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HomeMy WebLinkAbout12532 (13) � CTfY OF DIAMOND BAR COMMUNITY DEVELOPMENT DEPARTMENT � ��� � z166o E.Coplcy Drive suite t90 PRESS (909)860-3195 Fax(909)861-3117 � �'"^�'j BU]LDING PERMIT APPLICATiON FIRM�Y � ADDRESSc�C���, t �,C�ZO�� pAPEICATION i b � a N��E ���k� � issue rvP� occ APN LOT TRACT DATE CONST. GROUP p OWNE��C1�I h i P �_ LL ADDR{�SS ' ZONING SETBACKS z �� L,��c�C� ZIP ���v`S'TEL s�i-�� FRONT RW p g APPUCANT � c^.�,e'4-.�� 7E�. �'R � � SIDE/SIDE STREET RW ❑ CONTAACT � �; SIDE ❑ ADDRESS �F>>C ( 4_Sct� � CITY('�� ,,L,��y„^�C= ZIP ,�� 7EL�. (T��� PROPOSED USE o ARCWENG/ iz DESIGNER NO.D4VEL NO. NO. Q ADDRESS UNITS STORIES BEOROOMS � CITY ZIP TEL N cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREAN,ALUATION � OWNER-B�ILDER DECLARATION �q/qpp�EM O I HEREBY AFFIqM UNDER P£1ULN OF PERAIRV iH�T I AM FXEMGT FROM'fHE CONfMCTORS ll. Gel809/CBf�Ot1 W CENSEWVFORiMEFOLLQWNGREAB(7N(SEGT031.68U6WE661JbPROFESSIONSCODE:M1YGtY0A (n C.� COIMfVWHN:FIHEQU1qE5AVEW�111TOCON$Tf1UCT,PLTER,NiPpOVE.pEiqtlSH.pqpEpMpN1Y57RUC• 11.1 PefIQ�DBd( NqE,PRqR TO IT$�SSUANCE�L50 REd1i�E5 7NE�CR�ANT FOR SUCH PEMlIT TO FI�E A SI6NE0 M! � STATEMEM TUY HE OR SNE IS LICENSED pUpBUANT Rl THE PROYISIONS OF TNE COMMCTOR+^LM � � CENSE LAW([NAPTER f i���M7TM SECTION 7a0o)OF OMSION J OF TIE BUSNlE35 ANU PRp- POOV$pq � FESSIONSC�EJOqTT/ATHEOR5HEI5E%ENPTTNEftEFHOMPNDTHEBA315FORTNEIILIEOEDE%EYP• � V TpN.NyY VqLAT10N OF SFCTION 7031.s BYANY APPLICANT FOR�PERYIT 5U8JECT5 TNE APMICAfIT TD Z (j9.ppp� A pVIL YENAL7V OF NOT YDfiE 7MAN FIVE M1NbFEO DOLUWS lf5oo1.4 0 ❑I,ASOWNEROFiHEPROPERlV,OqMYEMPIOYEE5WITNWA6E5�51HE1N50LEC041PENS�710N, (`,pmmgfC�91 Z NIILL DD THE WOJiK,MA THE STRUCNFE IS NOT INTEN�60 OR OFiERED FOR SALE(SEC.7a�,&151� �J N NESS AND PHOFESSIONS OD�fi:THE CONTpACTOR5l10EN5E UW DDES NOT APPLV 70 AH ONMER Of ? 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G�S�T-� � V DATE I�"'Z��+S� CONTRACTai � W � WORKERS'COMPENSATION DECLARATION Q � 1 HEREBYAFFIRM UIqEH PENKTY OF PERNM ONE OFTHE F011ON11NG OECVIMTIONS: � � __I IUVE AND W�ll WM7TM1 A CERTIFICATE 0i C-0NSEMTO SFLFINSUqE FOR VAORKERS' _ OOYPEN5�TION,ASPpOVIDED8Y5ECTION370oOF7NEU60RWDE,FORTHEVERWiWNCE W Q OF TME WOFK FOH WNK71 TMIS PERAIIT IS ISSUED. � W �I IUVE AND WILL MAR11'AM WOPKERS'R7NVEN5�TION INSUfUNCE,AS RE01JIflE0 BY SECTqN Q STOOOFTNEUBOFtCaOE�TMEPENWHfAANCEOFTHEWOSKAIAWNICH7MISpERAi1Ti3 ISSUED.MV NK)NKERS'CdIPEN5A7NN�1�N9UNANCE CARR1Efl AND P�LICY NUA�Eq ARE: CONSTRUCTION } GRWER.��L PLANPEVIEW Z ra�crta�+�a6a �,(�S(�' /(7�-�/C�"�t1 ELECTRIC "� l � 0 RrssEc.manr�aoreEmeaF�oFnEVEw�swaa��oayas{s+mloa� PLlSM9�NG � �CERTIFY TNAT NI TME VEPFOf�iANGE OF THE W011K f-0R WII�CM THIS PEPo.CT l41$SUED,1 MECHANIC�U. (r} SH/LL11pT EWPLOV ANY PERSON W ANY MANNEH 50 AS TO BECOME SUBJECT TO TNE (/� 4WNKENS'COMPEN4�TqNlAWSOFCAIIFdiN1A,ANOAGREETM�TIFISMOULDBECOME IN5PECTIONFEE � `- SUBlELT70THEWORIlEPS'C01AP[i�5�71ONPpoVISION50F5ECTIW9]ao�TNEIABOp S cooe,�sw�u,ronnnHnrcor�a�rvnn+n�osEPpov�sqNs. �SSUANCE • O ff � ��p p OATE: O�'L./— _ APPLICANT. ,(� J - ENERGY P(C �.L►�!n'IC(TAT'Ny�' /� WAMINlk FMUNE TO SEWRE VADRKEF�S'COYPENSATION COVEN�OE 16 UNLAWFIA,AND SNALL BE P�►j'�k,r-T�'" � &161EC7MIEMPIOYEHTOCNWtULPENALTIE3ANOCIVILFlNESUPTOONEHUNDREDTHWSMIO ENERGYPERMIT �'T�RI�T(�J/�����r, - �OLLARSR��.DoO).wADD1710NTOTHECASTOFC94PEN5�TION,DAN�(3ESASFIiOVIDEDFORIN �-.--�"���`� � SECTqN9iwOfTHELABORCODE.WTEREST,ANDATTORNEYSFEES. 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