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HomeMy WebLinkAbout10543 (5) -----. __.._..-__� 1-�,.x�-- ------- �--� --------- .._ . .- - ------ _ - ------------ ------ ------- - - -- ------ - - . r - CITY OF DIAMOND BAR - • ' COMMUNITY DEVEI.OPMENT DEPARTMENT :,,.� 21660 E.Copley Drive Suitc 190 : ' PRESS (909)8643195 Fax(909)86l•31 l7 ' �'M'� BUILDING PERMTTAPPLICATION FIRMLY o DDRESS� J� • � � I V DATE AT' � _NUMBER���y3 :'� 1 o�.�.a�- (' e� ISSUE TYPE OCC • APN OT '• TRACT DATE � COf�1Y D I�Q�.� GROUP p OWNER�� '� , ADDR SS S ' �. ZONING SETBACKS � • � FRONT fl('T /1 r�Wr1nn p ; CITY ZIP TEL �" � 0"[Utjtf— APPLICANT �—S TELb �c�7+3.��b SIDE/SIDE STAEET RW ❑ � CONTRACT R � SIDE ❑ � ADDRESS PROPOSED USE 'E- o CITY � � ZIP � 3 TEL � _ �. wo ARCH/ENG/ � DESIGNER NO.DWEL NO. NO. ADDRESS UNITS STORIES BEDROOMS � CI7Y ZIP TEL � OESCRIPTION SO.FT. FACTOR PSF ADJ.AREANALUATION N p� ONMER•BI:ILDER DECLARATION SFR/ADDIREM O p I HEREBV AFFlRM UNDER PENALTY Oi VEiWRY TMAT 1 AA1 EXEMPT FROY il1E CONTRACTORS l4 ���0�n � � W CENSEUWFORTHEiIX10NVM1GREASON(SEG7m7.6Bu51NE55AHDPROFES510NSCODEAHYCfTYOR (� ..__.__._. U COUNTYYMICHREOUIRESAVfRMITTOCONSTAUCT,ALTE0.W7R0VE.0E40USN.ORREWiRANYb7RUG �JJ Pi110/DlCk .TUPE.PRqa TO R9 LSSUANCE K'+�NEOUMIES THE APPLICAHT FOR SUC/I PERWT TO FlLE A BbMED ;. W N E7ATEMEHT 7XAT NE OR SNE IS UCENSED PUR9UANT TO TNE GROV1510N5 OF THE CONTMCTOR7 L4 � CENSE UW(pUPTEN v(COYYENGNx3 YnT/5EC710N 7000)OF DMSqN]OF T1E BU3INESS MID PRO � PW l�Sp! � FESS�ONS COOE)pi iWU ME OR SME 19 E%ENPT iMEHEFpOY 1VO T11E BA515 FOR TME�LLEOE�E%EA1R �-r�� TION.ANYVqLATIDNOFSECTqN7071.68YANYAPPLIC�WTFdiAPERA11T5U8JECTSiNEAPPLIGNTTO Z R6�R001 V(1 y�,.�i 4(� � A CIVLL OENALTY OF NOT MORE iHAN iNE MINDRED DOl1ARS lf500I Y ,. � O�ASOWNEROFi71EGRO0ERTV,ORYVEYVLOYEESWITNMMOESA5THE1RSOlECOYPEN6AT10N, Q C��y���l , , . . M7LL DO THE WOfYC N!D THE STNUCfURE IS NOT WTENDEO OF OFFERED iOR SLLE(SEC.70u,BU54 J � NE33 ANO►ADFESSIONS OOOE:iNE CONT�UCTORS LICENSE Uw DOES NO7 APPLY TO AN OWNER OF ? , . PROPERfY WNOBUIDSOqIMPROVEST7EREON.AND WHODOES ffi1CN WOiiKHIMSELFORHER9ELFOR � Q THROU(iHHI50R/1EHOWNEMPLDYEES.PRDVDEDTNATSUCMWPROVEMEHTSMENOTME'OEOOR m , . � OFFEAEDiORSALEIF,FIOWEVERTNE9U4�NOORM�PNO�EMEHTIS50lDWITHNp1ETEANOF001ARE• Z TION.THE OWMEREUILDER WILL HAVE THE BUROEH OF GROVMKi TW1T WE dl 6ME OD MOT BURD OR = MPf�OVE iORTNE PURPOSE OF SALE� W 04�ONMEROFTNEPROPERTV,AMEXCIUSNELYCONTRACTNOWRHLICENSFACOHTMCTOR4 (= TO COHSTAULT 7NE V(iO.IECT(5EG 7ou,BU51HES5 AND PROFESSIOHS CODE:TNE CONTRACTORS U- Vlh1�1lOf1 �� ADJ.AREA W GENSEUWDOESNDTAPVLYTOANONNEROFAPROPEHlYNM1�OBULD90RMPROVESTHEHEON,AND � WNOCON7MCTSFON3UPIVRWECiSN1MACOHTMCfOR(S�LILENSEDPURSUNITTOTMELOHTMG pUANT1TY DESCRIPTION � FEE � � TORS LICENSE UW.} J � O IIL EXEYPT UNDER SEC. B.{V.G FOR TH16 REASON � Q � U ��" DATE OMMER � r'" . Z �U �¢ UCENSED CONTRACTORS DECLARATION ' w LL INEREBYAFFIRMUNDEROENiV.TYOfVf0.A1RYTHATIIMLICENSEDUNOEROROVI310N8OFduPiER V. p, f(C01�MENGu1O MrtTH SECTION 70oo)OF OMSiON]OF TNE BUS�NE49 MD VROFE5510N4 COOE,AND Z X UY IILENSE LS N fULL FO AND EFFECT. m � ���E �s C � ��.�.6 ! 3 � _ t� DATE 4^ CONTRACTOR � LTJ �� WORKERS'COMPENSATION OECLARATION � N IHERFBYAFFtli►IIM�ENVEIUITYOFiEIWRYONEOFIHEFOLLOWN6DEClMATIDNS U � "—' a � _IFNVEANDW4IMAMTAMACEHTIFlCATEOFCON..ENTTOSELF�INSUREFOiiW01iKER5' _ COMPENSATqN,ASVROVUED8Y5EGTqN]7o00FiHELIB011CDDEiORTHEPERFOfiMN10E �U OF ME WOiK FOR WHICH THI4 VERMIT 14155UE0. � � � �I HAVE/WO WILL MNMAN WOFY(ERS'COM?ENSATION NSUNwCE,AS REOUREO BV SECTIOH 7700 OF T11E IABOR COOE.FOR THE iERfORMAHCE Oi ME WOFK FON ri111Uf THS iERYR IS ����s� � LSSUED.W ERS' ENSIITION RANCE C1ARRIER/ND POLICYNUMBER ME: CANSTRUCTION � euw:Ea ���EE•'V �i4{1.f'• PLAN REVIEW � no��cYNweEn I/\VG ��1� ELECTAIC � (nasSEcitor+��noia�wr,aFimaFneaEa�r�waaEM�nr+�oalxasR�aya+�ss1 PLUMBINC3 Z ICERTIFVTHATNTHECERFOWAANCEOfiHEW0i1KFORWN1C11THISVEPINTIStSSUFA,1 MECHANICAL (�} SHALLNOTEMPL01'ANYVERSONYIANYMAINERSOASTOBECOMESIAJECTTO7NE .. (n YYOflKER3'LOGPENSATIONUWSOFGLL�F011MtiANDAOREE7HATIFI9HDUlDBEGOME INSPECTIONFEE � . � SUBIECTTOMEWORKERSCp.�PEN5AT10NVROV15�ONSOF5EC71CH]7000fTHELABOR � cme.�s�uu�� cor�v�r wi�Gs� ISSUANCE O ,-T_�_ • p DATE:y�L� APPLICANT: `"' C. SMIP � ENERGY PI1C WAW11Nfi:FAILURE TO SECURE WOR1(ER5 COMPENSATqN COVE W W E IS UNLANSUI.A/U SM�LL BE � SU6IECTANEMPLOYERTOCRYNALVEHALTIESANDpNLFP1E9UPTOp1EHUlORED7H0USAND ENERGYPERMIT� DOLLARS(t�00.0001.w AOD�TION TO 171E COST OF CIIYPENSATION,OAMAGES ilS VROYOEO FOR M � 9ECTION]7olOFTIELABORCADE,NlEREBT.AN0A7TDFMFYSFEE4. RETENTIONFEE. � a CONSTRUCTION LENDING AGENCY PRE•ALT FEE: � 1/1EREBYAFFp4WOERPENAL7YOCPEMIRYTMATTMEREISACONSTRUCT10NlENONOAGENCY ' FOR TNE VERW WAANCE OF iME W0/1K FON WM�CM iH18 VERYrt IS IS6UE0(SEG]oA,pV.C.} , . , � LENDERS WwE � � � IENDER'SADORESS � W ICERTIFYTNAiIWWEREADTIqSAPPUCATIduAMOSTATETYITTXEIIBOYE1NiONNA7qN19CORRECT. 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