol pivision 3 0l,he Business and P:ofess�ons Cade1 a that he is exempl Iherefrom �
a, ure me hasis lor d�e allegeJ�xempnon A�ry violaton of Seclmn 7031 5 hy airy applicam tor a permn su6�e[E �
K !hc ap;hcar;:o a avu Oenalry ot not nore thar live hundied dollars I55001� a
W
� Li,as awier cl•he properN,or rry emp;oyees with wages az Iheu sole compensatmn wAI ua ihe wa�k and
~ the stmcture�s�iul�mended a�olfered lor sak(Sec.1044 9usiness and Professrons Code The Canha�mr's Ucense
� :aw does v^i aOC�v�c an ewner of praperty who builds or�mOroves therean,antl who dces such work him�elf U —
' nr 1!:rougn his awn rmployees.promded Ihat such im0�ovements aie no;�ntended m affered lar sale If.howevec 2
m tl•e a�.nAmc nr imo:oaemer.t is sold wrthm one year ol complen�n.Ihe owner-huilEer wAI haue the burden al provmg a __
= tha:he d:d�et hmin ar impm�x Im the purpose of sale 1 Y
ti ❑i s nwaer n!ihe pmpeny am e:dusvely canlracuny wrth I¢ensed comra[rors W canslmct�he pm�ect(Se� W
o i044 dBesiress and Pmfessions Catle:The CoNractor"s license Law Aaes nol aVqY to an awnei oi Dioperty who � -
z I:uilds or�mproves�hereen,acd whn con[raue for snch pra�ecn wnF.a convacmqsl licensed pursuam to ihe Convacmr's
¢ L1Be"5e�a`"' " CONSTRUCTION
W ❑ I am exempt w�der e� �E PC.IA n c �a�� PLAN REVIEW _i�-G iX •��o�L�
o Cate "' �^ef ` ELECTRIC i
� WOflKENS'C9MPENSATION OECLARATION.I here6y aHvm that I have a certii¢ate al cansenl to self�insure,or
a cerFilicate a!Workers'Compensation Insurance,or a cerlified copy+.hereof(Sec 7800,lah C� PLUMBING
Q ❑c�<<�nea�aPv is h.eretry Lxnished � MECHANICAL
c ❑ Cerhfietl cepy is fileU.�ith Me Bwitling Inspechon Oepaitmem or Oepartmenl � GRADING
W
Z CERTIFICATE QF E%EMPTION FflOM WONNEflS'COMPENSA7IIXJ INSUflANCE This secuon neeA nat 6e completed (� �SSUANCE
� d Ine permn rs 1ai one hundred�S10D)a less I teruiy that�n the pedo�mante ol the v+ark lor whKh this —
y e m�t�5 issued,I shall�wt em o an
p r pl y y pe�wn m any manne�sa as to 6ecame sub{ect lo Ihe Nbrke�s'Compenution gMIP
= L'dws nl Cahfnnna W
o W PARiC FEE
p Dam AppLcanl �
j NOTICE TO APPLICANT If,alter makmg�his CertArta�e of Eaempuon,you shouN hecome sub�ep ro Ihc 4Yake�'s SCHOOL FEES
—� CmnDensation D�ovisions af Ihe Who�COdO,y0u mutt forlhwilh cOmD�Y wiih suth pOvispns a th�s permrt shalt
LL he AeemeA�evokN —_
J
� DIVISION Of INDIISfHIAL SAFETY PERMR CEflTIFICATION
W
d ❑I hr.rehy cenAy ihat na ex�avation hve(51 or more teet m depth imo whxh a p[rsm is repuuM to deumd,
0
¢ wdl he maM m connettwn wim xrork aulhw¢ed by Mfi permit,ard that no budOinp 5[rutlur4 SWfMEinp,talsewatk,
d or Aemolnimi m dismanth�p tMrtol,will he more than tAi�ry�rn�36)leet high.�Chap 31.Gry P.Art 7.Sec
W 341 Tnle 6.C A.0 1
S
3 ❑As owner-6wlder, I will not empky anyane lo da wark wMch would repmte a pemit hom Me Orv�sian al
� Industnal Sefery as noted above,unlcas such penon has a pe�mrt to da such work Irom Me diviaion
� —1
W ❑0.�ismr.ol Industnal Sale�y Permit No
d TOTALFEES
� CONSTR�CfION LENOING AGENCY:I 6erehy allirm Mat there is a construcvon lendup egmcy fn the perla�mantt �'�"
Z oi tne wnrk for which ihrs permrt rs rssad ISec 3097,Crv.C I�
� lender's Name COMMENTS
mLwAer's AAdress
Q CEfi�IfICA7E OF COA1Pl1ANCE AND AUTNORIZATdi OF EMAY.I certify 1 Aave�ead�his�pplKation e�d stah
�J Ih07�he iniwmavan pv¢n a[pre[I I agree to canply wn�aA stare laws and ciry vd�es�eYtliq m hutlEiip
y canstrucnon,and aulharue a rroaseircative nf the Departmem af Build'mq md SaiNy m m�er upon�he praperN
= lur wM1rth I have appl�ed lor Mis permn lo�tM pupose ot making mpelions
F �
Slgnatwe of ApdKmt oi Apent p'4 RECPT NO. � PAID BY VALIDATi�
WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GO�DENROD—File Copy,GREEN—Applicants Copy
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