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HomeMy WebLinkAbout05-314(9) 1� CITY OF DIAMOND BAR i' � DEPARTMENT OF COMIVIONITY&DEVELOPMENT SERVICES .� . 21825 Copley Drive,Diannond Bar,CA 91765 (909)839-'7020 Fax(909)861-3117 Building Inspection Hotline(909)839-7027 PRESS 9t1�' BUILDING PERMIT APPLICATION EIRMLY � JOBSITE APPUCATjO PEHMIT l o ADDpESS q/C � _ �}�- �� J DATE_ `'�����`�� NUMBER � �m ISSUE TYPE OCC Ai'N LOT �� � TRACT DATE oC CONST. GROUP p OWNER ����.�`6 I°��°L�C ADDRESS a�€�� R��b S�°'� SC��"1�. ZONING SETBACKS� �' t�' t � u� F ��sc, .��/b°^ E�-�E���a ��.5 `��, .� o CITY �'E�..S ZIP��` TEL.�@4 >�Z,°�.Lc�t��a FRONT _„�_ � _ �y �'p . APPLICANT TEL. REAR p �� SIDE/SIDE STREET qyy p CONTRACTOA SIDE � ADDRESS �p � CITY ZIP TEL. PROPOSED USE � ` F'fi6-�'�, '�,� � S w AACHJENG/ z DESIGNER w ���t'� � C�QE°i� � � � NO.DWEL. NO. � ADDRESS � �����` �- �^'�~"'� � UNITS �� STORIES� NO. �� � CITY t�.a� ZIP TEL���-��C» BEDROOMS � DESCRIPTION SQ.FT. 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PpOPERTYWHOBUILDSORIMPROVESTHEREON,ANDWHODOESSUCHWORKHIMSEIFORHEflSELFOR � CL THf1OU�HHISORHEROWNEMpLOYEES,PROVIDEDTHATSUCHIMPROVEMEMSARENOTiNTENDEDOR m Q OFFEREDPoqSALEIF,HOWEVER,iHEBUiIDiNUOqIMPROVEMENTiSSOLDWtTHINONEYEAROfCOMPLE = iION,THE OWNEA�UIlDEA WILL NAVE THE BUA�EN OF AROYl,NO THAT HE OA SNE D!D MOT 8U1W Ofl IMPROVEfOqTHEPURPOSEOFSALE). � ❑I,AS OWNER OF THE PROPERTY,AM EXq.USIVEIY CONTHACTINO WITH LICENSEU CONTRAC70R5 Q TO CONSTRUCT THE PROJECT(SEC.704q,BUSINESS AND PROFESSIONS CODE:THE CqNTRqCTOqS L4 V8N21I00 ADJ.AREA W� CENSEtAWDOESNOTAPPLYTOANOWNEROFAPPOPERTYWHOBUILD50RIMPROVESTHEREON,AND � W}iOCOMRACTSFOASUCHPAOJEC75W1THACONiAAC70A�S)LICENSEDPUqSVANTTOTHECONTRAP QUANTIIY DESCflIPTION FEE - x TORS UCENSE LAW.). . 0 ❑I AM EXEMP7 UNDEfl S�C. 8.6 P.G FOR THIS RFASON Q � � U zOpTE OWNER U � LICENSED CONTRACTOpS DECLARATION W � 1 HEREBYAFFIRM UNDEF PENALTY OF PERJURVTHAT IAA1 LICENSED UNOEp PROVISIONS OF CHAPTER � � � 9(COMMENCINOWITNSECTION7000)OPDIVISION30FTHEBUSINESSANDPROFESSIONSCADE,AND Z � � XX MY UCENSE IS IN FtILL FORCE AND EfFECt m �� LICENSE CLASS � lIC.NQ ��"'���� � g� � V DATE ������ _ CONTRACTOR �B"'LdPB��� g�L����� d W � WORKERS'COMPENSATION DECLARATION Q � I HEREBYAFFIPM UNDER PENALTY OF PEi3JURY ONE OFTHE FOLIOWING DECIAflqTiONS: U � Z Q _�,IHAVEANDWILIMAINTAINACERTIFICATEOFCANSENTTOSELFINSUREFORWOqKERS' _ Q COMPENSATION,AS PAOYIDED BY SECDON 3700 OF THE LABOA CODE,FOA THE PEAFOAMNlCE �U Of THE WOqK FOp WHICH THIS PERMIT IS ISSUED. 1� il.! �.._. _IHAVEANDWILLMAINTAINWORKERS'COMPENSATIONINSURANCE,ASREWIREDBYSECTION � 37000PTHElABORCODE,FORTHEPEflFORMANCEOFTHEWORKFORWHICHTHISPERMITIS . _ ISSUEO.MY WORKERS'OOMPENSATtON INSURAyCE CAflfliER AMD POUCY NUMBEfl ARE: CONS7flUC7ION � CARRIER PLAN REVIEW Z pa.ICY NUMeER ELECTRIC ¢ � (I}BSSECiK7NNE�NOTBE00M%.EfEDOF7HEpEMyiISFOqOryEFiIA�ORE00011Aq5(y100)ORLESS} PLUMBING � LtJ Z ICERTIFYTNATINTHEPERFORMANCEOFTHEWORKfORWHICHTHISPERMITI5155UE0,1 MECHANICAL C�3 SHALINOTEMPLOYANYPERSONINANYMANNERSOASTOBECAME5U9JECTTOTHE � WORKEFS'COMPENSA710NLAWSOPCAtIFOftNiA,ANDAaflEETHATiF1SHOt1LOBECOME INSPEC7IONFEE S SV&IECTTOTNEWOPKERS'COMPENSATIONPROVISIONSOfSECTION37000PTHELABOR CODE,I SHALL FOqTHWI7H CAMPLY WIiHTHOSE PROVISIONS. ISSUANCE 0 p OATE: APPLICAMi �SMIP W � WARNINO:FAILURETOSECUREWORKEPS'CAMPENSATIONCAVERA�EISUNIAWFUL,ANDSHALLBE ENERGYPlC � SU8JEC7ANEMPLOYEflTOCAIMItJAl.VENAI.TIESAMDCMLFlMESUP700NEHUNDAEDTHOUSAND ENERGYPERMIT JDOILARS(Si0o,000),IN ADOITION TO THE CQST OF COMPENSATION,ON.IAGES AS ppOVIDED FOR IN SECTION37080FTHELABORCODE,INTEREST,ANDATTORNEY'SFEES. � w AETENTION FEE: O CONSTRUCTION LENDINC,AGENCY PRE-ALT FEE: � 1 HEREBYAFFIRM UNDER PENALTY OF PERJUPYTHATTHERE 13 ACANSTRUCTION LENDING AGENCY FORTHE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC,3097,CIV.C,). W � LENDEWSNAME � I--- LENDER'SADORESS � ICERTIPfTHATIHAVEREADTHISAPPL�CATIONANDSTA7ETHATTHEA60VEiNFORMATIONISCORRECT. TOTAL FEES ��� ► ��o � �� � IA(3flEETOCOMPLYWITHALLCITYANDCOIINTYORDMANCESANOSTATEUWSREUTtt1GT08U1[DINa � CANSTRUCTION,ANDHEREBYAUTHORIZEREPRESENTATIVESOFTHISCOUNTYTOEMERUPONTHE ' Z ABOYE-MENTIONED PROPERTV FOR INSPECTION PURPOSES. 0 COMMENTS ���� �-�C.�'`.it'�.5'� �� � L�� -' � ,,�Ec�e� �ca;� --� a�����•����-nl -+��.-•���tj m ¢ PERMITTEENAME(PRlt�if) � � UJ SIQNATUAEOFAERMITTEE DATE ' _ _ FECPT.NO. PAID BY VALIDATION