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HomeMy WebLinkAbout13696 �J'/�� I `„�j/���?:��- �e7� `r I l�� CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY�DEVELOPMENT SERVICES � 21660 E.Copley Drive 5uite 190 (909)860-3195 Fax(909)861-3117 PRESS 'A�'� BUII.DINGPERMTT"" LICATION FIRMLY � JOBSITE "�`'"' y �. ,. APPLICATION /+� ,�+ PERMIT �>_q� P/C o ADDRESS DATE �� <3 NUMBER �s' / # .�.t`� " ISSUE TYPE OCC � APN�_ LOT TI�A� �'� qATE CONST. GROUP SOWNER '�✓,�"� . ';;��o- : ADDRESS � ""'" �—ry 20NING SEiBACKS � CITY ZIP " 1'EL. REART RW � APPLICANT ` TEL. � SIDElSIDE STREET RW !-1 CONTRACTOA �_ SIDE � � ADORESS `�'�` " '�' � � CITY TEL PROPOSED USE '�' D r w AR�FUEN�,[ �� z DESIGNEE� NO.DWEL. `NO. NO. � AD�RESS UNITS_ _ STORIES BEDROOMS � CITY ZIP TEL. � � – - DESCRIPTION SQ.Pl'. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILOER���CLAflATION` � SFRlADD/REM t �' -�� O p �HEREBV AFFlRhf UNDER PENAL7V OF PEiLIUPY THAT I AM EXEMPI"FROM THE CONTRACTORS LI- G8f8CJB/CBryJOff � CENSEUWFORTNEFOLLOWINGREASON(SEC.J031.SBUSINESSP.NDPROFESSIONSC�E:ANYCITYOR (n COUNTYWHICNREWIRESAPERMITTOCONSTRUCT,ALTER,IMPP.OVE,DEMOL'SH,ORRE IPANVSTRUC• W PBSiO/DBCI( NRE,VRIOR TO:TS ISSUANCE,AL50 ReQUIRES THE AVPLICAN7 FOR SUCM PERMiT TO�FILE A SIGNED w STATEiAENT 7H11:HE OR SHE IS IJCENSED YURSUANT TO 1HE PROYISIONS OF T1+E C7iWTPACTORS LI� W�-- � CENSE UW(CHIIPIER B(COMMENCINO WRH SECTION 7oD0)OF DIVIS!ON 3 OF THE 9USINESSANO PRO� �I POOUSpe FES510NSCOOE)ORTdA7HEOR5HEISE%EMPT7HEREFROMANDTHEBASISFORTi�EALLE6EDEXEMP� (� V TqN.ANYVI0LAT10NOFSECT10Y70:11.50VANVAPPLICANTFORAPERMITSU&lECTSTHE�P�PLICANTTp Z He-Roaf � ACIVIL PENALTY OF NOT MORE 7HAN FIVE HUNDREO DOLLARS(SSao)): � ❑I,ASONMEROFTHEPiiOPERTY,ORMVEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, � Comrnercia� WILL DO TME WOflK,ANO THE STRUCTURE IS NOT INTcND[D OR OFFERED FOR SALE(SEC.7D44,BUSI- J � NESS AND PriOFE5510N5 CODE:iHE CONTRACTORS LICENSE LRW DOES NOT AP?LY TO AN OWNER OF � PqOPERfY V�Vp BUM.DS OH INPiiOVES THEREON.AND YfiO OOES SUCH WORK HIMSEL�OR HERSELF OR � THHOUGHHISORHEROWNEMPLOVEES,Pi1QVI0EDTHATSUCHIMPROVE!AEWTSARENOTIN?ENDEDOR m oOFFEREbFOHSALEIF,HOWEVER711EBUILDWGORIMPROVEA7ENTISSOLDWITHINONEYEAROFCOMPLE __ Z TION,hIE OWNERAUIlOER WILL HAVE THE BURDEN OF VROVING THAT HE OR SHE DIU NOT BUILO OA � IMPROVEFORhI[PURPOSEOFa'ALE). � W C�.tiSO4NJEflOFh1EPR0°ERTY,AME%CL'JSNELVCJNYRACTINGWITNLI�ENSEDCONiRqCTORS d TO CONSTAUCT T}1E PRQIFCT(SFC.7044,BUSINE35 AND PROFES910N5 CADE:T"E:ONTRACTORS LI� V8I118110f1 ADJ.AREA W CENSEV.WDOESNOTAPPIYTOANONM'cROF0.PflOPERiYWHOBUILD50RIMPROVESTNEREON,ANO — —'"— Z W}IOCONTRACTSFORSUCHPROJECTSWITHACONTRACTOR(S�LICENSE�PUfiSUMITTOTHE:ANTRAG QUANTITY ' �ESCRIPTION FEE Y TORSLICENSELAW.I. . � GIAVE%EhlPTUNDERSEC.__ B.BP.^.FORTHISREA50!! J � _'__'_' Q , � -- —'----- U ��. � DATE OWNER F' Z W � LICENSED CONTRACTORS DECLARATION �i � W�_ _ 1 NEREBY AFFlRN UNDER P'eNALTY OF PEiiIURV THAT IAM LICEYSE�UN'�ER PROVISIONS OF QNAPTE�R �� � B(COMMENCINO WITH SECTION'I000�OF[11VISION30f THE BUSINESSANJ P•70�ESSIOM.SCOd�„kKl'J LLI MY LICENSE IS W FULi FOflCE AND EFFECT. 1'f m�— d LICENS�nE CyL�ASS_ �� LIC.NO.� .�r z 6 p �I- ~ DATE v/—��� J V CONTRkCTOR �+-� W l � WORf(ERS'COMPENSATION DECLAR��NI., �`l�! j� , z. IHEREBYAFFlqMUN�c`HPENALNOFPEPJURVONFOFTNEFOLLO`NI�G�E 4RTb �I � Q O __IHAVEA?1CWILLMAINTAINACERTIFICATEOFCONSFNTTOSEIf-INSlii7E:ORYlORKEAS' _ � COMPENSATION,ASPRciVIDEDBVSECTION31C90FTHEL4BORCO�E.FOqTHEPER-ORMAKCE , U Q OF7NEWORKFOftWHICNTHISPERMRI51551:ED. � [_1 �'� IHAVEANDW��Lh�AINTA�NWORKEAS'COMPENSA'ION�NS:IRANCE,ASP.E(>1::4ED9VSECTION � ;i]noOF THE LA60R CODC,�OF TH£PERFCRAIANCE OF TNE WORK FOR W�11C4'fHIS PeRMIT!S ISSUFD.NYWURKERS'�M?ENSATIONINSURANCFCAP.RIERANUPOJCY4UMBEFA� CONSTiIUCTION __,_____ _„_ � �' �� Q I �°' > CPARIEF_�.�F�_(� _ f' PLANREVIEW ______.__,___ .-r- � po��cv nuMeea_� �►� ��__,^�•-�_ ELtCTRIC ___ _���� ¢ j/j � (!HISSE(:fqNNEmNbTBEGx.PIETFDOFTV�yPEfJMS�HOkEHJNJi7cDD�lWiS(ElOo} _E } PLUMBING ___ .__,____._ Z I CERTIFI/THAT I�THE PERFORMANCE GF THF W(JRK FOR WH.CY.THIS PERNIT iS ISSi;E�1.' . '� � MECHANICAI _____ _ (�j S/ULLL NO i EMPLOY ANY PER50N IN ANY MANNER 5V AS'O BECOME SU W ECT 70 TH'c l� ' ;"�� F•.?7�R t� ;� � WORKERS'COMPENSA7iONLnW50FCAL'FOFNIA,ANDAGREF.THATIF�SHQULDB[CONE�+ i� INSP[CTIONFEE __ . i k� = SUBJeCTTOTHEWORK�RS'CDlAPENSATIONPROVt510450FSLCTICN37G00FTHELABOR �� J '"• " �- " e CfJDE.�SHALL FpRTHW:TH COMPLY Wlhl THOSE PROVI ONS ISSUANCE ;�."'�- �'� �� p II�/dQ - _ . .,.. . . `�r;.t.�> � JATE:�_xf)�l 1 APPUCANi: ____'_��__ SMlP ._ ., ., - . ,, _ _ �1Z� J WARNING FAILJRE TO S%C;RE WORI�RS'COMPENSATION COVERAGE IS 11N:AWFl1L A�D SHALLBE ENERGY PIC __ __ � SUBJECTANEMPLOYEATOCRIMINALPENALTIESANDCIVILFINESLPTOONEHUNDREDTHOUSAND ENERGYPERMIT D�ILARS(L�oO.00D).IN AODITION TOTHE COST OF COMPENSATIDN,OAMAGES AS 7qOV�DED FOR IN -------------- � SECI'ION 3lae OP TME LABOR CODE,INTEHEST,ANDATTORNEV'S PEES. RETENTION FEE: ____________ ____ d CONSTRUCTION LENDING AGENCY PRE-ALT FEE: p --�----- ;�,. �. � I HERE9V AFF;RM UNDCR P[IvALT1'OF PERJURV THA7 TNERE IS ACQNSTFUCTION LGYDING AGENCY _ �� _ fOR TN'c PERFOflMPNCE OF TN'c WOL1K FOP.WHICH THIS P TY'IS ISSUED(SEC.3037,CIY.C.1. Z � . �' li! — ..�.���,�.,�.y � � LEND'cR'S NAME '+ . 1— LENDER'SADDR � ���, , ;� � ICF.RTIFYTHATIHAYEREADTHISAPPLICATIONANDS'ATETHATTHEABOYEINFbRMAT10NISCORflECT., � TQTA! FEES , :� � IAGREE7oCqM.PLYWITHALLCTY.4NDCOVNTYORDINANCE5AND5TATELAWSRELATINGTOBVILDING'� ' � CAN57RUCTION,ANDFi'v-REBYAUTNORIZtFEPPESENlATIVESOFTHISCOUNTVTOE�ERUVONTHE Z A90YE-MENiiONED PROPERTY FORIN57ECTION PURPOSES. COMMENTS_ QI _—_ _. � , � —____ _ m PERMITTEE NM9E(PqINTI Q __ _ � ' __— — '..':�' ' � SIGNATURE OF PERMITTEE DATE ' = PECPT.NO. PAID 8Y - �IDATION ~ WHITE—De artment Co YELLOW—Finence Co PINK—Asses'sor Co GO L'ENROL1—F7fe Co G N— licant's Co P PY. PY. PY� _ PY� APP Py � . . � ' . , i , , . . � �'.i i � war., .a .y�,. 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