HomeMy WebLinkAbout17-22729' CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21810 Copley Drive, Diamond Bar, CA 91765 PRESS
(909) 839-7020 Fax. (909) 861-3117 Budding Inspecdan Hotline (909) 839-70274W FIRMLY
BUILDING PER ITAPPL[CATION www.cityofdiamondbar.com baddmg,^mdlamoadbarco.gov
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CONTRACTOR
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DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -NUR= DECLARATION
1 hereby 0. under Trish, tf penury that I am exempt tram on U watts Start Lowest Unit, M the mass")
tmlaeMd below by the ra s m mad, I hem pieces two M the W elcable Name} oWvtWo nos 5, Bminan ant
PMfnalna Cob Any cat a Canty that ragulm,, parent sane 4aft, lmptmro, dMMHW ar repair,eny
$Machine,prior Be Its twAM"Dk arm mgame the appawattw Opare I file wt a cloned ffmbn dOha aeNe
a llreBmdpurwMMMVm pinta COlNeotor'aStaMtemaee Lew (COaptel'B)Coannendnp wNN Sectbff
r000M OlaMkn D of tlm BCvinem PiNeaalBae Gob) ar the n, m nut N e%empi ham I!Ceneu9 9n0 the 48we Mr
thealegad aaemoL'on Any vMiOw of Section 705t 5by any app%mattaapemN b,gacb!Ae aoplkemioadai canary
of not nerd t m `I* hundred other lSSWj
UI,aBawnw'or Me property, or myemooyeeewBhwagftu thairadle 00mpanseYan, will do U 4I01 PO M11&
of the work and -a structure is not woman W cp4reo for Bale (Seclkn 7044, Marmys old Financial Cab The
Cori OnsetSMte Opened Lew was nn appYtp n carer of property who, ura@h amps' or" mom] Mint bolas
or ImprRmo Sin aspery, worded cal the mwp wm ws are not intended or offered fin "a If %wawa, the bounce or
Impmvarmet is sold wri one year of ComplBikn, dN Owner Baca ail haw NO burden at momtg Tat It was not ball
r improved fa the Phi n raid )
U I, ad Omer of the puny, We a ealvely cont aeNng with demwed Conewbirs M carman f Om project Atwon
70" Bu,o,w ant Pm Code The Contractors State LcnaO LBW Ones rot apply to on wear of proporry who
builds or Improves Merger, and whoamoacMfar the agonswebaPremium Cammnorpursuant to"comadel SMM
Lesions Leal
U I ere eremot non lioe<RuM On& the Conrsdows Stale Umucalaw for the following m Mj
.!, Dath _—ciao
'., year
e rofttotco coroner
of the oegd the, aurep!lr mypemanal rend,�Binwflkalna ooyalB,Mt)hwoOMdyfmN
mare Mmmp',elon ofthelwcontract 1.wed7ytetypb Ina snnnbpairydaitBat da% dMet a ardy, asn
direr ounce a a inns not been a filksm9e a N9 eT.rely by ode Is eWAcoatimem i wtlemwhe thin
a copy, at Ow
i BpplkB4a Mw, $OCNOn 7D44 M nine BldewaA 811d FfBM654:n9 GC40 IB a'9NDB pPt",5 R Who D,d appl Cb2'Gn is
�� submlda rei oN toapwtO WeD sla n^,ipMwwleyinfors Aev;ce!ew wadi
UMNSED CONTRACTOR'S DECLARAnoN
hereby any, WMa pour, of cartry that I am earned me, provNNns of Chepter g(ocrom gib won Mean 7000)
Of 3M6( of aBnw are, potassium, Code and,-st 8aenm b to Full force and affect
LICEtAEC5a Lip NO i Y
E%P DATE CW{iRACTDfl 7 ��
WORKER'S COMPENSATION UMARAnO
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLAATIDNS
_ I may ant will malnain a CetO= M tenses to Sett Inaore for Worker, Compensa^.on re workout by
Selson 3700 of the ursor Code, far bM overini M Se work for which this pemm M IsaNd
�!tNvaatkweli malnla'n Wpiw'eCanpoi IMnlndUmnCB M ins IEobySin;&s 3700 of the 19bor CAM,for
Ferry
epwt nDa erae CIMa workfe when thlapBmNin Meued My Worker`s CmnpanBmMn I:'NUmnce Car&eta
CORNwe
CORER TV] ICES
POLO LWBM
(iNISSE-HONWIEOW'BEGOWUEDFTeEtUWi SFGRMERIINDPEDD0OA%$100 QRLERM
IecOr Set Int to Min lmNRwnrwwmko.n Lo of pwmhia,Are ,iNr the
pa IN
becwe N;bfen Mglut Wayar's Gp3701)"Yoh tawsnde,I AM afire the!Ui6:a0uM bemre auDp;.t Mdw vroaMrw
peon Pre�a�"SSTr�mrMe LaborCa.'e,i tmthwidswiMAy'w'IMMose cohere
OATE�,'� I ApPLK'AgP i�`rr'� .
WARNWG to lure M occur, Worlrers Owen netlon cintingo Is 4i w w and sh31 an 0-00", M worse
way" am ran Ines up M one hundred OmUMnd oc%am al00.00(}, in Santa no the coal of MB
tlan . as pownea for In section 370E or prembar xd0,'�.ntered,end edmmJ's fan
CONSTRWTM LENOM AGENCY
I hereby edam UMar panty of penury Mat afar, is a Conic non Lano ng Agency far Pre patamanca of the was for
which thin pared N WW {Sap 3097, Cry C I
LENDER'S NAME _
JJNDER'S ADDRESS ....
ortMy that Neva read Ddae�t'Cann ant seta diet theahmre Inkrmal la Correct IagreeM=piP Nteaplryend
On,"mdLxnces ant s•1s taws miatiq M Watling wnebtslkm, ono away auprodre re ,teswa n this manly to
,soar coca the ebwa mBMWW mcperty Our wfuretim purposes
` ilION
PEAR ME NAM MART) .....
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SIGNAiLUE GFPERie�TEE DALE
APPLICATION DATE
ISSUE DATq_y.��
TYPE CONST _
PERMiTth
C'
OCC GROUP
Scope of Work
k DWEL UNITS _......—
d STORIES N BEDROOMS
DESCRIPTION
SO FT
FACTOR PSF
ADJ AREANALUATION
SFRIADDIREM
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fie-Rool
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Canxnaelrm
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QUANTITY
DESCRIPTION
FEE
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a
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CONSTRUCTION ,.......
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
...
SMIP
ENERGY PIC
ENERGY PERMIT
RETENTION FEE
PRE-ALT FEE
BASF
...
PLOTPLAN
ZONING CLEARANCE
TOTAL FEES
COMMENTS
a & 3 -a
.......
P/C _...... PAID BY
RECENT it PAID BY
VAUDATTOIN -..
VAUDATtON
WHITE—DapaeinaM Copy YELLMV—Finance Cuoy,PINK— Copy