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HomeMy WebLinkAbout10172 (5) � , ' � � - C1TY OF DIAMOND BAR � ' COMMUNITY DEVELOPMENT DEPARTMENT/, 21660 E.Copley Dave Suite 190 r (9(19)860-3195 Fax(909)R613117 � ��� PRESS� ''""^� BUILDING PERMIT APPLICATIODJ ��- FIRMLY � JOBSITE Q-� Q� �� c!/ �p) APPLICATION !� PERktIT P/C � � AQDRESS ��Jc�t LJ �`�L_T W fl� DATE y/��` � NUMBER/�I�� • �l ^r�� � � APN LOT TRACT ��VE �'/ �j/'�'� rrPE OCC DATE CONST. GROUP p OWNER � !� �` ADDRESS ZONING SETBACKS � CIN l'� ZIP TEL. .-� FRONT RW ❑ APPL ANT ACwt�=u �►�,3��'tS L REAR p � SIOFJSIDE STREE7 RW ❑ CONTRACTOR �'' SIDE ❑ � ADDRESS 'Z- �d� � �, � C�TY JA-LN,j�r Z�P 7 • .fE� -,�(o PROPOSEDUSE . w ARC N � g OESIG _ ` _ NO.DWEL NO. NO. � AD�RESS � UtJITS STORIES "� BEDROOMS � CITY �f}}��/!K 21P� TEI. L y DESCRIPTION SQ.Fl: FACTOR PSF ADJ.AREANALUATION � Q OWNEH•BL'ILDER DECLARATION Sfft/qODIREM O p 1 HEIIEBV AFFIqE1 UNDER PENAL7Y OF PERIUqY iHAT�AU E%EYP7 FHOMI THE WMMCTORS LF GBIAoB/C9tpoR ll! 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Y � ¢ Q{�` " �i..G+./7 � DATE OWNER U �� � �,��^ G� � UCENSED CONTRACTORS DECLARATION W _ J IHEREBYAFFW►IUNDERPENALTYOfPERIUHYTIATIMILICENSEDUNDERMWYISION80FCMAPTER u. � �S � T�/R� (� Y(CqWENGWOWIiNSECTION7000)OfDMS�ON�OFTHEBU51NE33ANOPROFESSIONSCODE,AND Z X t1Y LICENSE IS W Fl1Ll FORCE AHD EFFECL m � ��O f- s��� �Y llJ /� r� � uc�se cuss �.�%S-3 uc.rio.�$ I � � �iC.A � o�re W— �+ ��—ca+Ttucroa `' a w � WORKERS'COMPENSATION DECLARATION � � IHEREBVAF UrAERPENIILTYOFPE0.IURYONEOFTHEFDLLOWIMG0E4ARATIONS: � �G�S�{� �/ �tJ/1�.. /' . l G fd i/�' G MEANDWILLMAINTAIN�CEHTIfICFTE�CONSEMTOSElNNSUREFORWDRKEp3' Z Q OOYPENSI�TqN,AS PPOVfOED 8Y SEGTION 3loa OF TNE L�BOR COOE.FOR TME PERPoRMANCE W OF THE WaiK GON WH�CN TNIS PERMIT IS ISSUEO. � ' , � �� � _j=111AVEANDWILLMAINTNNWORKERS'COMPENSATIONINSURMICE.ASPEd11RE08YSECTION / � Q a1ro oF 7NE tAeON CbDE.FOR 7HE PEHPoP4NICE OF 7HE WONX FOH WHIqi T115 PENMiTIS �./�[�' ISSUE0.MY RS'WMPEN5�TION INSURMME CA0.HlFR/Y�POLICY NUI�Ep APE: .ro UCTION � F' y CANPIEP �/�� i/'f�1� �D i'nL.l,^� NREVI , ��i. /`/�• = � Z POIICY M1Y9ER� ,� /U ELEGTRIC �r j. 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