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HomeMy WebLinkAbout13792 J� CITY OF DIAMOND BAR � DEPARTMENT OF COMMUNITY 8t DEVELOPMENT SERVICBS � ;..^ � 2166o E.Copley Drive Suite 190 PRESS (909)860-3195 Faz(909)861-3117 � ���%�^��� BUII.DING PERMTT APPLICATION FIRMLY } JOBSITE }!],�, j_j;a��'����7� �f APPLICATION � 2� (� PERMIT ��� -2�� o ADDRESS�� «v`� � �'. DATE I NUMBER � -� ii c� ISSUE TYPE OCC APN_ LOT y TRACT f DATE_ CONST. GROUP p OWNER� ° ���' LL ADDRESS � `"'i J '/'It 9 ' ZONING SETBACKS w ��7f�.^' � FRONT RW ❑ � CITY '. a ZIP ^ ycc.' TEL. y REAR C CS APPLICAN�""'. . TEL ' '� SIDE/SIDE STREET RW C � CONTRACTOR r L/ f � -� ls� SIDE ❑ ADDRESS ' r'� ' ± L f---d�~� � CITY � C� - ZIP�.i- -� TEL. � - >- y� PROPOSED USE � �x'✓������'`� ��Z � �P� ' e"Q!J' � ARCH/ENG/ �' g�"��� '� z DESiGNER NO.DWEL. NO. NO. }� ADDRESS UNITS_ STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION Q OWNER-BUILDER DECIARATION SFR/ADDlFEM O I HEREBY AFFlRM UNDER PENhI.TY OF PEiLURY THAT I AM E%EfdPT FROM THE CONTRACTORS LI- G8f2gB/C3fpOfl W GENSE UW FORTHE FOLIOWMG REA50N(SEC.7031.5 BUSINESSAN�PROFESSIOYS CODE:ANV CITVOR (f� C� COUNTYWHICViRC-0UIRESAPERMITTOCONSTRUCT,kLTER.IMPROYE.DEMOUSH,OftRF.PAIflANYSTFUC- W patio/Deck � TURE PRIOR TO ITS ISSUMIC�.AL50q�OUIRES THE APPUCANT FOR SUCF4 PERMIT TO FILE A SIGNED w � STATEMENT iHAT HE OR SriE IS.ICENSED Pt1R5UdNT TO THE PROVISIONS OF THE CONTRACTORS LI- LL J � CENSE UW(CHAPTER a(CCMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE B1131NE5S AN'J PPO- POOVSP2 ) FESSIONS CODE)OR THAT NE OH SHE IS E%EMPTTHEFEFROM AND TNE BA515 FOR THE ALL'eGED EXEMP- TqN.M1YVKK,ATIONOFSECTIDN7o31.5BYANYAPPIJCANTFORAPERMITSUBJ[CT57NEAPPLICqNTTO Z Re-Roof � A CMl PENALTY OF NOT MORE 7NAN FIVE FiUNORED DOLLARS�SSOD).}: � ❑I,ASOWNEROFTNEPROPEfiTY,ORMYEMPLOYEESWITHWAGESASTHEIRSOLEWMPENSATION, � Commercial MALL 00 TMIE WOAK,AND THE STRUCTURE IS NOT INTEN�ED OR OFFERED FOR SALE(SEC.7044,9U51� J NE55 AND PROfESS1IXJS WDE:THE CONTNACTOFS LICENSE UW DOES NOT APPLV TO AN OWNER OF �{dq � PROPEFiTVINiOBUILDSORIMGROVESTHEREON,ANDWH000E55UCHWOHKHIMSELFOFiHERSELFOR � �•""� ^�'t'�+- � THROU(iFINI50RHEROWNEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTENDEDOR m — QOFFEAEDFORSALE.IF,HOWEVERTNEBUILDINGOFiIMPFOVEMENTIS50LDWITHINONEYEAROFCOMPIE- � TpN,THE OWNER-Bl11LDER WILL HAVE THE BUfiUEN OF PROVING THAT HE OR SHE D:D NOT BUIID OR ,�-�) � IMPflOVE FORTHE PURPOSE OF SALEJ. (f• � W C71,ASOYMEAOFTHEPROPEHTY,AME%CLUSIVELYCONTRACTINGWIiNIICENSEDCOMRAC?ORS � TO CONSTRLICT THE PROJECT(SEC,70N.BUSINE55 AND PROFE55!ONS CODE:TNE CONTFUCTOHS LI- VaIll.�tlGO �_ADJ.AREA______ W CENSELAWOOF_SNOTAFPlY70ANONMEROFAPRO?ERTYWHOBUMDSORIAIPROVESTHEHEON,AND � WHOCON7RACTSFORSUCHPROJECTSWiTHACAN7RAC'OR;S)UCENSEDsUfISUPNTTO7HECONTRIIG QUAN?!TV DESCRIPTION FEE Y TORS LJCENSE U.W.�. �F — � ❑I AM EXEMPT UNDER 9EC. 8.8 PC FOR THIS REASCNJ Q � � ` /L--'' �' � 3 --- ---- —-- ---- � cc "Z �t.'V1��' 4 `,/ � ,' Z DATE __ __OWNEF1' '____'_"_ ' (.~� �--- � Me�6. i '� r L�/ W � i LICENSEG CONTRRCTORS DECLA.FATION � W ��}— „�,\ •' � 1 HEREBY AFFIRM Uh1DER PEfiAITY OF PERJUR�TtiAT I�1.N LiCENSED UNDEH PflOVI510NS OF CHAPiEA I � I � � � B�COMMENCINGWITNSEC.ION7oa0jOFDIVI510N:10FTHEBUSINE33ANDPROFES910N5CO�E.AND Z Ltl �UCENSE�5 IN FUL:FOFlCE AND EFFECT. /� x/6-� �1------ '�'� � � L�CENSECLASS_ +���___— LIC.NO._��� �►7 ��f �� � t��';� �l ' � i � j ~ DATE__�i COPlTRAGTOH �_[,�{Lv�, � � � W /-�• �--- y-z w, � � WORK.ERS'COMPENSP,TIOY DECLARATIGN -� y I HEREBV AFFlHAa JNOER FENAITY OF PEfiIURV CNE OFTHE r0'_LOWING D[C;ARATNtiS: a � Z � !MAVE AfFJ WILL R9AIN.-AIN A CE�I�I�ATE O�CONSFNT TO SELF�INSJflF.FOR WOflKFFS' � �a,r� �� � COMoEN5ATIUN,PSPROViDEDBYSECTION3�ooOFTHFLAPARCOOF,FO:KTNEPE:IFJRMhNCE w ___ "*'� v� � �'r i OF THE WORK FOF WH'CH?H!S PFRMIT IS ISSU[D. � �� . � _ I HRVF MID WILL MAIPiT41V'.NORNf_RS'COMPE4SATICN INSURANCE,AS REQUiRED e�SECTION � � 31o00F iHE LiBUR CODC,FOR T!iE PERFORMANCE OF'HE WORX FUFl N:HIGH THIS PERMIT IS ISSU:D.>AY WO:iXERS'CO)nPENSATION INSU9ANCE CARRIER AND PO:.I.^.Y NUMBER AFiE CONSTRUCTION `/�� �� �� /� �� °.C..'i!� PLANREVIEW `') ��� � � CAHPoER���f7�_-- �— _ C_..+"—t_�__—_"—_ ,F � POLICYNUMBER_ ELECTRIC ____.__ ¢ �����---- , Q (fF+B^uEC,'�%XJNE�NDT cOOMPLE�E60FlYM:PEe�A1'TIG"ORONEHIMDREDDOLLafiS5f0010RLES3). I PLUMBING __"__ ��'�,;. �L,� w MECHANICAL � �1 j>'�I� Z I CERiIFV THA:IN THE PFRFORMANCF OF THE WGRK fOR WH:CH THIS PERMI?IS ISSL"cD.I --_...—____.___— y, (} SHn:L k0T EMPL�V AUV GERS(N11N ANY MANNER SO PS?O 9EC01AE Sl16JECT?O THE � WORKERi'COMPEVSrtTIONI.AWSOFCALIFORNIA.A40AGREETHATIFiSHOULDBFCOME IIVSPECTIONFEE '� � SUBJECTTO7HEW6RKERS'CO�iPLNSATIONPFlOVi5t045OFSECTI0Y37000FTHELABOR �I Vy CAQ//E,I//`SiiALL FOP.THWRH GOMPLY Wlhl'NCSE PROVISIONS. ^� ISSUANCE �J -�j y Q DATE:�y��'�AAPLICAM���G����S_ `� SMIP '___---'---'—"—' +"7 4 I_LJ J ENERGY P!C .. __—_ � WAflNING AILURETO SECURE WOFKERS'COMPENSRTION COVERAGE IS UN'JIWFUL,AND SHALL 9E � SU&IE�AN EMPLOYERTO�RIMINAL PENALilESAND CIVIL Fl�'c5 UP TOONE HVNDRED:510USAND ENERGY PERMIT '� � DOLLARS(5100,000�,IN AODITION TO THe CPST OF C9MPENSATION,DAMAGES AS PROVIDE7 FOR IY � SECTION37080FTHELA90RCWE,INTEFEST,ANDATTORNEY'SFEES. 1 RETENTIONFEE: �� �_= ' � g��'i d CONSTAUCTION LENDING AGENCY PRE-ALT PEE: ___ ' � L!� � 1 HEPEBV AF`•IRM UN�ER PENAL'Y OF PERJURV THAT TH'cRE i5 A CANSTRUCTION LENDING AGENCY �C - � n- FOR'HE PERFORMANCE OF 1 HE WORK FOR WHICH TMiS PERMIT IS ISSUE�(SEC.3'�8�,CIV C.). ------ LLJ — � LENDER'SNAME_ _' _' _'____ _ I�- LENUEF'SA�DRESS__ ._„____.._— —__—._. / � 1 CERTIFY THAT I HAVE READTHIS APPUCATION AND STATE THATTHE ABOVE INFORMATION IS CARRECi. TOTAL F E ES � �i�{ I�� W I AGREE 70 CAMPLV WITH ALL CITY AND COUNTV CRDINANCES AND STATE UWS RELATING TO BUILDING � � � CONSTRUCTION,ANDHEREBYAUTiORIZEREPRES'eNTpTIVESOFTNISCOUMVTOENTERl1PONTHE �Z�l_Z ZA00VE-MENTIONED PROPERTY FOR IhSPECTION PVRPOSES. COMMENTS `�� J — � =�'��'�,� . �-���r' � -�--1�- -- PERIAITTEE NM1E(PRINTj �" �` �=�-�.`.Z��"�.e.�c.....� G�=1� __� - - ; ,- N SI NA REOFPERMITTEE 1 DA7E � -� = RGCPT.NO. __PAID BY _�� VALIDATION ~ WHITE-Department Copy,YELLOW-Finance Copy.PINK-Assossor Copy,C,OL NRO ile Copy,GREEN-ApplicanYs Copy ' ,, , , .. ... ,. _ . .v `��r„ , ii.��'} _�lYl, .:•X,... :4.9 .w St1� �' . ;i ,,� ��, Y ' .,9;a.. .a € s.jx',���9. ,;e�.Y;,k; V,r:,,i ds;nv.;�;: .,rm, . � ..�i . .. . . . . . ,. �.v . " ��, . . , . . �t' F� R .. . . g " "f' , e .c � -. 'H. . ' � - .., . . .� . _ � '-.. .. 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