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HomeMy WebLinkAbout15766 (643) CITY OF DIAMOND BAR �� • � � ��---- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES ��;1� : � 21660 E.Copley Brive Suite 190 ''� _.� (909)860-3195 Fax(909)861-3117 pREsS ����N�° BUILDING PERMIT APPLICATION FIRMLY � JOBSITE �` �������` Ci� APPLICATION yy, p�.�,_ PERMIT 9 ''j` P!C o ADDRESS �� Il� DATE �' � �—f flv NUMBER i' ! • # � DA EE ,� �� �� TYPE OCC APN LOT TRACT CONST. GROUP � OWNER ��V l� 1''�i'�f�-�,/{.fZ'} O " AODRESS `{'� ���� �1�L Gt'"� ZONING SETBACKS w CITY D1R^ f3�/1'«.LR ' P �TEL.��J��^'« FRONT _ RW ❑ � APPUCANT Avly 1"Y•A�R�4 �'��TEL `ta� iaC'`fih� REAR � � SIDE/SIDE STREET RW � � CONTRACTOR SIDE ❑ Q ADDRESS PROPOSED USE � CITY 21P TEL. - oARCFVENG/ z DESiGNER NO.DWEL. NO. NO. � ADDRESS UNITS__ STORIES BEDRODMS � CITY ZIP TEL. _ y DESCRIPTION SQ.Ff. FACTQR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADD/REM O i HEREBV IIFFIRM UNDEfl PENALT'OF PERtt1RY THA7 f AM EXElAPT FPOM THE CONTRAC'cas u� GaragelCarport W CENSELAWFOR7HEFOlLOWINGREASON�SEC.7031.5B1151NE5SANOPftOFE5510N5CO�E:ANYqTYOR (J� ZCOUMYWHICHAEWIRESAPERMtTTOCONSTRUCT,ALTER,IM7ROVE,OEMDUSH.ORREPAIRAN�STqUC- W pgitOlDBCk w NRE,PRIOR TO ITS ISSUANCF.ALSO REOUIRES tHE APPLICANT FOR SUCH DERMIT TO FILE A SIGNED W � STATEMENT THAT HE Ofi SHE IS IACENSED PURSUANT TO THE PROVISIONS OF THE CANTRACTORS LI- c CENSE U1W(CHAVTER 9(COMMENdNO WITN SECTION 7000)OF CIVISION 9 0F TFiE BU31NE95 AN�PRO� � POOVSpB T FESSpNSCODE)ORTHATMEORSHEISE%EMPTTHEREPROMANDTHEBASISFORTHEALLEGEDE%EMP� (� V TqN.ANYVIOL�TIONOFSECTION7031.5BYANVAPVLICANTFORAPERMITSU9JECT5THEAPPLICANTTO Z Re-Roof r ACML PENRLTV OF NOT MORETHAN FNE HUNDRED ODLURS(5500).): � ❑I,ASOIMIEROFTHEPROPERN.ORMYEMPLOYEESWITHWAGESASTHEIRSOLECAMPENSATION, ❑ COmm9fCial WILL 00 THE NHJRK,AND THE STRUCTl1RE IS NOT INTENOE�Ofi OFFEREO FOR SALE(SEC.70d6,&JSI- J NESS AND PqOFESSIONS WOE:THE CONTRACTORS UCENSE LAW DOES NOT APV�V TO AN OWNcR OF � PROPERTYWFWBUILDSORIMPROVESTHEPEON,ANDWHO�OESSUCHWORKHIMSELFpqHERSELFOR � ['C THHOUGH HIS OR HEHOWN EMPLOYEES,PROVIDED YHAi SUCH IMVROVEMENiS ARE NOT IMENDED OR m QOFFEREDFORSALEIF,XOWEYERTHEBUILDINGORIMPROVEMEN71550LDWITHINONEYEAROFCAMPIE� Z T10N,TNE OWNER-BUIIDEN WILL HAVE TME BUfl�EN OF PROYING THAT ME OR SHE DID NOT BUILO DR = IMPROYEFORTHEPURPoSEOFSALE). C 1,AS OWNEN OFTHE PROPERTV.AM IXCLUSIVELV CAN7FACiiNC WITH LICENSED COMRACTOIiS � TO CONSTHUCT THE PHOJECT(SEC.70ee,BUSWESS AND PROFESSIONS CODE THe'CONiRACTOFS ll- V81UB�i0n ADJ.AREA_ W CENSEIAWDOESNOTAPPLYTOANOWNEROFAPROPERNWHOBUIL�50RIMPROVESTHEREON,AND --- � NM1IOCONTRACTSFORSUCHPAQIECTSKITHACONTMCTOR�S�UC'cNSEDPUR511ANTTOTHECONTRAG QUANTITY DESCFIFTION FEE Y TORSUCENSEUW.j. � .OIAMEXEMPTUNDERSF.G__ e aC. FOqTHISREASON Q � _ _ U ! � � DlTE ��`4"j"O� OWNEfl I __ U W � LICENSED CONTRACTORS DECLARATION W � INEREBYAFFIRMUNDEflPENALTYOF?ERJURYTMAiIAMIICENSEDUNDERVROV�510N50FCHpPTER , � RE��t �,�.�_��"� � Q� 9(COMMENCINGWITHSECTION7000�OFD�VISION30FTHE9USINESSANDPROFESSIONSCO'JE,AVD Z X MY UC'cNSE IS IN FULL FORCE AND EFFECT. �8��v R ro m �O �t C8"f � LICENSE CLASS LIC,NO. � p�( oc�:+� -' V DATE_, r�r �"'"��� GONTRACTOR_"'���_ ��t^ d W L� WORECERS'COMPENSATION DECIARAI'ION � � ¢ � I HEREBV AFFIRAI UNDER PENAL'Y OF PERJURV C'dE OFTH'c FOLLOWING DECi_ARATIONS: u � � Q — — � IHAVEANOW�LLMAINTAIHACERrIFICATEOf CONSEPfrTOSELF-INSUREFORWOHKERS' _ � CCiA1PEN5AT10N.ASPROVI�E00YSECTION370aOFTHELABORCODE,FORTHE?ERFOFiMANCE U OFTHE WORK FOR WHICHTH!5 DERMIT IS!SSU[D. W � � W IHAYEAND WIILMAINTAIiV WORKERS'COMPENSATION IYSURFNCE,AS REQUIRE'J BY SECT:ON Q 37GOOF THE LA80R COOE,FOR TME P[RFORMANCE OF 7HE WORK FOR WHICH THIS PERMIT IS ISSUEO.MYWORKERS'�MPENSRTIONINSl1FANCECRRRIERA40POL'CYNUMBERARE' I CONSTRUCTION .____,.._._______._—_ -� � cnRqiEa— — ----- PLAN REVIEW ----- � voucv Nu.�aea _ ELECTRIC Q — -- --- "' (1}i65CC�Y7NNE�MJ7BEWM1�fED�7H[PEGIMTLSWRaNEF0.X�DF'F�Dd_IARsiS�ODI�LE55). PLUMBING __ B�?� �"14'x. Y � W MECHANICAL —�'��`'g{ Z ICERTIFYTHATINTHEPERFOAM4NCEOFTHEWORKFORINHICAiTHISPEaMITI515SUF�,I ______._ (} SHAILNOTEMPLOYANVPER50NINANVMANNER50ASTOBECOM.ESUBJECTTOTNE INSPECTIONFEE � WOPKERS'COMPENSATIONUWSOFCAUFORNIA,ANDAGREETHATIFISHWLDB'cCAME _—.__._ SVBJECT TO TFIE WORKERS'COMPENSATION PFlOYISIONS OF SECTION 97Co OF THe UBOR ,,i`!�'. = ISSUANCE _z�?�'�;.+' � e,�„�f CODE,i SHALL FORTHW;TH COMPIY WITH THOSE PROVISIONS. , � SMIP � p DATE: APPLICANt ___'.__'__—.—'.—_— --,. 1_ ,. '�'• w "F�"�'If `1.��'e' x .�lil��:'.�04�P�.D s..h.`i.tn JWARNINGFAILURETOSEGUREWORKEH5COMPENSATIONCOVEHAGEISUNLAWFJL,ANDSHALLBE ENERGYP/C " ' ' SU&IECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND �' '� � i Sr'�;�� ��`-' �� � DOLLARS(5100,0OO�.INADDITION70THECOSTOFCOMPENSAT'�N,�ANAGESASPROVIDEDFORIN ENERGV PERMIT��''-._._�x���3%�+�'"•'- +�`e'•�`���:� J SEC7aN 37oe oF THE LABOR CODE.IN?ERES7.ANDATTORNL-"�'S FEES. RETENTION FEE: � pw._ CONSTRUCTION LENDINGAGENCY PRE-ALT FEE: ,_____ O S IHEREBYAFFIRAIUNDERPEhALTVOFPERJURYhIATTHER'cISACONST�UCTIONLENDINGAGENCY d FOR THE PERFORMANCE OF?HE WORK FOR WHICH?HIS PERMR IS ISSUED(SEC.3097,CIV.C.}. — Z W — -- � LENDER'SNAME__ _,_ __ ____._— _ _ F- LENDER'SADORE55 __.__--_ � ICERTIFVTNATIHAVEflEA�THiSAPPIICATIONANDSTATETHATTiEABOVEINFOiiMATqNISCORRECT. TOTAL �EES �,�'� W I AGREE TO COMPLY W1TH ALL C!TV AN�C�UN?V ORDINANCES AND STATE:AWS RELATING TO BUILDING � � CONSTRUCTION,PN�HEREBY AUTHORIZE REPFeSENTATNES OF7}i15 COl1NTYT0 EMER UPON THE ZABOVE-MENTIONEOPROPERTVFORINSP'eCTIONPUFPOSES. COMMENTS � �,qv t M��� ��s ------ ---�- _ - � -- - m ITTEE (PRINT) !9 f� _____ � __ �� � � v __ _ '____ SI 'Clif.iEOFPERMITTE 0.7E RECP7.NO. PAID BY t VALIDATION ~ WHITE—Dopartment Copy,YELLOW—Finence Copy,PINK—Assessor Copy,GOLDENR D--File Copy,GREEN—ApplicanPs Capy �� ..�,. •'�:..r .'.';,�t.%.�:.:A'::...F"„-;, .,. ..,:.W ." ....' ..� ' .a .. , . ... . „ . .-.. � ... .... r: e....r., . ..�. . v � - . . �n:.Ye�i �.$ .D1.�� i.n.,__ .. . . sE°''..� K.._j••'. ; .�. ., �.L'i4.,,v.r .:��. '�•f . .*. ... �.' � "•} c.... . .. '°��•"3:':5;, . , - „ : v :. . � . .5 +' v a.^t". . , a�.: v �'�'� �i� � .r � .q "a" '&c ti �� � �, S ;€ w � �'^ , . "� f� � �"� . y . . . , ,.. , .�... - �. . � � . ,t... ., .�..�,. . �i, x '( ��Yru . r:�:� ~'aFx��� _ ;tf: y'�9 , . ,. 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