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HomeMy WebLinkAbout11989 (6) . - CITY OF DIAMOND BAR COMMUNITY DEVELOPMENT DEPARTMENT _;,,� 21660 E.Copley Drive Suite 190 PRESS (909)86(�3195 Fa�c(909)861-3117 L�''�"� BUILDING PERMIT APPLICATION FIRMLY � o O R'ESS � � e � ��� APPIICATION�„Z f�� PERMIT PIC��-� ' �ATE � NUMBER 1e ! c� ISSUE TYPE OCC APN LOT�_ TRACT DATE CONST. GHOUP � OWNER ,G E W " ADDRESS C`n i'M , ZONING SETBACKS Z CITY ZJ P TEL. REARr RW p g APPLICAN7 / TEl SIDEIS�DE STREET RW ❑ � CONTRACTOR A I �' �J SIDE O � ADDAESS �-1t � ROPOSED USE �'{ � oL. Sy� o CITY ��Ct IHv ZIP�(�[� EL.��, `�_-�„Z,� �"P�"�~� u� ARCHlENG/ p J�G/!Lr �C� Z DE5IGNER ,/�Q►� NO.DWEL. NO. NO. a ADDflESS.���/ - sts ` ,,��1 UNlTS STORIES BEDROOMS � CITY - ZIP2�2 TEL._�5�f,� � ��5�� � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION OONMER-BCILDER DECLARATION SFp/ApD/REM p I HEf#BY IIfFlRM UNOER PENALTV OF PEFiJUHY TFIA7 1 AM E%EMPT FROM tNE CONTMCTONS U- .���(Ca�h �y,! 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" � r � O 1 AM pfEMPT UNDER SEC. 9.a P.C.FOR THIS REIISON U K � � � OATE OWNEP V � LICENSED CONTRACTORS DECLARATION � � w IHEREBVAFFIRMUNDERVENJu,TYOFPERJURVTH�TIAMLICENSEDUNDEHPibVISION60FCHAPTER � � .Y�COW/ENCWOWITHSECTION7o0D)OFONISqN30GTMEBU5WES5N10PHOFESSqNSCO�E.MA $ MY LICENSE IS W FULL FORCE�MD EFiECT m lLl ? l 7! � LICENSE C�U�SS+����7-J . LIC.NO. �/ v � __._ j � VOATE—f f7.:J 1.�.�f,�_CONTRAC70R � � W —��--T / � WOAKERS'COMPENSATION DECLAA ION C�3 q � V U � IHENE9YAiFlRNIXJUERPEN�LTYOFPERJURVONEOFTMEFOLLOWIN6�ECUiUTqNS: � Q ' � _IH�VEANDWRLMAINTNNACERTIFICATEOFCONSENTTOSELFdNSUHEFORWORKERS' � WMPENS�TpN,AS PROVIDED BV SECTION 37ooOFTHE UBOA WDE,FOR THE VEPFORIAMICE W OFTNE WORK FOR NMICH THIS PERMITIS ISSUEU. � G w __I HAVE MID WI11A1AiNTA1N WOFiXERS'C0IAPENSATIOl1�NSUiUNCE,AS REOUIRED BV SECTION Q 97000FTHELABORCWE,FOflTHEPENWflMANCEOFTHEWORKFOflWHIqiTF113PERY1T15 O ISSUED.A1Y ERS' pENSA INSURANCE CARRIER AN�POIICV NUY6ER ARE: CONSTHUCTION � J j uRRIEq � PLAN REVIEW Y Z POLICV NUTABER�/_�CV - ELECTRIC � a (nassec'roHr�nrneemnatr�oFnErew�rmioaa�r�ooat�s6�ao)orrt�. PLUMBING � '` ` Z ICEFTiGY THAT W THE PERWRMANCE OF T1E WDRK FOR WH�qI TNIS PERNIT IS ISSUED,1 MECHAN�CAL \ V V +�} $HA�{,NOT EMPLOY ANY PERSON IN ANY MANNEfl SOAS TO BECOME SUBJEM TO TNE y WORKERSCONVENSATIONLAWSOFCALIFORNIkANDAGREETMATIFI5F10UlDBECOME INSPECTIONFEE S 3U&IECITOT}tEWORKERSCOMPENSATqNPRON510N50FSECTION37000FTHEUBOH �SSUANCE � CODE.�SM�LLL FOR7iM�ITH COMPLY W17H P 5. � � SMIP I � p DAiE:� APPLICANT: _ W � —'� WARNINii:FALURETOSECUNEWOirCERS'COM�PENSATIONCOVEMOEISUNLAWFUL.MrDSH�LLBE ENEHGYPlC � SUBJECTANEYPLOVERTOCfiIMINALPENALTIESJWDCNILFINESIJPTOONEHl1N�FFDTF/IX15l�N!) ENENGYPERMIT }, OOLLAR31fi00.OW1.INPWITIONTOTHECASTOFCOMGENSATiON,D�M�0E5MSPROVIDEDFORIN � 9ECTION 970E OF THE UBOR CW E,MIiEREST,AND ATfORNEYB FEES. RETENTION FEE: � W CONSTRUCTION LENDING AGENCY PRE-ALT FEE: a� � 1HEPEBVAfFIRMt1/mFRPENALTYOFPERIUHYTHATTHEREISAWNSTHUCTI�NLENOINOAGENCY iOR TME PERWRMANCE OF THE WORK WR YRUCN THIS PERMIT IS ISSUED(SEC.30Y7,CIV G�. Z W � tENpEWSNr1ME 1� LETqEFI'S�DDRE55 i�� ' a�c TOTAL FEE � ' � W 1 CERTIFY THAT I F1�VE REM TF115 MPLIC�TqN M1D SYATE hIAThIE hBOVE FIFORIdATqN IS CORRECT. a IAGREETOCOUPLYWITHALLCITYANOCIXIMYOI�INANCESANDSTATEIAWSREUTING708UILOIN6 � CONSTRUCTION,ANO NEREBYAUTNORRE REPi7E5EN7A71VE5 OF THIS COUNTV TO ENTER UPON THE �y S� ABOVE�MENTIONEO PNOPEHTY FORI INSPECTION RFiPOSE3. 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