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HomeMy WebLinkAbout10287 CITY OF D[AMOND BAR• �/� �. ; ��..,�' � COMMUNITY DEVELOPMENT DEPAI�TM�ENT 21660 E.Coplcy Drive Suite 190 l/ , PRE$$ T (909)86a3195 Fax(909)861-)117 . '. '""'� BUILDING PERMITAPPLICATION FIRMLY oJOB5ITE ,p}��y�—I ������� I DATE CATION ( NUMBEF'�v O x�C Q ADDRESS f -N � APN LOT�_ TRACT ��� �SSUE TYPE OCC DATE CONST. GROUP �p OWNER �IYI�NZ�CY'/�'�•'o /-�. �h. K2 ' p ADDRESS d - 4� � 20NIN(3 SETBACKS � CITY ZIP�' j TEL REART Rw p APPLIC NT + TEL � SIDEISIDE uTREET RW ❑ CONTRACTOR�/r7L{,�LJG/�+ SIDE ❑ � ADDFESS � CIN ZIP TEL PROPOSEDUSE �L"����G-� _ � o ARCWENG! � DESIGNER NO.DWEL f NO. • NO. . ADDRESS UNITS d STORIES - BEDROOMS � CIN ZIP TEL � c�i� DESCRIPTION SO.Ff. FACTOR PSF ADJ.AREANALUATION Q . OWNER-BCILDER DECLARATION . - SFR/A��/REM � - � � � � O • � I HEREBY AFFIRM UNDER PENAITY OF PERJURY hUi 1 AM E%EMP7 fROM T/E CONTMCi0i19 U- G0fpq9/CHIpOfI� W CENSEUWFONTNEFOLLOWWOREASON�SEG7D7�.59USINESSMIDPRDFESSIONSCODE:ANYGiYOR . 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' ' � O 1 M�E%EMDTtMDER SEG &1 P.G FORTMIS REASON � � � u" DATE +� � OwNEN� Z � LICENSED CONTRACTORS DECLA ION � IHEREBYAFFUiMUNDERVENAITYOFPERIURYTWTIAYLICENSEDUNDEHVROVIS10N90FC1LVTfR V. . � f�COMMENCwOWRHSEGiqN)o00�OFON15qN]OFiNEBU5INESSANDPROFESS�DNSCWE,ANO Z X� YY UCENSE IS IN FlAl FORCE ANO EFFECT. m LLJ � UCENSE CU155 IIC.NO. j �j OATE CONiRACTOR � ' d W � WORKERS'COMPENSATION DECLAFiATION a N INEFEBYAFFIliMUNDERVENALTYOFYEiWRYONEOFTHEFOIIAwWODELUMiIONS � � _IHAVEANOYALLAWNINNACENTIFICAiEOFGONSENTiDSELFdNSUREFORNUfiKERS' COMPENSATION,AS CROVIDED BY SEG710N 77o00F TNE UBOR COOE,FOR THE PERFOIWANCE OF THE WORK FOR NMipl THIS PERMIT 1915SUED. � � w �IMAVEANOWILLAWNTAWWOAK[RS'COAIPENSATqNINEURMICE,A3REWIREDBVSECTION Q ]700 OF TNE LABOH CODE iONTHE PERfORMN1GE OF THE WOHR W q WHICMTHIS PEfiMIT IS � tSSUED,MYWORKER3COMPENSATqNINSURANCECARRIERAN�POUCYMIMBERME CONSTRUCTION """''_"� . _ CARRIER PLlW REVIEW -- - � POIIGYNUAIBEH E�� 0 (IfcS5EC7qNNCEDWTBEaoA('IFiEDOFnEPEw.�TsfORONE1R.wqFD00uAFiSlS+0010R1E5^ul UMBIN � W ;� n�� Z ICERTIFYTMATINTMEPERFORIAANCEOFTHEMCRKFONMMiCMiHigpERY1TISISSUED,I MECHANICAL ���`�r,,,y.. �+���� (7 SNAIL NOT EMPLOY ANY 7ERSON W�NY uANNEH SOAS TO BECOME SUBJELT TO THE 7' r � WOfucERS COMPENSATqN UVl9 OF CALIFORNiAAND AGREE iM�i iF I 5`KK/lD BECOME INSPECTION FEE � �� y ,''�"" ' SUBIECTTOTHEWORKERSCO�.�OENSATIONVi-0�VISIDNSOFSECTqN77000FTMELABOR + � rj eooE�snuironretmrneor.�r�rwm�nasevrwhsar+a ISSUANCE vv � SMIP - � DATE APPLICANP. � ENERGY P/C WAiW INO:FA4URE TO SECURE WORKEAS CdAPEN5AT10N ODVEMGE IS UNUWi1JL,MD 511ALL BE LL SUBJEGTANEAAPLOYERTOCRIM?l�iFENALTIESANDGV4FWE5UPTO0NEHUNOREOTqUSAND ENERGYPERMIT r DOlLARS(t100,0o0�,INADDITION707HECO5TOFCOAIPENSATION,DAMAGE5A5PROVDEOFOIiIN � SECTION�7000F7HELA9WiCO�E�NTERESLANCATTORNEY'9iEES � F3ETEN7IONFEE:� � � �� QCONSTRUCTION IENDWG AGENCY PRE•ALT FEE ' � IHEfiEBYAFFIqHUNDERDENKTYOFCERIURYTHATTHERE15ACONSTRUCTIONLENOYJ�AGENCY � FOR 1HE PERFOFYANCE�F THE WORK fORNT11G1 T115 PERMIT IS�SSUED(SEC.7arl.GV.C.). � � LENDER9 NAIAE � � . � LENDEN'SMDRESS - � ICERTIFYTNAfIHAVEREADT/15AVPLIGTIONANDSTATETUTTHEABOVEINFOHMATqN19CAqRECT. 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