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HomeMy WebLinkAbout17-12105I 0 3 LL I Cj I in ED a z t ii CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21810 Copley Drive, Diamond Bar, CA 91765 PRESS (909) 839.7020 Fax: (909) 861-3117 Building Inspection Hotline (909) 839-7027 FIRMLY BUILDING PERMIT APPLICATION wwwejtyofddamondbarcom buddeng@diamoodbarea.gov JOB SITE ADDRESS Y g _ �� APN LOT RACT OWNER ADDRESCITY CITY �TA�+ J�ZIP T L APPLICANT TEL CONTRACTOR `� all ADDRESS 2-115I CITY bA1 fJ!` ZIP akjW TEL ARCEUENG/ DESIGNER — ADDRESS CITY____ ZIP TEL DWNIEA41ALDF3t OECLARAnDN '..,. I nurses' mmm >+kf penalty of perjury that I am exempt from me Fammma Slats License Law En the romonot log d bekw by era eneCkms'kpn I rave proem mz to me opp4mle are" LxeaDan 7031 5, eusmm and Pmtmionn Cott Any day ar county that mmlhse a permit m canalfri mar, mlprm, drnloNeh, ar npah, an ehomma,of* thlM l4awnco,ete, 1puiles ffm aimPArtni air the permit toff a aN' w semmardtat the on she 1 It UonneadPORM W UmpmNalom of Ue CmhraMr'a PAU Lio oLaw (OiOa9)Com Fria with SeCUos 1 of mvidm Bat Use eusinm and PmhPoism OW o ilia he or SW %summer from 4osrerrs and the Erik for me alleged smmp2Mn AM Yeal of Section 70315 by sag spareantfor a permit sOIBM she apPlcard to a avo parody m not mom men MM nrmdmd deism (1500) U 1, as owner of the propel({, mmy employers win wages as vi we mmpmsaom, We 0U as Ot&U ponWle of the work and the structure Is nm',.ntanded or mfemd tot ask (Scromm 7044, Uress end Pmhi Cade no CAmmsea s' State LkBroa t%N am rot apply to an marOf mapdrFywho, through annotate' Jr pemanal effort builds a Improves ins property, Farmed Var the ImpmMmems are net Intended or aflered for sae H hpwmVer. �_ addlnif or impressment Is sold wlmat ends year dmrpletion, the Ofermir BWlde willhaM me twor of eroding Hat H was nor built an Immpmetl+m the wpm of eIe } U 1, ae mar of the propet'.y, am ow.du0umy canbacabg wit a onM Cmnmms to conatrum the project ISKUm 7044, Buarou and ProfeMmns Code The cmdracu re' Brae Leroy Law errs& Not apply-4 an merar act property who buads or Impn"s Grand, and wit for the project wan a a^^.kiaad CammM Prouant m me Contrasnrs'State License Las) U I am mmpt From Neareum dMer Um Dmmxtn'e Ste Lomas few far am knowhsp reassnls) Doe 9gn By mrs mgnshers baker I Acknowledge mat aYaept Im am p85Cnal msithes INw!aeh I I" have meared V a lead one Year pnorth n of the lmprovamers mvemd by the amnia l cannel lagseY sea mmchus net l hero frig ag an built, 011 lies rat Dean constructed or era satisfy by licensed overacting 1 Trieretend that a emery of At applItable law, Burden 70" of the Cadmium NW Pref so lers Cade Is available upon Maus winds this apd am is Mbmllterl oretnc tpik.Wng'A'eh inns M1MpAnrry erAMo as pnaaaiaw hfmi LICENSED CONTRACM'S UEULARATION i nsmby affirm rest pan liym perky ilia I em Its dad wider persons of Cheptorg Wamnm'srmi WAn Sectlan T000) m CIWNon3M`Jam;&sees antl �mMmoro CaOdAemy iiewNe4 kl.'I:JIForct/'e.'�'a)nd�elh/'elyci—'ia SenTad (�•'fJL LICENSE CLASS LIC NO Ear DATESCOWWT WORKER'SCGMkMTMN DECLAMATION i HAINY AFHAM UNDER PENALTY OF PEFLURY ONE OF TIE POJ.UWING DECLARATIONS —.._, base and *1 mmnhdln a CetHrpaT of Consent to Bad Imam to Worker's Compansdart, pee proud by Sauhan8700 of the Labor Code, Ua t!a performance mite wAfor wfach INS perrpt is ended ;hare and WAN mamtaln Warsar`s Ccmpxnibon insurance, sa rapWmd by Sedan 3700 of me Law Cads, Mar the palolmenca alone which this pe"It le Ind My Nkrimra UampsnsaUon Inamm�m {Rrrera'c �war(kfa Ade seurr are 4�llt-� �Vr CAARNA POUCY A'UNnER I1HSSEGTtCNNEED NOT BE CDNSA£T F7tEWJMO IS FOR Oil 4LYG!gt7 DWARS BOB OR LENT beam mmint peM slued 1911eanot ernPmywYM�nInpee)'mwrtere of is ins wuna krware; of toWVWs eftrut Comma subject tome WG7!er a temoanoaUm: Laws m CaShtma Mtl spree that rf I ahaAo aecr'Iw Re�H k me WaoNs tbmpe an��rooLSerUm algOM per niSheYbMaMin inn NsMthUndeapadakim D41E rs�,^N f 7�_+GNNJDAX7 .__ ......... .... ...--- WARNING Russiak Merle Worf Comppnsmen mrom L'"AlL and Slai Foci an Idol to admeel Peranee and dW1 &nee LW to one fwndmd thousand CUlaze EStOq , In addlaor to the cast of me compensation. dani an prosIded fa th satin 3T060 ire lebcrtode basest and mtemey's fees CONMUCTMDN LENOINDAGUCY I hereby ali under density of pmjury that(rare is a CDnowr Lmddg Ai for the pelmorews of me work for whafthep"ll k Issued (Ser 301 Ci LVIDERS NAME .. .... LENDER'S ADOUSS .......... I mr!ty that l ImYe men the spp I &tan antl state Hat thin eama Information is Correct I Agree to comply with al eW aria ardice we comaIowa Mang m buimdg mlainuor ,antl hselay llpriM.mp'e9aMeGMs of ma Maly to enter uses the same "iffmned property far!nMmtlpI purpdM9 au L PEAMITiEE NAMEF NT}�. ..._ SIDNAPJAE DF PEAMATFEE DA-E APPLICATION DATE 013, PJC# 1 R I — 12 105 ISSUE DATE 7 PERMIT# __RRI2^ I a ►o5 TYPE CORNET OCC GROUP SCOpe Of Work — tL # DWEL UNITS # STORIES—Z2AA# BEDROOMS DESCRIPTION SO FT FACTOR PSF ADJ AREA/VALUATION SFRtA=FtEM Oa'UUe+CarPort ............. W PattaloKk z e-Rea g Cammeroim al m S U! VeluaWoa Ad) Area QUANTITY DESCRIPTION FEE , � pQ CONSTRUCTION 1 SIG, c„t 4J PLAN REVIEW ..... ELECTRIC PLUMBING MECHANICAL _..... INSPECTION FEE ISSUANCE .31 I Z SMIP (O G _ ENERGY PIC ENERGY PERMIT RETENTION FEE Z• C}© PRE-ALT FEE BASF PLOT PLAN ZONING CLEARANCE .... .. t_ TOTAL FEES 7. "1 9(o to 3 COMMENTS T bud Idi t r+ i pond Qr fAL_ e b 1Sia1—p r)C oiC- that- W `�ePn ghere pr?ar trs 19Py - 4C PIC��/_—/ �� g'j_ PAID BY �s VALIDATION FECEIPTes7 eOVJ� PAID BY _("0 VALIDATION WHITE —Department Copy,YELLOW — Fnenda Copy, PINK— Assistant, Cagy