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HomeMy WebLinkAbout1155 DIAMOND BAR BL (21) ��_ CITY OF DIAMO1�iD BAR � DEPARTMENT OF CONIMUNITY&DEVELOPMENT SERVICES � 21810 Copley Drive,Diamond Bar,CA 91765 (909)839-7020 Fax(909)861-3117 Building Inspection Hotline(909)839-7027 PRESS �����'�� BUILDING PERMIT APPLICATION '�e.� �s'�on5 FIRMLY � JOBSITE APPLICATI�N PERMiT PIC o ADDRESS ��� S. ��R`�'`�'''9 �' � T DATE � � ��"�� �� NUMBER 9'g� # �i C% o ISSUE �\ � \�F-� 1 �- TYPE OCC :`-' APN LOT TRACT DATE CONST. GROUP p OWNER " ADDRESS ZONING SETBACKS o FRONT F1W ❑ ' Z C�7Y ZIP TEL. REAR ❑ o APPLICANT TEL. SIDE/SIDE STREET RW ❑ � CONTRACTOR SIDE ❑ ¢ p,� � ADDRESS PROPOSED USE �''�``�"�-a'� '- ��'►'S« ��NI�S"f o C�Ty ZIP TEL w ARCWENG/ �� `�` z DESIGNER NO.DWEL. NO. NO. a' ADDRESS UNITS STORIES SEDROOMS � CI7y ZIP TEL. � DESCfi1PTION SQ.Ff. 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J V DATE CONTRACTOR a W � WORKERS'COMPENSATION DECLARA710N � � � U � I HEREBv AFFIRM UNDER PENPLIY OF VERIUFY ONE OF 7HE FOLLOWwG OEQ.ARA710N5: � Z 0 I HAVE AND WILL MAVJT/Jl'7 A CERTIFlCATE�F CANSEN7 70 SELFINSURE FOA VJORKEAS � � COY7ENSATION,AS PROVIOm BV 6ECTIOH 3]OOOF THE UBOR CODE,FOR THE PERFORMANCE W , OF hIE WORN FOR WNldi 7HI3 PEAMIT 19 ISSUED. � � W _1 HAVE M�D'MLL NAIMAIN WOfU(ERS'COMPENSATION INSUR/WC�AS REOUIRED BV SECTION Q ' J70o OF THE LABOA COOE,FOATHE PEAFOAM►NCE OF THE WOfiK FOR WN1CH THIS PERMIT IS �SSUFA hry Wp{y(Ep3'COMPpI5AT10N INSURANCE CARRIER ANO POLICY NUMBER ME CONSTRUCTION jc.naaiea PLAN REVIEW �1 S ' 2-�p � POLICY NUMBER ELECTFlIC o Rrass[cnonr�wreEaor.aFrEooFnfvew.+rsf�u+ar+eMa,a+�ocuus�s�ro)oa�ss� PLUMBING W MECHANICAL Z 1 CERTIFY TNAT W THE PERFOFlMANCE OF THE WOAK FOR NMlpl THIS PE�IMIT IS 4SSUED,1 �r} SFW.LNOTEMDIOYAHVDERSONINANVMM1tJER50A5iOBECOMESU&lECTTOTHE INSPECTION�EE � � WOflKERS COMPENSA710N UM5 0F C.ALIfORNIA AND A6REE THAT.IF I SHOUID BECOME SU6IECT TO7HE WORKERS COMPENSATIDN PROVISIONS OF SECTION a7oo OF THE LABOR ��uANCE � CODE.I SHALL FORTHVA7H COMPLV V/17H TH0.5E 7ROV�510ft4. � O SMIP p DATE: APPI{CAM:. , � W ENERGY P/C � WARIJINO:FArtA/RE TO SECURE WOHI(ERS'COMPENSATION COVEMGE IS UNUWFUL,AND SMAI.L BE SUBJEC7 AN EMPIOYER TO CRIMIIUL PENALTIES AND CML FWES VP TO ONE HUNOflED THOUSANO E.h1ERGY PEFMIT DOLLM9(5100,oao�,N1 ADO�TION 70 THE COST OF COMVENSATION,DAMM3ES AS PROVIDED WR W � eEC710N]7o60FiHEUBOfiCOOE.WTEREST.MIDATfORNEYSFEES � RETENTIONFEE: . � CONSTRUCTION LENDING AGENCY �PRE-ALT FEE: � 1 HEREBY AFFIFM UNDER PENALTY OF PERIUR'/7HA7 7FIERE IS ACANSTRUC'f10N LEND�N�AQENCY � FOR tHE PEqFO(iMMICE OF TME WORK FOR YM�CH THIS PEHfA1T IS t55UED(SEG 7ogl.CIY.4} , Z W ' � LENUERS IU�LI£ � LENDEFZSADDAE54 � ICERTIFVTiATIHAVEREADTWSAPPLICATIONANDSTATETUT7HE.�BOVEINFORMATION�SCOFiRECT. 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