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HomeMy WebLinkAbout13604 (628) .�� CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21660 E.Copley Drive Suitc 190 � (909)860-3195 Faz(909)861-3117 � � PRESS �'��'� BUQ.DING PERMIT APPLICATION FIRMLY o� JOBSITE G APPLICATION pE MR 2 1_� p/� ADDRES DATE NUMBER -•��l� � � ISSUE r�� /`n�`w 7ypE OCC APN L TRA DATE—J �"�`�I CONST. GROUP � OWNER o ADDRE ZONING SETBACKS �W CfTY ZIP TEL. FRONT RW ❑ APPLICANT TEL. SID SIDESTAEET � � RW � CONTRAC � � ((... �' SIDE p � ADDR S PROPOSED USE�1._J � � 4►IP TEL ��-;�, � � ARCH/ENG/ ,,R — — • v�-�•-�6 � DESIGNER `v NO.DWEL NO. NO. = C'DTMDRESS Z�P TEL UNITS STORIES BEDROOMS � N OESCRIPTION SQ.FT. 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FEE �S J ^� O I AA1 EXEMPT UNDER SEC. B.i V.G,FOR TN:S RCASON Q 3 � V" DATE OYMER F�- Z U � UCENSED CONTRACTORS DECLARATION W � IHERCBVAFFIRMUNDERPENALTYOFpElUUi1YTHATIM1l ENSEDUNDENiROVISpNSOFCHAVTER � S •�COMu[NCNOYrtTHSECTqX7D0o) SqN70FT SINESS�ROFESS!ONSCOOE.AND Z �L W LILENSE IS W F'ULL FORCEAND EF ECT � � UCEMSE CLA55 LIC.NO. O � �j DATE CONTRACTOR d W � WORKERS'COMPENSATION DECLARATION' � ' Q •• � � � ��. NIHEREBYAFFIRMUNDERPENALTYOFCE0.RIRYONEOFTHEFOLLOWINGDECUMTIONS � � � � Z . I � �IMAVEMIDYNILAAAINTAINACEtfirtICA7EOFCONSENTTOSELF-WSUREFORNVRKERS' ` _ . ' ' , - . . 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ISSUANCE -t:���`�'t��' �� O ,�^ v•,:L� ' DATE: APFLICAM: SMIP !•� \` t � WMNiN(7:FMURE TO SECURE NOPo(ERS'COMPENSATqN COVERAGE I5 UNUWFUL,M1D SWLLLBE ENERGY P/C .�i l�� � � SU&IECTANEMPLOYERTOCRIYTIALVENALTIESANOCMLFNESWi00NEMUNDRCDiHOU5AN0 �' ���"+It100,000).N/DOI710NTOTHECQSTOFCOMPENSATION.DAMAGESASVROVCIE�FORIN ENERGYPERMIT J SECTtlN770lOFT11EUBORC-0�E,NTEREST,M'DATTORNEY'SFEES. RETENTIONFEE: LZ OCONSTRUCTION LENDING AGENCY ppE-ALT FEE: � I HCREBYAFFlRM UNDER VENALTY OF PERIURYTHATTHERE IS�CONSTRUCTION LENDPIC 11GENCY FOR iHE PER�OiWANCE OF THE Y/OHK FOR WH�dI Mi5 PERAIIi IS ISSUEO(SEG wai,CN.C.). � � LENDERS NAME 1 � LFNDER511DORE55 � ICERTIFYTHATI ISAPPLICATqN,WDSiATETMTiHEABOVENFO tqN SCDRRECL TOTAL FEES � �� w IAOREETOCOM N7 LGTYANOCOUNTYORDWANCESANDSTATFU 70BUd�1NC � CONSTRUCi [BYMJT4qRREREVpESEMATNESOFT Y fMERj1�WJIfE ' ZABOVE�M ERTVF v q P E5. �/ � 9 /� �� COMMENTS � ¢ PEiWRTEENAYE�a T) N � SIGIUTUREOFPER4ITTEE DAiE � RECF'T.N0. 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