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HomeMy WebLinkAbout10601 (5) t; C1TY OF DIAMOND BAR COMMUNTTY DEVELOPMENT DEPARTMENT :,.� 2�6[�E.Copley Drive Suiu l90 PRESS {909)860-3195 Fax(909)861-3117 ^'"'� BUILDINGPERMCTAPPLICATION FIRMLY � JOBSITE j J APPLICATIQ�`� PERMIT �' Q ADDRESS 1�0 � G I bKOI Q�_ DATE a�t7'Q 7 NUMBER� � APN LQT TRACT �SSUE TYPE OCC DATE CONST. CiROUP ip OWNER "T 1 Y+��OI�l K �? AD�HESS IO ZONING SETBACKS � CITY � n ZIP TEL��(��077� FRONT pyV ❑ APPLICANT ' �.u E n rr��e EL. REAR ❑ SIDEJSIDE STREET RW ❑ � CONTRACTOR �n.� Y� •. SIDE C} ADDRESS � CITY =�p T� '1I PROPOSED USE � ARCH/ENG/ DESIGNER NQ.DWE4 NO. ND. ADDHESS UNIT& STORIES l BEDROOMS � CITY ZIP TEL. DESCRIPTION SQ.Fl: FACTOR PSF ADJ.AREANALUATION � OWNER-Bl:1LDEP DECLARATION gFRlADWREM O � I NEREBV AFfIRM UNDER PENAL'fY OF PERNRY TW�T I AM EXE/AP7 fROAI THE OOMITNACTOqS LF G81pp6�C91pD11 C£NSEUWPOiiTNEFOLLOWWOREASq7(SEC.70st.6W5WE55AN6VFOFESS10N500DE�.NIYCTYOR (j� COUNrVWHICNREOUIRESAPERMATOCON3TiR1CT,AlTEi�MPIIOYE.DEMOUSF{OFNEPIJRANY6TRl1C• � P8f1�/D6CI( TUqE,►R1017 TO ITS ISSUANCE,ALSO REW IqEe ME APPUGANT FOp SULN PEpYR TO FllF A IIIlWEO BTATEMENT TYY17 NE OR LNE IB LICENSED PURSU�INT TO THE V110VISIONS OF T1E ODNTMCTOR9 LI• � .CENSElAW�CHAFTEFY�MIAMENCW�WITNEEC7qN70WJOFDIVISqN�OFTNEBUSINESSANUVR0. 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O�YA EIfEMPT INDER 6EG. B.�P.L.FOR TXIS qEAYON � V LL DATE OWNER � U �Q LICENSED CONTRACTORS OECLARATION W LL 1 NENEBY 11FFIRM UNUEN PENAL7Y OF PERJURY TW1T I/JA 110EN6ED UNDEN PfpVIS10NS OF CHAOiER � p� �(OOMMENCINO N7iN 5EC7UN 70W�OF DIVISION]OF iME DUSINE33µ0►RDFE3310N9 OODE,�NO Z X W LICFNS615 W FULL FORCE AND fFiECT. LLI � 0 UCENSE CLASS LIC,NO. R t��0� ��,,1 �j DATE CONTMCTOR �„�'f�_ a W � W RK S'COMPENSATION DECI.A TION � � 1 NEREBY 11FFWIA UNDEH PEfULTY OF PERJURY ONE OF TME i011OW1N(i DEC1AMTqNS. � Z .. � ,__INAYEANDWILLLIAINTAINAGERTffICATEOFCONSENT708E1F-INSUREFORWORNERS' S GqAPEfYSAiION,ABVRDVI0E0BYBECTIONaM00FTNElABOHCODE,FOHTNEPERFO 'U OF THE WORK WR WHlp/THIB PEW�II71S IBBUED. g O ��.I II�VE AND WILL WINTAIN WORKEflS COAIVENSATION INSURANCE.AS REQUIRED BY SE ^� Qn 97a0 OF THE lABdi OCOE,FDA iHE PERPORMINCE OF THE YVORK FOR N711CH 7HI9 PEM1 IB / �y►J IS9UEO.MVWORKE ' ENSAf10NIN5l/FWJCECARRIEHAN�POLILYHU►9ERME � CiON$TRUCTION v �/ � CARFIER U �� PLAN REVIEW � POLICYNUMBER ELEC7RIC � � ptasEercx�tr�no7eem.atE�Eooc7�vea�.rrewnaF�Onm Ai�'i� 1 PLUMBING ICERTffYTHATWTHEPERFORMMKEOF7NEMIORKFORWH�CHTWSPEPM1T18185UED,l MEGHANICAL (�J &IALLNOTEMPLOVANYPEHSONiNANYMANNERe0A5TOBECOAlESUBJECTTO7HE vj W0/1KEHS'COMiENSATpN LAWS OF CALIFORHIA,AN�Al3REE THAT IF I BFqULD BECOME INSPECTION FEE � SUBJECT TO T/IE WORKERS'COMPENSATqN PFqVIS10N3 OF BECTION�70o OF 7HE LABDN ovooE.i sww,waniwirH cowa�r wnn�nase vqrnnsaws. ISSUANCE p DATE: o_�– APPLICANT. `�'� � �� SMIP � WMMNG:FALURETOBEWFIEMIORKERSCOMPENSATIDNCOVEMOEISUNWWFl14M10&BLL.IBE ENERGYAIC � 8UBJEC7AN EMPIOYER TO CRIMINAL iENAlTIE3 M1C CML FNES VP TOONE HUNDHED T�0U6AN0 ENEHGY PEqM1T y DOLLAR9 K1a0•oaol•W ADOITION TO 7HE CO57 OF COMPENSATqN.�MUIOES AS PqOVIDEO FOP IN � BECTpN97oBOF7MElABONOODE,W7ERE5T,AN0ATTORNEY8fEE9. RET'ENTIONFEE: CONSTRUCTION LENDINCi AGENCY pqE-ALT FEE: O gI HEREBYAFFIIMI UNGER PENALTV OF P6RJUItY TMAT THERE IS A CONSTRUCTIpV L6NDW0 AOENCY PoR TNE PERWRIIANCE OF 7HE 1NDRK PDR NM1IICH Ti113 PERMIT IS ISSUFD(SEC.10D7,CIV.C.�. � � LENDER'SNAIAE � lFT1DER'9IDDRE55 � ICERTIFYTqATINAYEfiEMT115APPLIGT10NNiDBTATET4ITTHEABOVEWFORMAT10N19CORRECL TOTAL FECS IM3REE TO GOYPLY N7TN ML CITI'AND LOUNTYOFDWANCES ANO STATE UWS XELATM6 T08U0.DMO CONSTqUCTqN,AND lIEq�YMIT1qFIZE NEPRE6EN7ATIYES OF TMIS COUNTY TO FNTEN UPON THE ABOVE.YENTIONED iNOVEHT'Pofl pYSPECTDN R1NP09E5. �' �,t.�,f�o-J CAMMENT3 Qa� � ," u.L, ,� � u.�.2 � woo a C m IERM�ITEE �E�pR�IN�f)/�/ ''7 � � �s {,{) � ilOW1D�EOFPEX►IITTEE � • '� �DA� / � / � REGPT.NO. PAID BY VALIDA710N WHITE—DepaAment Copy,YELLOW—Fhance Copy.PINK--Auessor Cq�y,OOIDENROD--FIIe Copy.OREEN—Applkant's Copy . r.r:.'Nitr'J>:'.�...,>.���i���.r.��...4'r..,. •�� .. . .. . . ..... ..`".!i; '�J.'...•.::..: ��...,. � - �. ciTv ca� ni�Mot�a �aR � , :� . 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