HomeMy WebLinkAbout15039 (17) C1TY OF DIAMOND BAR
,. DEPART2dENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Ihive Suite 190
(909)860-3195 Faz(909)851-3117 PRESS
'�'�. BUILDING PERMIT APPLICATION FIRMLY
� JOBSITE / �J APPUCATION PERMR n P!C
o ADDRESS �� CA��/� CIZL,�ST DATE , � � NUMBER 1t
c� ISSUE � � TYPE � OCC
APN LOT TFACT DATE CONST. GROUP
� OWNER S�IZ.tZ�I
ADDRESS C' N1 - � ZONING SETBACKS
u' CITY ZIP TE � FRONT RW ❑
� APPUCANT 'T�ti( !L�c-'� TEL _ REAR ❑
� � SIDE/SIDE STREET RW O
CONTRACTOR 1�1�t'I�NU T�,b�i=�^��"t SIDE ❑
gADDRESS I G�3[v '�D1C - (.� �� pROPOSED USE T o f��(- NST � L W�
CfTY T�[ �3 ZIP TELG��1 /-7�4 . N /t.F' ' rN
� AFiCWENG/
DESIGNER NO.DWEL NO. NO.
ADDRESS UNITS STORIES BEDROOMS
� CITY ZIP TEL
y DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION
p� OWNER-BUILDER DECLARATION SFR/ADD/REM
� - - - -
p I MEREBY AFFWI LNOER DENALiY Of VE0.AJRY TMAT I All E%EA1iT fROu TNE CAYTRACTORS ll Galepa�C2fpOfl
W CENSEUWFONTHEFOLLOWwOREAfiOH(SEG7oJ1.6BU5WE55N10PqOiE55lONSCO0EMIYGTYOR (� . _ . .. . .
L7 OOUMIWlOR1REO{AqE9APEAWiTO00N57HI1CT.ALTERMPROVEDEAqUSM.ORpEPAIHANYSTRUG W Patw/Deck
Z TURE Vi110R TO fi5 ISSUMICE ALSO REW YiES TNE APDI.ICAHT fOR SUtlI DEiUUT TO FI�E A SIGNED
� STATEAIENT TWV NE Oq SHE IS UCENSED PURSUANf 70 7HE PROV�SIONS OF iHE CONTRACTORS LL W
� cFe�aE uw�auwrER o tcouu�cwa vnm sEcrion iaoa�oc ansior�a ef n+e euswess�rro vAo- � PooVSpa
FE5.910N5 OODE)ORiMAT ME Oq 511E IS E7tEYPT 711ERFFR04�ND T11E fi�WS iON TME iLLLEGEO EILEII0. e�
TIDN.ANYYqLA7qNOF6ECfqN)071.6BYM7YA7PUCAHTFONAPEFWTSUBJECiSTHFA7PUCAN7T0 Z RaRoof !i
',_, AqV�GEluLTY OF N0T MOfiE 711AN FIYE MR�OREO DOLIARfi IfSaD)1:
� ❑I��MMEROFiHEGRDPERTY,ORWf1ADLOYEESWIiNWAGESh5THE1R50LEC041VENSATqN, ❑ (`,pmmefCial '
WRL 00 THE MbiYC MID T11E ST%1CTUfiE 4S NOT Y7TEHOEO OR OFfERFO FOR S.LLE(SEC 70N.BUSF J
NESS At�VROFESSlONS CODE:THE CODliMCTOiLt UGENSE lAW DOES NOT MPLV TO�N OWNER OF =
� VHOPFA7YYRpBUlD30ltYPiqVESTMEREON.ANOVAqD0E55UCHWOFiKWMSELFOHHERSELFOR
(= T}WOU6HWSORNEHOWNE1�LOVEES,PiiOVIDGA1NAiSUpiYVROYEUEMSMEHOTMENDmOR m
_ - � OFFEAmWHSAIEF,HOIYEYEIlT1E&14DWGOIIYPFiDVEbFML450LDWfT/WONEVFAROFCpAPIE- - . . . _ - .. . . .._ _ _.. _ . _ .
'TION.TYIE OWNERBUILDER VALL MAVE TME BURDEN OF PROYWO TNAT ME OR SHE D�NOT BU4D OR
_ _ _ � wIPROVFFORTIIEPURPOSFOFSAIE} _
� Ol/30YMEROFiNEPFOPEKfY,AYEXCLU5IVE�YGONTRACTNGWI7HULENSmCONTAACTORS- -
TO CONSTftl1Cf THE YR0.1ECi(SEG 70N.BUSINE55 AND VROFESS�ONS CODE 7HE CONiRACTOKS LL V81Udt10t1 ADJ.AREA
CENSE UW DOES NOtA7VLY TO/Jl OWNER OF A CNOPERTY VAq BUILDS OR KIGROVES THEREON.AND
wwcartw�cTswnsua�rnaeaswin+�oonrw�cTor�s�uc�r+sEowruwwrron+ecorrtr� pUANTITY DESCRIPTION FEE
� �otis ucasE uw.> , . - - .
O I/JI EXEYPT UNDER bE0. B.�P.C.FOR TH1S REASON �
U
�
�=' DATE OWNER �
� W
LICENSEO CONTRACTORS DECLARATION �
� W
IHEREBYAFFWNUNDERPENALTYOFVEfWfiYTMAT1uAUCENSEDtRlDERiROvi5qN50FCwNTEH Vr
S 0(001AA1ENCINO WTiH SECTION)ao0)OF DMS�ON�OF iME&15�NE55 AND VROFESSIONS COOE,AND Z
lL iflULENSEISHFUIFWiGEANDEFFEGt
�93 � gz m
a ��«� c 3 9 �.No. �
� w� �g ( 1 I l.e-r�u carrrucroa ?�l t"1 a
� WOHKERS'COMPENSATION OECLAMTION 4 .
� U
� IMEREBY/FFYWUADEHPFHKTYOFPENA1iri0NEOFi}iEFOLLAYlWODEGIARATqNS:`t �
. Z
` 4
� _IYNVEANDYALLMANT/UNACERT1f1GTEOFCONSENTTO5EWN5UREFOHY.OPxERS' 2
� COAIPENSATION./SPROVIOEDBYSEGTION]7000FTMELABORCOOE.FOR7MEPERFORMANGE w
OF THE WOFl1C FOFflYMICM iM45 PEFJ�IT i31S5UFA �
�
�I HAYE AND 1Y41 AIAPRAI!!WOFiKERS CDMVENSATqN WSURANCE�FiEOUIREO 9Y SECTION
Q 77GOOFTMEU1BOflGODE�TMEDERlORMANCEOF7}iEWORKFORW1/1A1iHIuPERIdIT15
�55UEp,yyWppl(EqSCOYPEN5A110NW5UHANCECARR7ENMIDPOLICYNUMBERARE: CONSTHUCTION
� �Ep /V L'��✓L PIAN REVIEW
� PaLICY MllABEH `� ELECTRIC _
8 (MSSECTON�r.qTSEm641EfEpOFnEpFAAiswnar�Enut�lFD0atK6p�m)aHLE55} PLUMBWG �
Z ICEHi1FY7}iA7NTHEPERFORMANGEOFMEWORKfORWM1(71T1i15PEM1RI5155UED.1 MECFWNICAL i y/:• "�
(�} SMILL.L NOt EAIPLOV ANY VERSpJ N ANY YAw+ER 50 AS TO BECOAIE SUBJECT TO THE '�""�r
� WORKER5COAIFENSATqNLA»50FCAUFOFwV�hNOAGRFET1uTIFISHIXADeECOA1E INSPECTIONFEE
S SUBJEGTTOTIIEM�ORKERSWMPENS�iqNPROVISpNSOFSECTqN97o00FiHEl�80R ISSUANCE /
COOE 151ULL fORiM111TH COAIPLY WITH TMOSE GROVISpNS. '
� � i �w�: ��.t i�.��--t SMIP �� I L U ' � � _
o ��
WARNINO:FA0.UiiETOSEWREY.OFiKERSCOMPEN5AT10NLOVEHAGEISUNUWfULANDSMNLBE ENERGYPlC +'� "'•� �"*�• • • "�•'�r �
� SI/�IECTAHEMPIOYERTOCAiMWAIPENALTIESANOCMlFWE5UPi00HEHUNDAEDiT10USAND �ERGYPEFlMIT - _ ' -i,..,.�....-^.�
WLLMSISIOD.Wo�WADD�i1CNTOTHECOSTOFCONPEN5AT10N.DMMGES/�SPROYIDEDFORW �j'\lJ I-il�L J�.a�.-•i •
J 5E�{pN�7popF7}1ElAB0{iGOOE,MTEFEST,ANUA7TOFWEY'SFEES RETENTIONFEE:
� CONSTRUCTION LENDING AGENCY PRE-ALT FEE
O
CiL IIiEREBYKFIRMUNDERPENKTYOFFER1URYiHATTHEPEISACONuTRUCTIONLENDWGAGENCY
�Z- FOR iHE PEHFOW.IANCE OF TiIE WORK fOR WMICM 11LL5 FERMIT IS ISSUFA(SEG]oi7,GY.GF
W
� LEHDER'SNAME
�S LENDER'SADDRE53 /�
w ICERTIFYTHATIHAYENEADiHISIPPLK.ATbNN�DSTATEiW�TT1EABOYEINFORAlA1qNI5COPAECT. TOTAL FEES � I O e��
� IAGfiEETOCpAPLVWIiHALL�fT`�N�OCOIMTYORD�NW�CE5MID5TAtEUWSREUiWfiTOBUILDINO C �
CONSTRUCf10t1 AND NEREBY AUTIK)RI2E REGRESENiAT1YE50f TWS COUNiY TO EMER UPON iME ,
S� /�BpyE.yFN{pNEppqppERTYFpqINSDECTIONPUNDOSES COMMENTS
9 �i (-f�j
m PERMITTEEWWE(� �
Q /�
�
� S�GN�7UFfEOFP EE DATE
� RECPT.NO. PAID BY VAL1DA710N
WHITE-Departmenl Copy.YELLOW-Fhence Copy.PINK-Assessor Cop�.GOLDENROD-FileCopy.GREEN--/WplicanYs Copy