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HomeMy WebLinkAbout13324 �� CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY'&DEVELOPI4IENT SERVICES 2]660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 RESS ���'�� BUQ.DING PERMTT APPLICATION __ FIRMLY . . . ._. . . .. _. . . .. . .. ... . . ...:..,.-,,,..,wr.X.�:.a � a:.�:.w.-:.,nns�as,...... � JOBSITE ztt�7� 1Y' �.,^ APPLICATION PERMIT Pl o ADDRESS �J� Y��ilJ��I ��s'�-�T DATE h���1�}�Qq NUMBER/� #�j-I 1� c� ISSUE TYPE OCC APN LOT �� TRACT g� � DATE CONST. GROUP p OWNER L5 Q-./� "' ADDRESS2Fj7I VCG �' I�E� G'r" ZONING SETBACKS �W CITY Q� ZIP TEL.�I7�0��7 REART RW G APPLICANT C'.• .d.Y�,�� TEL.�,�,_—�I�AI�; � —'r� r—'� SIDEJSICE STREET RW ❑ CONTRACTQI�, '� S 9� SIDE ❑ ¢ ADDRESS 3L PROPOSED USE ��`�L u r' G o CITY ZIPq r7 o TEL. ? � w ARCW,�N�/ Z DESIGNER �Ae- NO.DWEL. NO. NO. � ADDRESS .°�[' l.6� UNITS STORIES BEDROOMS � CITY ZIP�D� •TEL. " y DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARA710N SFR/ADD/REM O � I HEREBY AFFlR►1 UNOER PENALTY OF PERJURV TH�T I AM EXEMPT FROM THE CONTRACTORS ll- G8f89B/CefPOfl W CENSELAWFOHTHEFOLLOWINOREASON(SEC.7031.58USINESSAN�PROFESSIONSCODE:ANVCITYDR (n � COUMVWHICHREOURESAPEA�MTTOCONSTRUCT.ALTER,IMPROVE.�EWOLISH.ORflEPAIRANYSTAUC- W PaiIO/DBCk NRE.PRIOq TO ITS ISSUANCE.AL50 REOUIRES THE APPLICANT FOR SUCH PERMRTO FILE A SIC�IEp (L � STA7EMENT THAT HE OR SHE IS LICENSED VURSUMtTYO THE PpOVISIOFIS oF THE CdIdTRAC7DpS LI� � � CENSE UW(CHAPTEfl B(COMMENqNO VNTH SECTKKJ 7000)OF DIVISION S OF iHE BUSMESS/N�PRO- � POOVSPB FESSIONS�E�ORTFIATHEORSHEISEXEMP7THEREFROAiANDTHEBASISFORTHEALLEGEDE%EMP• � TqN.ANI'YIOLATIONOFSECTION7031.5BYANVAPPLICANTFORAPERMIiSUBJECTSTHEAPGUCN'JTYO Z R@-ROOf � ACINLPENALNOFNOTMOFETHNdFNEHUNDFED00LURS�SSoo).): � ❑I,ASOWNEROFTMEPFOPEHT/.OHMYEMPLOYEESW�THWAGESASTHEIRSOLECOMPENSATION, � CommerCidl lMLL DO 7HE WORK,M1D THE bTHUCTURE IS NOT INTH.IDED OR OFFERED FOR'SA,LE�SEC.7aL 6u51- J NE55 AND PROFESSIONS CODE:THE CANTfUCTORS UCENSE UW DOES NOT APPLY TO AN OWNER OF � PROPERTYWHOBUILDSORIMPiiOVESTHEREON,ANDWHODOESSUCHWORKNIMSELFORHERSELFOR � Q THRIXI(iMHI50HHEXOWNEMPLOYEES,PROVIDEDTHATSUCNIMVROVEMENTSARENOTINTENOEDOR m QOFFEREOFORSN.EIF,FIOWEVERTMEBUILDINGON�MPpOVEMENfISSOLDINITFIINONE�EAROFCOMik.E- Z iION,THE OWNEF-BUILDER WILL HAVE TNE BUROEi1 OF VROVINO 7HAT HE OR SHE DIO NOT BUILD OR = IMPpOYEFOR7HEPUPPOSEOFSALE�. ❑1,AS OWNER OF THE PROPERTY,AAA EXCLUSNELYCOMRACTING WITH LI�ENSE�CONTRACTORS �����'] � TC CONSTRUGT THE PRWECT(SEC.1oH.Bl1SINE5S AND PFIOFESSIONS CODE:THE CONTRACTORS LI- V01U0tiOn � _�SL'_ ADJ.AREA. W CBISELAWDOESNOTAPPLVTOANOWNEHOFAPROVERTYNhiOBL11LDSOflIMPROVESTHEfiEON.AND � WHOCONTMCTSFORSUCHPR0.IELTSWIhIACONTqACTOR(S�IICENSEDPURSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FEE Y TORSLICENSELAW.). , � J Q O I M1 IXEMPT UND£R SEC._ B.8 P.G WR 7NIS REASCfJ Q 3 � '��1�t � � DATE OWNER _ U Z W - �Q LICENSED CONTRACTORS DECLARATION W S 1 HEHEBYAFFIflM UNDER PENAI.TY OF PERJURY THAi I AM LICENSEO UNDER PROVISIpNS OF CHACTER � d 9(COMMENCINO WRH SECTION 7n00)OF DIVISION 30FTHE BUS!NESS AND PROFESSIONS CODE,ANO z ___ X MY UCENSE IS IN FULL FORGE AN�EFFECI m ,^^�.� L1J r. � � (GJ•� 0 LiCENSE CLASS �^�� t IC.NO.� O � � U �-��l—�-�— �� DATE��� O �� CONTRACTOR O � a � WORKERS'GOMPENSATION DECLARATICN U � �Q � � � I HEFEBY AFFIRM UNDER VENALTY OF PERJUflY ONE OF 7H'c FOLLDWING DECIAPATIOUS: � z ^ ¢ � _iHAVEANDWILLMAINiAIkACEPTiFICATEOFCANSENTTOSEIF•INSUFEFORWORKERS' _ Q COMPENSkTIOIV,ASPHOVIDEOBYSECT10N370oOFTHEUBORCO�E,FOR7NEPERFORMANCE W OFTHE Y/ORK FOR WHICH THIS PEFAiIT I6�SSUED. � W �1 MAVE AN6 WILLMqIN�A1N WORKERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTION I I ,^ � 37000FTHELABORODOE,FORTHEPERFORMANCEOFTHEWORKFGRWHICNTH:SPERMITIS Z(�.� 0 ISSUED.A/Y WORKERS'C�MPENSATiON INSURANCE GFilRIER ANO PO!ICY NVM6ER ARE: CONSTRUCTION 1. � CARRIER �� � PLAN REVIEW '�e-r- �L ZPOLICY NUMBER �'t ELECTFIC _ �–f. c v ¢ � � (fF11S6ECTIOHNE�NOTBEWRAPLEfEDaFTHEPERMIfSF00.adEMM7RE�001.lf3i5(S1fA)ORI.ESS). PLUMBING ��"� ^ �^'"� Z iCERYIFYTNAiINTHEPEflFpRMANCEOFNEWCRKFORWHICHTHISPERMITISISSUED.I MECHANICAL •�_i�,i++ `_�S.L �;J SHAL4 NOT EAIPLOYANV PERSON IN ANY MANNER SOAS TO BECAML SUBJECT TO THE ''� � WOFNERS'CONPENSATiONLAW50FCAUFORN�A,AN�AGREEh1ATIFISHOULDBECAME INSPECTIONFEE �— �� � - S SU&IECTTO TNE VMRKERS'COWPENSATION PfYOVI510N5 OF SECTION 3�00 0F THE LABOR `_ �'��� : CDDE. SHALIF RTHWITHCOMPLYWITH7$lpSEP VISION� ISSUANGE � � O 7 :'4 p DATE:�"� APPLICANT. l�, SMIP �:.<���La ��� w ENERGYP/C ^� r�' ^+�"'Y�` J WARNING FAILURE TO SECURE WORKEHS'COMPENSATION COVERAGE IS UNIAWFl1L,AND SHALL BE ,"�•T�-T� LL SU&IECTANEMPLOYERTOCRIM�NNLPENALTIESANDCNILFINESUPTOONEHUNDflEDTHOUSANU ENERGYPERMIT _ -• ° DOLLARS(i10o.o00�,IN ADDITION TO THE COST OK COMPENSATION,DAMAGES AS GR�VIDED FOfi IN A-� J SECTION37080PTHEI.ABOFCO�E,INTEREST.ANOATTORNEY'SFEeS. RETENTIONF E:'�� `�^�`` � �J � E"'`.�';. � '. d OCONSTRUCTION LENDIAG AGENCV PqE/JA�LT�E�`'�,q��— � I HEREBY AFFIRM UNDER PENALn'OF PERJURY THAT THERE IS�CONSTHUCTION LENDING AGENCV �[__ ��' � FOR THE PERFORMANCE OF THE W�RK FOR WHICH TMIS PERMIT IS�SSUED ISEC.3DB7,CIY.CJ. a��� T1�S � LENDER'S NAME ._ 9 ,J y"'C�`L.1'�-� F- LEN�ER'SA�DNESS - T WICERTIFVTNATIHAVEAEADTHISAPPLICATIONANDSTATETHATTHEABOVEINFORMATIONISCOFRECi TOIAL FEES d IAGPEETOCOMPLYWITHALLCiT'ANDCOUNTYORDINANCESANDSTATELAWSREIATINGTO8UILAING CONSTRUCTION,PhD NEREBY AUTFIORIZE REGRESENTATIVES OF THIS COUNTYTO ENTER UPON THE ZPBOVE�MENTIONEDPROPERTYFORINSPECTIONPURPOSES. COMMENTS � �� �� � ¢ PERMITTEE N (PRI 'l Q - N � � v� f�� � SIGNATl1REOFPE �ATE = RECPT.NO. PAID BY VALIDATION ~ WHITE-DepaRment Copy,YELLOW--Finence Copy,PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy _ . . .. . .. �.: � � .. .. ... . , . , . � . , � , , . � �. . ; , -. . ., " : .. . �. 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