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HomeMy WebLinkAbout10263 . . I ... . _ .. . . . _ � /�-� - CITY OF DIAMOND BAR COMMUNIT�'DEVELOPMENT DEPARTMENT �/ :,.; . 2I660 E.Copley Drive Suite 190 / PRESS (9D9)860-3195 Fax(909)861-3117 "�", BUILDING PERMIT APPLICATION FI RM LY .10BSITE .�n � /� -�,����� APPLICATION r I� PEHMff _ f P/C o ADDRESS 01�'�� �-c)� �-K��: DATE- l JI W�� NUMBER L���/�/�J N � ISSUE TYPE ��7 OCC APN LOT TRACT � DATE � CONST. GROUP p OWNER �' � .�• "' ADDRESS • � � ZONING SETBACKS • w /'1..•.� � oct�(�� FRONT RW ❑ CITY���y.�. ZI. •f-��, TEL. Z. t5 APPLICANT � TE�- SIDE/SIDE STREET RW p � CONTRACTOR �''-!f�lti'C/"�, SIOE ❑ � ADDRESS PROPOSED USE � CITY ZIP TEL. , ' ` � � o ARCH/ENGI � � . DESIGNER �j NO.DWEL ' .NO. ` ,� ' NO. � n. ADDRESS UNITS STORIES BEDROOMS � C17Y ZIP TEL. � DESCRIPTION SO.FT. FACTOR PSF ADJ.AFiEANALUATION Q OWNER-BI:ILDER DECURATION SFR/ADWAEM O 1 HEREBV AFFUTAA UNDER►ENALTY OF PE0.JURY TMAT 1 AA1 EXEMVT FRdA THE CONTRACTORS L4 GB18�dCltpOR W CENSEUWFORTNEFOLLOWWOREASON(SEG70.1/.6BUSINESSANOPRCfESS10NSCODEANYCrtYDR (n � U GOUNttWNtUfpEOUIqESAVERMiTTOCOn57RUCt,ALTE0.�PA�.DEMOU;�f,ORREFURN1YSiRU6 W P91iO1D6Ck � � 7URE.iRqR 70 rt3ISSUNICE AL50 REWIRES T1E APPUGHT FOR SUCH PEiWR TO F0.E A SIGNED W � � STATEMENT i}IAi ME OR SHE IS 11LENSED VURSUANT TO 7HE VRD1r15iON5 OF THE CONTMCTORS LF � . � CEN6E UW(CNAGTER i(�YENLNO NA7H SECTION T0001�OINSION 70F TNE BUSINESS Mb PN0. � POOVSp! FESSION4 COOE)Oq THAT NE OR SHE IS EI(EUPT iNEREF110Y AND TNE BA315 fOR TNE ALIEGED EXEYP- TION.IWYV10lATqNOFSECTON7071.lBY/�NVADVLICIINTFOi1APERutTSU41ECTSTMEMPLIGWTTO Z Re-Roof � ACMLVENALTVOFlqT40RET1UNiNEHUNDREDDOLURS�f6W).�: O1�30WNEROFTHEPROPERTY,ORYVEMVLOVEE9YATHWA0ESA5THEIf150lECOMPENSA710N, � (',pmmBfClBI - �� W0.l DO TNE WORK,AND T11E Sifq1GTURE IS NOT MlTEPWED OR OFFERE�FOR SFLE(SEG 7oN,BUSI• J N NE55 AND PNOFESSiONS COOE:iNE LONTMCTORS LICENSE UW DOES ND7 A7PLY TO AH OXMER OF � � � VROVERTY YAp BUIIDS OR MVROVES THEREDN.M70 YMO DOES SUCH WdiK HIMSEIF OR HERSELF OH � 7MROUGMWSORHEROYMEMPLOVEES,DROVIDEOTHATSULNYPROVEIAENTSAPENOTMTEHDEDOR m � OFFEpEDiORSI1E1F./10WEVER7HEBULDINGORIYPPAVFUENTISSOLDW17HwONEYEAROFCO4PLE- Z 710N,THE OWNER�BUILDER W1LL HAVE TNE BURDEN OF PROVINO iHAT F'E Oq SHE DID NOT BULD OH � MVHOVE fOR THE PURGOSE OF 3ALE} � W OlA50wNEROFh1EPf10GENTV,AME%0.USIVELYCOMRACTIN�WTILKENSEDCOMTHAGTORS (= TOODNS7RUCT THE iHOJECT ISEG 70N,BUSINESS IWO iROFE55pN5 GOOE:T1E WNTMCiOfiS Ll- V2111Bt1d1 ADJ.AREA 11J CENSEUWDOESNOTAPPLYTOMIOWNEROFACAOPERTYYVNOBU0.DSORMPROVES�MEREp1AN0 � YAqCOMRACTSiORSUWVRd1ECTSWITHACONTRACTOR�S)LICENSEDCURSUANTTOTHECOMRAG pUMfTITY DESCRIPTION F�E . - � TORSLICENSELAw.). . � O IAM E%EMPT W�DER 9EC. B.�V.C.Fd1 TN19 REASON . � � � V � lL �F " � DATE �� OWNER • t - . Z W � __ ., �'�:'x.�` ' F LICENSEDCONTRACTORS CLARAT N W � ��.(ik,-�,. � IMEREBYAFFIRMUNDERPENALTYOFPEiWRY7MATIAMLICENSEDUNDERGROYISWN50FdMPiER � . p. �(COMMENCNOWITMSECTIDN70oo)OfOMSiON]OFTMEBUSINE49M1DPf10iES5lONSCODE,AND Z `X W�ICENSEISINFULLFORCEIWOEFiECL m � LICENSE CLASS LIC.NO. J V DATE CONTRAGTOR n- W � WORKERS'COMPENSATION DECLARATION � � � INEREBYAFFIRMUNDENiENALTYOFPER7URYONEOFTHEiOLIAWWODECUMT10NS: Z . � _IIUVEAHDWIlLMA1NTAWACENTIFlCJITEOFCONSEMTOSELFIASUREFORYARNF0.5' 2 � C047ENSATqN,ASCROVOE0BY5ECTIONl70oOFTHEI/BORCODE,fORTHEPERFORUANCE W OF THE VfORK FOR YMICN TT113 PERMIT IS ISSUED. � C Q _I HAVE IW D VALL MAWTAIN WORKERS COMPENSATION MSURANCE,hS REOURED BY SECTION 77000FTMEUBORCOOE.FORiHEGERFOiWANCEOFTNEWO(i1cFONMM1FCHTHI9GERYRIS � ISSUED.MYWORKERS'Cq1PEN5A7qNIN5UiW�ICECARR�ERANDVOLICYMIMBERME: CONSTRUCTION _ ����� � CARRIER PLAN REVIEW ---� -.. --va�cr r+u�aeen . - - ._ _... 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