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CITY OF DIAMOND BAR � COMMUNiTY DEVELOPMENT DEPARTMENT 21660 E.Copley Ihive Suite 140 PRES� � (909)8b0-3195 Fax(40l)861-3117 '�'� BUILDING PERMITAPPLICATION FIRML� y J08SITE APPUCA710N PERMIT � P/C � ApDRESS Z�^ � � DATE� � NUMBEp� �t , c� ISSUE TYPE 4CC APN LOT�_ TRACT�" �_ DATE CONST. GROUP p OWNER �MA LI ADDRESS tr` ZONING SETBACKS � PPLlCAN�-������e/TEI.�L�,�,�' S�S16E S7REET RW ❑ n ❑ SIDE ❑ � CONTRACT�R C � � ADDRESS pRQpOSED U3E S�K /�R�7�J�a ����{-�� RCFUENG/ p ?JZIP EI.. S^�]i�L.J.� �'fL�'b��� � DESIGNER ADDRESS NO.DWEL. NO. NO. ` � CITY ZIP TEL. UNITS STORIES BEDROOMS } `n DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATfON I �? � OWNER-BCILDER OECURATfON SFq1ADD/REM i � - 0 1 HEPEBY AFFIPM IRJ�Efl PENAITY�F PEflJUHY TW V 1 M/E%EAM7 FqOM iHE OONTRAG70RS tl� (�aro�`8�K � W CENSEUWFORTHEFOL4OW�N(iHEASMI�SEC.7mt,5BU5xlESSANOPROFESSfON5CO0E�NYCITYOR (n £ C� COUN7YlYH�Cl1(iEWN1ESAVEqA/RTOCOfJSTRUCT,ALTER.IMPRO'JE.➢EMOl�5N.O11i1EP41PANYSTRUG `W P8Ii0IOBCJf 6 i�qE,pqpq 7p Rg iS,qUANCE,rL50 REWINES THE APCLICANT FOH SVCN PEFW IT TO FlLf A S�GNEO � � ST�7EMENI THhT HE OP SHE IS UCEIiSED PUflfiUM'T TO TTIE PROYISIONS OF TNE�MTR�CTORS L4 p CENSE lAW(ClIMTER 9�Cd1YEMCHiU YATH SECT%]N]OW)Of OM51�N 3 OF TME BUS�N£SSIWD PF�. � PooVSpa FESSIONSCODE)OR7MATHEORSHEISE%E�TTHEREFROMANDTHEBASISfORTHEALLEOE�EXEYP� (� V TqN.ANYVqlATY0NOF5ECT10N7011.56YANYAVPI,ICANTFOHAPERMITSUBJfCTSTMEAGPLICMITTO z qe.Roof � AGIVILPENAL7YOFNOTNORETHNJFriEHUNOREDDIXAAR3�S5aa).1: � CII.ASOYMEROFTHEP�PERTY,ORMYEMPLOYEESWITNWAGESA6TIffIR80LECQA�PENC/,TION, � CORiT0f�i8) WILL DO TNE WOW;Mm THE STRUCfURE 45 f�i INTEN�EO OA OFGEREO FOR SAIE(SEC.70N,BUSI- J � NESS/NO PHOFESSIONS COOE:THE LONTPACTORS UCEN$E LAW OOES Id�T AGPLY TO AN ONMER OF ? 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O 1 Mi E%EMPT UNOEH SEC. &!P.C.i0A iN�3 REASQN � � LL OAtE OWNEH Z � LICENSED COhRRACTORS DECLARATION � I HENEBY AFqiW UNDER PENALTY 0f PERIUR�'THAT I AM LICENSEO UNDER PAOVISIdNS OF CHRPTER � . � )�GG/AiF.NCMIRWiTH6ECT10N]o00)OFDIYIS�QVJOFTMEBUSINE4$AND�ROFE4410NSCWE,AND �X MY lK7EN5E IS MI FUII FORCE AN�EFFEC(. �� �]w/ � G•�w � ucsr+se cuss C 2 ��c.r�o. � � �j DATE.,,��COFRMCTOR �� d 6� WORKERS'COMPENSATION DECLAH TION /� � � N 1 HEfltBY AFFIRM 1M�ER PENl1TY OF PERK!(h'ONE Oc THE FOLLO`MNG DECUMTIdVS:� � y � __IFNYEhNOWiLLMAINTAINACEPTIFIW7E0FGONSENT705ELFJN3UREiORUbRKERS P7MGEN4ATfON,AS PPOVIDEO 6Y SECnoN 9l00�F rnE 1A00R CODE,FOR THE PERWRMWCE DF THE WOflI(iOH WHlpi THIS PERMI(IS 155VED. � W I W4YE ANO WILL NAMTRIN WORISERS'CC]MPENSATqN INSVMNCE,AS PEd11RED 8Y 9ECTq11 Q 310oOFIHEUBbACOOE,WHTHECERWRMM'CEOF�FiEN'OPKFORWHIQITHISPENAlIT1$ i55uE�.MYNORKERS'WMPNS0.TIONMISVPANCECARRIEPANDPOIICVNVMOEHFPE: CONSTRUCTION y CMIVER �'�� � �.arv REWFw � POUCY M1616ER � EIEGTRIC � �� RN65ECf1oNN�NOT�WAFLEfE00FTFEPE4wifSwHIX�HUUPED00tlA1KiKImloillESSy. �- _ W MECHANICAL � 2 �CERTIfY�/1A�W THE VEPFWI4IANCE�THE riK1RK FOR WHip1 iM1S P£fpAlT B ISSUED,I ., C� SHALL NDT EMPLOY ANY PEASON IN IJ�Y MANNEA SOAS TO 9ECOME 51)BJECT TO THE (fj INOW(ERS'CONVENSATqNUWSOFC�IJFOkNiAANDAGREETHATIftSHOUI.DHECOME INSPECTI4NFEE = SURIECTTOTViEWOR%Efl5'COFIPENSAT%1NPiqVISqNSOFSECTION970oOFTNEIABOR iSSUANCE � O CODE,�SNALL POFTMMTH COWVLY WITN E PR�NS S � � �� p DATE:��q��� APPLICANF. SMIP W �� ENERGY PIC W�pNINO: TQSECUPEWOH%ERS'dJMPEN A VUAf1EI5UNL ANOSNAlL6E ty St�IECTAN EMPLOYER TO CPW W�1L PENAL71E3 ANO CML FIItlES UV M ONE MINDRED T7K)USANO ENERGY PERMIT DOUJ�R9(5100,00�).IN A�ITIdi TO TNE COSTOF COMPENSATqN,DAM/�GES AS PPONOED Wq IN J $ECTpN atW OF iME UBOR COOE.WTENE37 M10 ATTORNEY'3 FEE3. aETENn�N�EE: 4L7 � CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � IHEREBYAFFIPMIlNOERPENALTVOFVEPJU0.YTMATTNEAEI9A�NATf1UCTi0}1lEN�W6AGENCY 2 FOii THE PERNfiMANCE OF THE MIORK FOR'NHICM THLS PEHIAIT 13ISSUEO(SEC.9�97,dV.C.1. W � tENDEpSNNAE � lE1AER5A00RE55 /� W10ERTIFVTIIATIHAVEq£MTi13MPlICATIONANOSTATET1iAT7H£rHOVE1NFOFiM/d10N15CORRECT. TOTAL FEES '//� � IA3AEETO�WKYWITH�LlC1TyM1pCOIJNTYORdH11NCE5AN�STATEtAWSPELATWGT08VILDING ✓ �� CONSTRUCTION,N�D HEAEBYAUTMORIZE REPRESENTATIVES OF THIS CtlUNN TO EMER UVON TNE S� ABOVEJAENTIOM1IEOPROPERTYFORINSPECTIONP11iWO5E5. 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