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J� CITY OF DIAMOND BAR � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES .� � 2(825 E.Copley Drive - (909)860.3195 Fax(909)861-3117 PRESS BLJILDING PERMI't APPLICATION � FIRM�.Y � JOBSITE IIZZ .J/ • ��An?p�✓� �a� � APPLICATION �` I`� .PERMIT P/C o ADDRESS DATE � NUMBERI��N Oi-�� � APN LO R T �SSUE G1 � � TYPE �... p�C �9 DATE CONST. --—GROUP � OWNE��- ^' / /� O o ADDR S � — ZONING SETBACKS z C / �' 7J�P L. �' G FflONT ` RW ❑ g APPLICANT TEL REAR p SIDE/SIDE STREET RW O Q CONTRACTOR � � ' �I SIDE p ADDFiE�S S ` � CIN I� -S C ZIP TEL L' �2 — PROPOSED USE F��� S� /�Lr�r C .S S t o ARCH/ENG/ �98 `D���'n � !/C- z DESIGNER w NO.OWEL. NO. NO. a ADDRESS = CITY ZIP TEL. UNITS STORIES BEDROOMS � N DESCRIPTION SO.FT. FACTOR PSF ADJ.AREANALUATION � ONMER-BUILDER DECLARA710N SFR/ADD/REM O � 1 HEREBV AFFIRA/UNDEF 7ENALiY OF PEiLF1RY THAT t MA EkEMPT FRdA THE CONTMCTORS LI• G2feg&�CBfpOR W CENSEUWFORTHEFqlOWINGREA50N(SEC.7071.SBUSINESSM'OVROFESSIONSLOOE:ANVCIiYOR (n U COUNTyWHI�}IREOUIRESAFERA11T7000NSTRUCT,ALTER�MPRpVE,DENOLISN,OPREPAIRANVSTRUG (L w TURE.PRiOR TO ITS t55UANCE./1�50 REWiRES THE�oFUCJiNi FCR SUC11 PENdi7 TO FRE A SIGNE� W Patio/Dack � STATEIAENT iNAT HE OR SME IS IICENSED 7U0.5UANT Tp 7ME VROVi5loN5 OF TME CONTRACTORS LL � � CENSE U�M(p1�PTER Y(CDAIMENCIN4 WITM SECTION 7oW)OF DIV1510N�OF THE BVSiNE94 AND FRP Poo✓Spa FE55qN5LODE)ORi11AiMEORSM[ISE%EMP7iHEREFRpAlWD7ME6A515FOqTNEALLEGEDE%EMP• C7 TION.ANVVIOLATIONOCSECTION>D71.58YANY�PVLICANTFORAVEAMITSVBJECTSTHEAPPLICANTTO Z Ra-Rool ACML VENA�7y OF NOT MORE T/WN FIYE HUNDRED DOlURS(1500).�: � ❑L�OWNEHOFTIIEPROPERTY.ORMYEM7LOYEESINTHWAGES/STHEIRSOLEC011PENSATIDN, � Commorcial Z WILL DO TXE WORK.AND THE STqUCTURE IS NOT IMENDE�OR OFiERED FOR SALE(SEC.7M�.BUSL �J N NESS AND PRpFE5510N5 CODE:iME CONfMC70fi5 UCENSE UW ppES NOT A7PLY TO AN OWNER OF ? 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Y(COAI!AENCINCWRMSECTqN7oa0JOFD�`/i510N70FTHE8U51NE55�NDPROFES5iON5LOCE,MID z X W LICENSE IS IN FUIL FORCE AND EFFECT. `J m � IICENSE pCUS �'`,�� LIC.NO. ��/O• � j WDATE /���COMMCTOH � ..✓�� d � WORKERS'COMPENSATION DECIARATION ¢ � IHEREBYAFfIRMUNDfRPENALTVOFPE0.NRYONEOF7XEiOLIOYANGD[Q.AMTIONS: Z � �INAVEANDWRLGIA:NTNN�CERTIFICATEOFCpNSENTTOSELF�INSUREFORWORKERS' _ Q COMPENSATION,AS VpOV10ED 8�SECTION 7�000F THE LA80R COOE,FOR TNE PERFORMANCE U Q THE WORK FORKM1IICN THIS PEFiAIT IS ISSUED. � W �_IXAVEANDWILLMAIN7AINWORKEPS'GOMVENS►TIONINSUfLWCE.A3NEWIRE�BVSECTION Q 7TOOOFTHEU[tORCOOE.FOflTHEPERFORMANCEOFIH[WORNiORWMICHTH15PERMITI4 �U•�� 2• O ISSUED.MYWO fi5' APEN TIONIIi51�F�NCEC 'ERANDGO�ICVNUMDERARE: CONSTRUCTION � j CANRIER ������ �L��� PLANREVIEW � POLICYNUMBEF J� 7 _ ELECTRIC � (110.sscCnoNNEmuoTElE0.1.c'lFr[DocnEv[w.RsrrnaSluLNiEoOatuiS(t:¢�ontEssl PLUM�ING Z ICERTIFYTHATNTHEPERFORAIINCEOFTNEWORKFORWHICHTHISPEPMITISISSUED.1 MECHANICAL .S�O ('J 311AlLNOT EMP�OY/JiY iERSON N AN1'Mb4NER$O TO BECOME SVBJCCT TO TME N WORNE 5'COAAPENSATIONLAWSOFGLIFOHNiAAND GREETHATIFISMIXA�BEfA�AE INSPECTIONFEE SUBJE TOTH NqRKERS'CddPEN5AT10NPNOYIS MS FSECTION]700OFTHELADOR OS�AIl TMYi7HCOMPLYWrtHiNOSEP V! �. �$.SU/�uN(�iE � ^` ' ` p OATE: ' APPLICANT:' SMIP .[ lJ J W/JWiNG:FAIIURETOSECUREYlOfiKERS'COMPENSATqNCOVEMCEISUNUWFIlLANDSH�W.BE ENERGYP/C �y SUOJECTIWEMVLOVERTOCFIMINALPENALTIESANtlCNILFWESl/PTOOMEMVNDREDTFqVSANO ENERGYPERMIT DOUAi15(i 100,000),W FOOITION TO TNE COST OF�OMPENSATqN,DAM�GES AS iROVaED FOA IN J SECTION7)OBOFTNEVIBOPCOOE,INTEREST,ANDATTORNE`15iEE5- p� RETENTIONFEE: . C��,_ oCONSTRUCTION LENDING AGENCY PRE•ALT EE: � IHERfBVAFFIF4UN�ERVEN�ITYOFPE0.AIRYTHATIMERE15ACON5TRUC710NlEN�INCAGENCY �' FOR TME PERFORMAMCE OF THE WOitK FOq WHICH THIS PERMi715155UED�SEC.70D7,CIV C.). . Z W � IENDER'S NM1E � S 1-� LENDER'S:IDORE55 � .^,' W ICEfl71FYTHATIMAVEREADTHISMPLICATqNANDSTATETHATiMEAbOVE WFORMATqNISCORR[CC TOTAL FEES I��� y V p., I�GREETOfAMVLYVYIiHALLCITYANDCOUNTYOfiDINANCE5AYD5TATEUwSREUTINOTOBUIL0ING � Cd�STRUCTION.AhD HERE6VAUTIbHIZE NEOqESENTATNES OF THIS COUNTV TO ENTEq UPON TME Z AOOYE�MENTIONED OROPE TY FOR MSPECTION VURPOSES. � ,„�i J ��_ / COMMENTS J � �/ �1/ � N VEHMITTEE NAYE� f� � /�j �/ V ` (n S�GNA7URE0 7ERMITIE �TE � �_ RECPL�O. _PAI� _VALIDATION WHITE—Dopanment Copy.YELLOW—Financa Copy.PINK—Assessor Copy.GOLDENROD—File Copy,GFiEEN—Applicent's Copy .... .._..... ...._ .._.�... .... ...... .,_ _, __ _ _. ..... .. :..... ... . ...:..,... . . ...,, . .- --- �;i`� s1�= t:i��.i�r�3i�'3! �i�F? 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