HomeMy WebLinkAbout17-8189A
W.
ti
0
' CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21810 Copley Dni Diamond Bar, CA 91765 PRESS
,., (909) 839-7020 Faa. (909) 861-3117 Building Inspection Hotline (909) 839.7027 FIRMLY
BUILDING PERMIT APPLICATION "Secityoldiamondbarcom buddmggadiamondbareagov
JOB SITE ADDRESS
APN LOT T
OWNER
AD� ES Sb c 2 ap
,dci= C P T)1
CTTYYiA'riduh 17 �4.'t�zlP TEL
APPLICANT TEL 2 Z— C
2
CONTRACTOR(,,
,,
ADDRESS _k o r�.. Sa_7+%Q,tJ %t9'f Z> "'/ S-T
CITYAL)-AA'mi'-ky zIPL^X * EI -L — %2-10
_._.....
ARCHIENG/
DESIGNER
ADDRESS.....
CITY ZIP TEL
DWNER4PADER DECLAMATION
I hereby eilVm atXer mnanNry of perjury Fret I am exempt from the Contractors Store Li:9nte Law for the mad, }
Mig and leis/ by the eh%WeM(S), i have preSO And to the menn abre item(a) (Secum TOTIA, BU$IMBM NO
Palo Ions CONS ANyoity m mums ihM requ nen s MmM m oamtwt, aft, mipMve, demolish, "repair, any
eWcdure, prior to Na MSWNW. Bill MUIMe Oil&WtUNtatn PeMiR M file a diNd ebra tthat he an She
to BB ea psreuam M Lam prmaboof NO Conn Ws$bb Uk Law (ChaeterinC with Secpon
7p00MpIYIMOn3aUs ffiw ProfaslBM Coda]or Nwk Mettme's exomptiromleefwura sans iNa 405la/or
ao S#din 7031 Bby Say appiiratnflra Mr'o',f91mIBetBfa �^plkant taadnl mnNry
carsBxan
oneNo unriioiaolnot
a nat metre man Iha nwarea ap3dm BEac;
L}L Mowrrer#fMe vmperty,aay vdthwapMasihekml94ompetaatlon wllldoUallofwUpauns
of its work, antl the stmtture 0 wt fntentlad or offered for mq ISOCUN 7044 BuSaus and PmfeMkme Carle The
tkmbacmes Stabt a
Law tloMat
orpeBaalefWO
pl4foan mmar propwlywa,Ihrouatfor
", "do the Ta ,If Ina ers;
1/ving
or IrommerpsWit wthioneye Nef d'retmo meere natter
engda theadtooseta
Met we VAR
or Improved Mr Ob puppose of all)
L) I as omwaof the property, am sxclushady S#n#udrg web Pleased Con#lulma IS cwfwhuct the project (Seaon
7044, Business and Hoke m "Ad, True Cartmacre' Wria Umme Law does mar Apply ben mrawr of pigmy who
bu'Ids orlmprav scwmern, and AN wMmms forth# projects Wh affmnmtl Con#ectar Fireman to ins Canpeamm' State
Umwalew)
U i one exempt Node P nermae lndwil% C91maPbr's State ttGNe law for the following reaamgb
Date I....._--_S,Bn
By mys4ysium na.'ow I Acbrowledge Met, ex'mpi for my personal reddaNw in whole'.. mur. hev0 waded foratgaatam
year Vic, to mmWedan of the ImPmremwaamwrod bythm pormitl nanI0.Ylesepy at a mucfum Mat I haw aM:M an
Omer bLN(gr if It Lae rrit bean constructed in ITS elwrety by licensed wntmsbw I understand that a copy of des
applicants law, Seoul 1044 of the Business and PmFmoni Code Is smash!a toot Rquest wmn this eppP#a:An is
submitted or view bedewing Web site RtfoMWY(iaykfble gPi?celew Mml
LICENSED CONTROZMR'e DECLARATION
therapy Orion War Penalty Of po'luy Met I am Seamed abet pownhmof Chapbr N (mmmanoeg wit, Sacikn )DOOI
of uvldon 3 of rho BusSce}}se jjob Pmlasti�as Cod# a..im�knori fp11 faro antl atteq
LICENSE CLASS i V
CONTRACTOR D4C-IV /H'rl.i
EX? DATEr)('
r a
WNM,S COMPENSATWX DECLARATION
I HEREEW AFFNW U40€R PENALTY OF PBULW ONE OF THE FOLLOWING CECAARATIANS
i sain, #rod whi mentain a CAmpcab of Consent to SPM-Ini m for WaHrw a Complimagon, as prai by
Ss,'tia137WaNe tabor Cods brow poNptnance ctMe work mrwNFM itM ps+nMq gouBtl
I row ealwie mnntab Worker's COMDenwrm Insurance, asrerimd bYSergm' 3781 a Cw tabor Cade, fro
yNthBwork brwhkbMNpermPa Wusd My Worker's Coro anureace Camsrantl
Roryeaccur are
CARRIER
—....... ....... ..._
FMCY NOMER
ME SECTION rEFDAT BE MW E M IF THE PERMIT IS FOR ONE HP4OREDDOCARS $100 OR LEW,
.. i Nwii th4 #rosily AnY pereln in #rid mM� Apr a b
I ewidy that h MB pwbrmgnoa vF ft wak fm w!tlC' maw" eirakedWM
becmrw Bu^.t&pbthe WollwCsion3swmiku, LBaeof Ce,iowito dome ^.raty B'wld becomeexbje4 biw WaroMs
a;of 5ectlon3td0 ail tstrrClog,lelrell hA angkywNAi pmNNan9
OAtE* t1. APPI1C44T ._2�r ✓iED___.^T .J
WARONSFarliere, b secure Worker's Compwombn oranaps Is unlawful, ad dal Sapient an anployar To MmxrN
Mmi ere UA ffiws up ON and hum id caumme m!tam 4100 M, In andllmn NO Ms mat of if. mmpB on,
damages m provided fat in moron $700 of the Near tam meant, and momay'e tam
COWMUCnGR LENMNG AGENCY
I names affirm under panato or pa0uy that there is a Commodoon Lending Agency far the psw nWO M the work for
when this permit IB IMum {Sol REST, Dv Of
tFdsOEA'S NAME
LENDER S ADDRESS
I cwhiy that t seas reed Less applkalkn and stab ihai Me coo e, Thomason sloarept I some to compy'w0h wi day add
orm;m;GM and state laws reletkg b bWWog casmidion, am Tommy evddcns, representatives Of ills Co anon
error upon the Save mentioned property for Inglichanvuryoms
PERMITTEE NAM# :)-
�,� v-7to / -7
SIONANRE DF MTTEE IDATE
APPLICATIONDATE_
ISSUE DATE ��, �+
'i'4hE CONST
n- .t ,_PtC# ra j
PERMIT#Q�
OCC GROUP
Scope of Work l 1
#DWEL UNITS....., #STORIES_._ #BEDROOMS
DESCRIPTION
SO FT
FACTOR PSF
ADJ AREANALUA71ON
SRTR/ADDA
OeregetCenpott
w
PaNdDeck
''..
L.
PooVSpa
'
Z
Re Roof
Coromandel
�I
YBtNBt on
Ant Area
OUANTRY
DESCRIPTION
FEE
t9
S
E
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
...
/S9
MECHANICAL
...
INSPECTION FEE
ISSUANCE
STAR
ENERGY PtC
._-
ENERGY PERMIT
RETENTION FEE
PRE-ALT FEE
BASF
PLOT PLAN
ZONING CLEARANCE
...
TOTAL FEES
COMMENTS
/
P/C PAID BY VALIDATION
RECOPT RA _ PAID BY VALUATION �ry
WHITE — Department Copy, YELLOW —Finance Copy, PINK— Assa94or Copy