HomeMy WebLinkAbout16734 *f '� - - _ - , . _—._ — /����
, J� CITY OF DIAMOND BAR / �
� DEPARTt.�ENT OF COMMUNITY dt DEVELOPMENT SERVICES
. 21660 E.Copley Lhive Suite 190
• (909)860-3195 Fax(909)861-3117 ' pRES$
` ��•>�� BUILDING PERMIT APPLICATION FIRMLY
o� JOBSITE l (� �t.� /1-{� APPLICATIO�1 O� NUMB R (���"M�
ADDRESS f C� � ��ll�� C�1 DATE�Tn ��f
� . ISSUE TYPE OCC ,�
APN LOT TRA T DATE CONST GROUP
� OWNER �
o ADDRE S ZONING SETBACKS I
"' CfTY IP TEL Z FRONT RW O
� APPLI A T TEL. flEAR � I
� SIDE/SIDE STREET RW O �
CONTRACT R -� SIDE ❑ �
c� ADDRESS � PROPOSED USE
o CITY ZIP�' � TEL -
� ARCWENGI i
DESIGNER NO.DWEL O. NO. I
ADDRE55 UNITS STORIES BEDROOMS
� CITY ZIP TEL.
N DESCRIPTION SO.FT. FACTOR PSF ADJ.AREANALUATION
�
� OWNER-BUILDER DECIARATION SFF/ADD/REM
O
p 1 HEREDY AiFIM UlAER►E/ULTY OF VEM7RY TNT I MA E%EMPT FROM 1NE CONTRACTORS U• GHf99elC0�p0A
W CEN6El/,WFOqT5/EFOLLUvw�RE1l.ON(SEG70�1.68USHESSANOiROFESSiDNSCDDE:ANYCT'Oq (n
(� WUNf7MMNREOUWESAiERMRTOCON57PUCT,ALTERMPROVE,DEM0U5H.ORREiNRANY3TRUG• LLJ pa�iaDeck
�� fURE,PNOR TO RS 199UANCE.AL50 NEIXI�NEB TMf MPLICAM FOA SUCN OE��T TO�lE A 5�6uEp W
sTATFLBiT 1HAi ME qi 9ME t8 UCENSED NItSUANT TO TME VROV�SIONS OF TME CONTMCTOi13 LF
� CEqyEUYV�f71APTEq�(COGMENCNOWITMSECTION7000)OFpNS�ON70FiNEBU5INESSANOGRO� u' POOVSpe
fES410N4OOD�OR TMAT ME OR SnE IS E%EMPT iT�EREFFqM ANO TME BASIS FOH iMEALLEOEO ExEMP•
TIpN,ANYV1ptATpNOFSECTqN7W1.68YANYAPKIGHiFOF1APEiMUTSUBJECTS7NEAPMILANTTO Z RB-Roo1
� ACN�LVENK7YOFNDTFIORETNANFNEHUNDREOD0.Wi5(i5ool.Y
� O�ti^+�WNEROFMEGROPERTY,ORMVEIAPLOYEESMnTHWAGESASTHEIRSOLECO4PENSATqN, ❑ CDf71mBfCiB�
WLL DO ME MIOfUC 11lM iHE 9TRUCRIRE 6 NOT RRENOfO OR DFFERFO FOfI SALE ISEG 7oN,BU51. J
N NES!N1D iROFEs410NS CODE:T/�COHiPAROR4 UCENSE UW OOES NOT APPLY TO AN OVMER OF ?
� yNOpEqYYW1/pBUtDSOf1YVf104ES7HEREON.A/AWMOODESSUQ7Y40HKMIMSEIFORMERSEIFOR
7TWp10NN80RHEFOWMfMPIOYEES.PAOVIOEDiHAf5Up1IMPROVEMENTSMENOTMFIWE00i1 m
OFFEAEO POR SALE IF.VqNIEVE0.7ME BIA.DMW OR M7NOVEN@RL4 SOID Wf�MN ONE TEAR OF CDYILE�
�7qN,iME qNNEpdUItDER YALL HAVE THE BUipEN OF ViWV W 6 iFUT XE Oi15NE 0�0 NOT BURD OR
MPROVE iOR TNE Rli1Po5E OF Ent�.
p�A1 OWMER OF i11E i110YERfY.AM E%CLUSNELY COHTMCTNO WIT/UCENSEO tOHTiUCTOR3
MCOMSTWCTTHE VRO.IE[T(SEG)W.6U9�NESS�MD VROiE5510N4 CODE:iNE CONTRACTON9 LI• ValUBtIM ADJ.AREA
GO/SE IAW OOE6 MOTMPLY TO AN OWNEq OF A►qOiERtY NM1�O BUL09 OH W iROVES iNEREON.AND
r/1p�pfTAACTSipq6UCM0iqJECTSWITHACONfRACTOR(SjL�CENSEUiUPSUANTTOTMECOHTRAG QUAHTfTY OESCRIPTION FEE �
� 10RSl10ENSEUW► . J
OIAMDfE1WiUN0ERSEG B.ti.C.FONTWSREASON Q
U
2
�=" DA7E ONmER V
� LICENSED CONTRACTORS DECIAMTIOD� -�
� w
IIIEREBVAFTNHUNOERVENAL7YOFiERn1RYiHATIAA1lICENSE0UN0ENYRONSIONSOFCMAPiER V.
� �(OONIEHGtqWIMSECT10N7Doo)OFDMSqN]OfTME8U51NE55ANDPROFE5510N50D�E,IwD Z
MY ULEMSE L4 N FlAL FOPCE MO EFFECi. m
� UCENSE CU55 R --C�'Z!�--- IIC.NO. � ��� �� J
�j DATE COMPACTOii �'/ a
� WORKERS'COMPENSATION DECLARAT N ' � • 4 •
= U
� IHEREBYIIFNWIINDERVENALiVOFiER1U1iYONEDFTNEfOLLOYnNGDEQ.ANiTqNS: — � .
l� Q
G ^�IMAVE/41DW4L►NWTAWACENiIFIG1TEOFCONSEMTOSEIFJNSUPEFORWd11cER5 S
Z COUPExS�Tipl,�a VaowDED Bv 5ECT10N 7700 0F TNE UBO�i COOE FOR TNE 7ERFOqMAnCE U
�p OF iME WURK fOH WMp1 TIa9 iERMtT IS ISStIEO. �
Fw ^_I NAVE.WD WILL WMTAH WORI(ERS'GUMFENSATION MSUNNCE,AS REWIqFA Bv SEC7�ON
O J70CG'7HEL�180RCODE.iOHTMEPEFFORYAHCED�TMEWORKfORMM�dITN15GERMiT15
ISSUED.MYNOHKE '�DEH�4A.T.�IONWSUR�NCEC�NPoE(R�II�f�A+D� �crr+uueeau�: CONS7RUCTION
� CARPoEH �p�'y.,+� ' C �'�'� PLAN iiEVIEW
Zra.�crerwaen � ` ' �' ELECTRIC
6 ,
� (iH55ECI1p��EEDN0TBE0C�I.ETEDOchEPERAff6�d�EwaPED00.1AlISR�mlOALESSI PLUMBING
Z 1 CERTIiTTMA7 N TNE PERiOAMANGE OF}ME WORN i011 wNICN iM3►ERYIT 5155VED,I MECHANICAL �
(,'} SMALLNOTE�APlO�'AN'/PEuON�NANvuANNfR50/�TOBE�E3UBJECTTOTHE I
Vj NOiKERSCOMPElIS�TK7/UWSOiCM1FOfiNIAANpA6AEEtHAT1i19HOUlDBECOME INSPECTIONFEE
S SUBJFCTT07NEWWME0.5'C047ENSATIONDRONSIONSOFSECTpN7T000GTMELAHOR �SSUN'10E
eooE,i sFuu�onn+wirN couv�r win�n+ose vRovisa+s. �
� SMIP !
� p�tTE: ADpLICANT: .
w ENEFiGY P/C I
� WAANINO:FAlIUiIE TO SECtiRE WOAKER3'CO�APENSATION COVEqAOE�5 UNUWFUL,M10 SMAU BE
�y SUB.IECT�NEMPLOYCRTOCRIMWALFENALT�ESIWOCMLFINESUVTOONENUNDREDTMOUSAYD ENERGYPERMIT '
pOLURS(7100,000),N�OOiT10N 70 TNE COST OF CpAPEN$AfqN,OAMACES AS OROW EO FOR IN j
¢ SECTION77a�OFiNEU80ACO0E.MEREST,ANDATTORNEYSFEES. RETENTIONFEE: �s
�W¢¢¢ CONSTRUCTION LENDINGAGENCY PREAIT FEE: 3(
�HEREBVARIFN{1NDER VEN�LTY OF PERJU�'iF1AT MERE 15�CONSTRUCiqN LEN0iN0 AGfNCY }
FON ME 7EN�ORWANCE OF TME WORK FOR W WCH T WS vERM'�i IS ISSUED(SEG.70i1.CN.G). �
� LENDEII'SNwE �
� LEHDER'S�DORESS
w ICERTIFYTNATIMAVEREADTHISAViIILATpf111NDSTATETMATTME/�BOVENFOiWATqN45CORREtT. TOTAL FEES �
p_ IMflEETOCGA7lYWRNALICrtYANDCOUNI'YDNOINANCESAMISTATEUWSREUTMlQTOBU0.DIN(i �
CONSiRUCT10N.AND NEREBY 14lf110RIZE REVRESENTA71VE5 Oi TNIS COUNTY 70 ENTER UPON iNE
� PBWE�MEMqNEDPROPEqn'FOR�NSPECTIONPURPOSES. COMMENTS
J I
�
m FERAAtTTEE NAME(PNHn �
Q I
N
y $IGWTU�1EOFVENWT7EE DAiE �
T RECP7 NO. PAIO BY VAU�ATION _
F— WHITE—OaDanmerft Copy.YELLGW—Finenee Copy,PINK—Asaessor Gopy,GOLDENROD—File Gopy,6flEEN—ApD�ieant'a Copy