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HomeMy WebLinkAbout14215 �_ CITY OF DIAMOND BAR � DEPARTMENT OF COMMUNdITY&DB MENT SERYICES 21660 E.Copley Drive Suite 190 (904)860-3145 Fax(909)861-3117 PRESS ���� BUILDING PEBMIT APPLICATION FtRMLIf � JOBSITE • Q APPUCATION�� � � PERMIT � P!C o ADDRESS L fJfS �.���D DATE NUMBE �k � ISSIlE TYPE OCC APN LOT TRACT DATE CONST. GROUP g QWNER � C� M "' ADDRESS G � !i ZONING SETBACKS Z CITY ZIP��� TE�� REAR RW ❑ g APPt4CANT 1,,, s�+�!���+5{_ �. � SIDE/SIdE STREET RW ❑ � � CONTRACTOR �O►� �. ;n t+ln SIDE ❑ ADDRESS v .� f � g CITY ZIP� O(D TEL� SO y PROPOSE�USE � ARCFUENG/ DESIGNER NQ.DWEL. NO. NO. � ADDRESS UNlTS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREA/YALUATION � OWNER•BUIIDEA DECLARATION SFR/ADDlREM O Q I 11EREBY�FFlW/IRIDER VENAL7Y OF PERAIRY 1N�T 1 MA EXEFdPT FROM TNE 0�1t�RACTORS Lw Garape/Carport �1J CENSELAWFON7}iEROL10WINOREA90N�5EC.7031.58U5MIES3MI�PROFE5510N5CODE:AHV41TYOfl (� . � OOIMiTYWIMCHREGUWESAPERMIiTOCON87AUCT.ALTERMIPROYE.OEAqLISN,OqREPI.IRANYSTpUC- W POtIWDBGVC 7URE,PWOR Tp 1T3 ISBl1MICE,/�LSO R[9U4RE8 THE APPLICM7T FOR SUCH PEHMIT 70 FlLE A SIGNED w � STATEA�lf 7HAT FIE OR SHE i5 UCENSED PURSUANT TO 7HE PRDVISIONS OF THE CONT/UCTORS ll• � (�UW(QIAGTE9 Y(GUGYENC WO YflTX SEGTION 1mo�OF�NIS�ON 9 OF 7HE BUSINE55�NO Pfl0- u' POOVSPB fESSqHS CaOEJ OHhUT HE OR SME 15 E%EMPY7HEPEFRqA AND TIE @A513 FOfl THE ALLEGED EXENV• TqN,ANYYIOLATI0NOF5ECTION7087.58YANYAPP��MFORAVERMITSUBJECTSTNEAPPIiCANTTO z Re-Raof � ACMLPEN�l7YaFNOTMOFlE7liM1FNEHU�DRED00tURS(SSool.k � p1,ASONMEROF7HEPROPEN7Y,ORMYEMPLOVEESWITHWAGESASTNEIR50lECOMPENSATqry, � �pmmercial - W�L OD 7NE N�INO iNE STRIH:TURE IS NOT IHTENOEO OP OFFERED f-0R SALE(SEC.]OU,BUSI- J �<c MD PHOFES&IONS ODDE i�GOHTMCTORS LiC£NSE UW DOES NOT APPLY TO AN tltMER OF � pqpPERf`/WFIDBUILp50q14PRDVES7HEPEON.MDYMODOES3UCHMDAKHIMSELFORHERSELfOA � ([ 1lY70UGHINSOt1HEqOYMEW40YE6S,PPOVIDEDTHATSIICFIWPROVEMENTSARE4bTINTEND6UpA m LL� ,O�EDFORSIILEIF.YIONIEVFq.TMEBVILDINCORqAVPOVEYENTi550LDWRHINONEVEAROFC04VLE Z7qN,THE ON'NER�UILOEfl 1M�LL II�VE THE BURDEN OF Pf�V WO?MAi HE Ofl SHE DIO NOT BIAtD OR � MPRDYE FOR 7HE W RPOSE OF SALE4 �y ❑I,A90U7lFHOFTNEPRDPERTY,MIEXq.l151VELYCONTMCTIN6NTfHLICEMSEDCOMRACTOR3 � i0 CON6TPUCT THE Pf#OJEC7(8EC.7ou,BU51NE55 hND PROfESSIONs CODE:7HE CONTR�CiORS U- Velufltian ADJ.AREA fF113E IAW DOES NO'f APP�V TD AN 014NEFi OF APROPERTY WFID BUdD50R MPROYES 1MFPEON./,ND WtbpplriRACTSWrISupiviq.iECrsWITHl1fANTPACTON(5)LICENSEDPURSUMRTOTIECONTMG OUANTITY �ESCRIPTION FEE � TOfi8l10ENSE UYYJ. ❑I AN EXEI/PT UNOER SEC. B.L P.C.FOP THIS RE0.50N � � U 2 LL pATE ONMER F � � LICENSED CONTRACTORS DECLARATION W � I NER�'AFFlIW VNDER PENALTY OF PERNRY TUT I AM UCENSED UNDEfl PROVISIONS OF CHAPTER � �(COAMIENCNqVATHSECiqN7000)OFOMSION�OFTHEBUSINESSANDPROFESSIONSCODE,AND Z ytY�ICETI$518 ql FULL FOACE AND EFFECT. � 0 LICENSE CLA53 4��ltC.NO. � n � v o�� ►O• K • g �{ cc�raacroa �' G a w g � WORKEflS'COMPENSA710N DECLARA710N —� { U � � INEREB`IAFFlRMIAA]ERPENN.TYOF�ERIUNYONEOFTHEFCA.LOWINGDECLAMTIONS: k � Z � a IMAVEANDWILLMAINTMIACEFTIflCATEOFCON^EMTOSELFINSI/REFOAWORKERS' _ ^CpyPENg�TpN,i1SPROVIDEDBvSECTION37000FTHEL.ABOI1Ca0E,FOR7HEPEHFOW.IANCE �U lNE riORM fOR WH1CH 1H15 PENMIT i5155UED. � W � IMAYEAEDWILLMAIHfAINWONKER5WMPEN5�T10NINSUP.WCE,ASRC-0UiRED8Y4EMqN � a7a0 OF 1/1E LA90R CODE,idl iNE OENfORMPNCE OK iHE WORK fOR WHICH 7HIS PENNIT IS � ISSUED,W E�s PENS�T �NSURIr�y CARRIEFANUPOLICYNUMBERARE: CONSTRUCTION � CAPNIER�!����4��# PtANREVIEW . � � voi.�cveaAeEA�. � � � ELECTR� �1 t 0 (n+ssEcrbr+N�NoreEooMLErmoFn+ePEaMrswna�EMrnaEoaouuisa�m oaL�ss! 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W 7.y��'� � WARNINO:FA0.URE TO SECURE WDRKERS'C�MPENS+UION COVEMGE IS UNLAWFU�11ND SHALL BE ENERGY P/C �y�l v i�r�.:+...S J 'r.�, �y SUBJECTMIEMPLOYERTOCNMIMALVENALTIESANDCMLFINESUPTOONEMIXJDREDTFi0U5AND ENERGVPERMIT �TT�n - � � DOLUR&(it00,o0o),NIDOITIONTOTHEGOSTOFCqAPENSATION.OAMAGESASPROViDE�FORIN g�-���!t-=T7'�� +� � sEcran a�a oF n�e uaoa cooe,arenEsr,u�o aroaNers�s. qETENTION FEE: a CONSTRUCTION LENDING AGENCY PfiE-ALT FEE: � 1 HEREBV IFFIRM UNOER PENALT!OF PEfUURY THAT THERE IS A CONSTAUCTION IENDING AQENCY FORTHEPERFORIA EOFiHEWORKFORWHICH7H�5PER1Ali151S5UE�(SEC.3u9"f.GV.G). I � � IENDERSNAME �h0 ' F LENDER'3ADDRESS � ICERTIFV?MATIHAVEREAOTHISMPLICATIONPNDSTATETHAT7HEA60VEINWFMITIONISCONRECf. TOTAL FEES W 1 AGREE TO COMPLY WITH ALl CRY M�D Ca�Nn OROIWWCES MID ST�TE UVlS R£UTMO TO BUILDiNG � CONSTRUC710N.ANO HEREBY AUTHDNRE PEPRESEN7ATIVES OF THIS WUNTY TO EMfER UPON THE � ANOVE-MENTIOIVEO PROPEflT'FOR INSPECTION PUflPO5E5. 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