HomeMy WebLinkAbout16987 (894) �� CITY OF DIAMOND BAR �� � DEPARTMENT OF CO�v[MUNITY&DEVELOPMENT SERVICES 2I825 E.Copley Drive (909)860-3195 Fax(909)861-3117 PRESS BUILDING PERMIT APPLICATION FiRMLY � JOBSITE �g.2 7� � �-� APPLICATION (�i_��. U� PERMIT �C��� �/C o ADDRESS DATE � NUMBER � � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER �` ADDR ZOUING SETEiACKS g� FRONT RW O CITY - ZIP�J��� T .��O REAR p APPLICANT TEL. SIDE/SIDE STREEf RW p � CONTRACTOR �"+� SIDE ❑ � CITY � L_ ZIP� t3a TEL��___�-5�1 PROPOSED USE� — D � / � o ARCFVENG/ -� � � z DESIGNER w NO.DWEL. N . � = CIDTMDRESS Z�P TEL. UPJITS STORIES 8 DROOMS � � DESCRIPTION SQ.FT. FACTOF PSF ADJ.AREANALUATION � OWNER•BUILDER DECLARATION SFFilADD�AEM O p I HEREBY AFFlPoA UNOER 7ENALTY OF PERNRY THAT 1 AM EXCMPT FROA1 TNE CONTMCTORS lJ• Gd�8g0/C0�p0I1 W GENSEUWFORTNEFOLLOWINOREASON(SEC.70.t1.SBU51NES5AND7ROFE55lON5CODE:ANYCIT'/DR (n V COUNTYYMIpIR[OUIqESAPERMITTOCONSTRUGf,ALTEH,IMPROVE,�EMOLISM,ORREPAIRANYSTRUC• W w TURE,PHiDR iOITS ISSUANCE,ALSO RE�UIRES TME APPLICAYT FO�SUCM PE W.aT TO FILE A SIGNED w PdtiO/DOCk � SiATEM[NT THAT HE OR SNE IS LICENSED FURSUANT TO THE PROYiSIONS OF iH[CONTRACT�RS LI• � CENSE UW(CHAiTER Y(CAAl11CNCINC YATII SECTION7000)OF O�YISION 70FTHE BUSINES$AN7 GRO� LL" PooUSpa FESSqNSCODE)ORiHATHEOR5HE15ExEUPTTH[REfqOrAANDTNE8+l5i5FOR7MLAlLECEDE%EMP- (� � TpN.A4VNOUTqNOFSECTION70]1.SBYANYAPPLICANiFORAP[RMIiSVBJECTSTHEl1PPUGWTTO Z Re�Rool �CML PENALTY OF NOT MOFE TNAN FIV[HUNDRED DOLURS(i5a0).�: 0 Ot�OWNEROFTHEPROPERT',ORIAYEMPLOYEESwITMWAGE5A57MEiRSOLECOIAPENSATpN, 0 CpmmerCial Z WILL 001T�E WORK AND TNE S7RUCTURE 6 NOT INTEN�E�Oa OFFEREO fOfi 57LLE(SEC.70�1.BU51- J N N[5511ND PROFESSIONS CODE:TME CONTRACTORS LIGENSE LAW 00[5 NOT APPLY TO AN OWNER OF VR07ERiY1N10BUILDSORM�ROVESTNEREON.N:DYh1000E55UCHWORKMIAISELFOPHERSELFOq � K TMROUGHM5011MEROKNEMPLOVEES.CROVIDEOTNATSUCN0.IPROYEIACNTSARENOTMENDFDOR m Q OiTERED�ORSALE.IF,/qWEVEi�THEBUM1D�NCORIAIPROVEMCMI550lDW1TFCNONEYFAROFCOMPLE- z TION.THE OWN[R�BUILOER VALL H�VE TME BUROCN OF PROViNC THAT F1E 011 SME DID NOT BNLD OR � IAIPROVE FORME PURPOSE OF SALEJ. �y,� OlA50WNEROFTNEiROPEflTY,AMEXCLUSNEIYCONTRACTt:O'MTHULENSEDLONTMCTORS [[ TO CONSiRUCTTME PRO.IECT(SEC.77N.BUSINE55 M10 7ROFESSIONS LODE:TXE CONTRACTOf35 U• Vditl2fiOf1 �D ADJ.AREA W GENSEUWDOESNOTAPPLYTOANOWNLROFAFROPEfl7YMMOBURDSORIMPPOVESTFIERCON,AND � YRqCOMRACTSFORSUCHVROJECT5WITIACONTRACTOR(S)LICENSED7UiL;UANTTOTN[[DN7{UU QUANTITY OESCRIPTION FEE Y TORSLICENSEUW.�. � O I AM E%EMPT UNDER SEC. B,t PC.FOA THIS REA;ON Q � U li.. � Z DATE OWrdER � �¢ LICENSED CONTRACTOFlS DECLARATION w CC IHERfBVAFFIRAI�JNOERPENALTYOFPf0.A1RYTHATIA�dLICENSEDUNOERPfiOVISIONSOFCHAPTER � a Y(CqAMENCWCN7TH5ECTION7000)OFC�ViSION]OFTHEBUSIN[SSANDGROFE5410NSCOOE.A.YD Z X MY UCENSE IS N FULI FORLE AND EFFECT. � LLJ 0 LICENSE��J45S� LIC.NO.��� _ � V DATE1j_�D ' a / corrrrucroa ` -' W � WORKERS'COMPENSATION DECLAFATION Q NIHEREBVAFFIRI.IUNOERPENALTYOFPERAJRYONEOFiHEFOLLOWINGDECLAMTqNS: Z � �IMAVE/uJDWI��MAINTAMACERiIFIGiEOFCONSENTTOSEIF-INSUREFORWORKERS' _ Q COAIPENSATpN,AS GROVIDED BY SECTKKI 7�00 OF iME LMGR CODE,FOR iHE PERFORMANCE U Q OF TME WORK FOR WHICN iH15 PCRMIT IS ISSUCD. � QW �I NAVE M1D YVILL MAIMAIN WOP1(ERS'COMPENSATpN INSUfLl4CE.AS pEOUtRED BV SECTiON ' �5. �� 77000FTHELA[iORCO0E.F0(iTHEPERFORMANCEOFTHEWORKFORWHip1TH13PERMlT1$ . 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ISSUANCE � �""�"� %!"�`• � � � � �� O p DATE: pPVLICANT: SMIP t 1 O � WARNINC:FAILURE TO SECURE WOqKERS'LOA�PENSATqN COVERAGE IS UNUw�UL,AND 51uLL BE ENERGY P/C A U � + �y SUBJECTANEMPLOYERTOCRiAAwAIPENALTIESAN�CIVILFINESUFTOONEMUNDRE0t110U5AND ENERGYPERMIT DOIUAS�i100.000),IN AODITION i0 iHE fAST OF COMPENSATqN,OAMAC[S AS iROY:DED FOR IN ¢ SECTION7l080FTHEUBORLOOE.INTEREST,ANOATfORNEv5FEE5. RETENTIONFEE: ��-�r. OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: - �"�^-'� � IHEREBV�FFIRMUNDERCENALTYOFiE0.1URYi11�iTMEREL`ACONSTRUGTIONLENDINOAGENCV FOR THE PERFORMlWCE OF TME WORN FOR WHid17H15 FERMITIS ISSUEO�SEG,]091,PV.C.). Z W � LENDER'SwwE S F— LENDER'SA'�DIlE55 w IGERTIFYTHATIHIWEREADTMISAPVLICATIONANDSTATETNATTMEIIBOVENFORMATIONISCORRECi. TOTAL FEES I S�J v � IAGREE TO LOMPLY WITH ALL CRV AND COUN7Y ORD:NAYLES AN�STATE UwS REUTING TO BUILDING V, CONSTRUCTION,ANDHEHEDYAUTNORREREPRESENTATNESOFi1115CWNTYTOENTERUPONTNE Z A90VE�YEMIDNEOOROFERTYFORINSPECTION7l1R�O5E5. COMMENTS 0 J � ¢ P �TTE N�ME(VRINT' N �� _ �-�� - o� y UIIEOF7EFMIT+CE DATE � � RECPT.AO. � PAID BY VALIDATION WHITE—Department Cepy.YELLOW--Finance Copy.PINK—Assessor Copy.GOLDENROD—File COCY.GREEN—ApplicanCs Copy c��:• ar ��G,r,���tit� �;r�.r-: �i`�i��r;'iC3�•�! FL�C�G _.� ___._.____.�.__...____.__.____...____.._.- -- - ----___.._..._---•---- - • -•-----_-.._ __t_.___.____---------------------- I�`k-'7.!='z,fl�)►�! �'!:':r= I.�}�1��=c;-;�j�. I���.`1;�=:c. ^tcl►'; i'a�`�:"' (i��`f;-�=�':�r�.). '1 --.._._.._._........ ...--- -.-..._ _.. _. . .. . .. .. .. ..... .... . . ... ... ... ... . ..... .. .. _ ... . _. ....__. _..... .._._ . .___..._------- SET 6i-:CK ' � ', FLOOR JDI�i ; .-i. 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