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Home My WebLink About10004 (5) � � � Fx - CITY OF DIAMQND BAR � I� Pf COMMUNTI'Y DEVELOPMENT DEPARTMENT� ��Q � �,.,� 21660 E.Copley Drive Suito 190 /�r (909)860-3195 Fax(909)861-3117 `/ D� , PRESS ��"' BiJILDING PERMIT APPLICATION �QO� FIRMLY � �'SS / - �O ��-'"�� `*" /�.� �PPLICATION PERMIT � P/C ; DATE NUMBER p�� M $ ISSUE TYPE OCC APN LOT TFIACT DATE CONST. GRQUP p OWNER �U�� "' ADOFESS 5��7 ZONING SETBACKS g APPIJCANT �P /S,r TEL, R�ORT RW �❑ � SIDE/SI�E STREEf RW ❑ CONTRACTOR ��L � U/I � SIDE ❑ Q ADDFlE�S �_• � • � CITY �IJR�+1 r%T ZIP�7� TEL. ,�� PROPOSED USE / w ARCH/ENG/ z DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS STORIES �BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AAEANALUATION � � OWNER-B�ILDER DECLAAATIQN SFR/AD0lREM O p I HEREBY AFflRM UNDER PENALTY OF PERJUNY TNA7 1 AM EXENPT FROM THE CONTiUCTOqS LI• G3f8QB/Ca1p011 W CENSEUWFORiNEFOLLOWINGHEASON(SEC.7037.5BUSMESSANDVPOFESSIONSCODE:ANVCITVOH (f� C.) 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W (n+ssEcnp.ir�Horesop�r�ocn�pErawrsFrna�Mr�a�n � i.yFs} PLUMBINC, / � � 1 CEflTIfYTHAi IN THE PERFORMANCE OF hIE WORK FOR WHICH THIS PERMIT IS ISSUED,( MECHANlCAL y+�� SHNL NO�ENPLOY ANY PEFSON IN ANY MANNER SO A$TO 6ECOME SUB.)ECT TO 7HE � � WORKERS'COMPENSATbNUW50�CALIFDitYI/SANOA�REETHATIFIS BECO �NSPECTIONFEE r S SU&IECTTOTHEWOflKEHS'CAMPENSATIONPPOVI SOF CT�J37 TME R ISSUANGE /�J � � E,I I�LLiORTHWI7HCONPLYWIiHTHO P IS �+7� p DA7E:�� APPLICANT. __yR�� '�v� SM1P `1 V � ENERGY P/C J W3pWNf3:FAlUtRETOSEIXIREKORKERS"C041�ENSATqNCOVEpAGEISUNLANM1IlL,ANDSHALLBE � SUBJECTAP7 EMPLOYEfl TO CRN�IM�L PENALTIES AND CN!LflNES UP TOONE HUNDRED TNIXISAN� ENERGY PERMIT OOItARS(St00,aao),IN ADbIT10N TO T!{E C95T OF COMPENSRTXMd.�AMAG£S AS PflOViD£D FOR IN � SECTIDN3�OBOFTHEU80flCWE,MI7EREST,ANOATfORNENSFEES. R�'{�NTIONFEE: d CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � IMEPEBYAFFIqMUNDERPENN.ttOFPERJURYTH�TTHEREISACONSTPUCTIONLENDINGAGENCY Z iOq THE oER W RMNJCE OF THE WORK FOp WH�CJi TM�S 7ENMIT IS ISSUE�(SEC.30W,CIV.CJ. W � I�NpEA'S NAME F— LENDER'SADDRESS ¢ ICERTIFYTHATIMAVEREADTMISAPPLICqTIONAND5IATETHATTHE/�BOVEWFORMATIONISCORRECL TOTAL FEES � I A�REE TO COMPIV VATH KL�'AND CdUNTV OR0INANCES AN�STRTE UN�S REUTIN6 TO BUILDING CONSTRUCTION,IWD HEREBYAUTT10flIZE REPRESENTATIVES OF TFIIS COUNTV TO ENTER UPON THE Z �BOVE•MENTIONED PflOPCRTY FOR INSPECTION PURPOSES. COMMENTS � /'��i/��i� /��l�o� � m PENYR7EE RI N 3 2 y-�i7 N 91fiN�NREOfPENMIT7EE DATE � aEcar.No. nio er vqua►twN WHITE-0epartment Copy,YELLOW—Finance Capy,PINK—Asseaeor Copy,GOLDENFO�FiIa C,Dpy,GREEN—ApWklrft's('.apy ..__.__�...�__.�__ _. _ _... _. �_. .__ __�__. __.. _. -- , _ _ G� ('3 k � �, ._�-- il � � (' (��6 _ U f�� il � T "t -i l'�i�� ' G9 _ r, r� j I � � I � _ r� r i r r � i- � I� r � �i z ri � ;� � -� r`� q � r; z I r. C) � " G � O �� ; __ � i� � ��..� � �7 i •� �. _ �r ( C� C � .i � t', � C� a C��. 'oC�1 i � , n� : C� a . ` C r� � c� v? � � �� p�� - � i� i r': [ , �c "3 rr� O � C> �' I ` � i r �� I � � r; Ic�Ci i Ut � �`'I � c'I�c`U. � � f) � �I�' �! � cI� � c I C� ,� i, I � Zr; I�� r��I - � � _-�I-I C I -' I C,; � � �O G;� -, ��,r,� � I :. � � .I � ,�� _..al� �:ln � � Gi� �.. .� �c C ni - m�.�l � � I � . I � � �` ��" j�'�; .� � it�, � `�n a ' � , I I . ,, � rri� �' I I � -I--- , . � . p r- . ,. � . _ I � � � : ! . I � ' - I ! + I ��. 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