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HomeMy WebLinkAbout15899 (32) / � { �� CITY OF DIAMOND BAR �]�(�i' DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES T� 21660 E.Copley Drive Suite 190 #` ���'� BUQ.DINGPERMITAPPLICATION FIRMLY � JOBSfTE APPLICATION r PERMfT \� QpC P/C o ADDRESS �DS(c+ f A/Lt-� L��C DATE I �'� NUMBER 1 J 0 1 I r g issuE rrPE occ APN LOT TRA T DATE CONST. GROUP p OWNER�� .1'-tt�.��r n Pn�.R A?U p ADDFiF�7S�7S f[�s �/'r ` ' 20NING SETBACKS � CITYIJJNi-t�.v/J P__ ZIP41�F5� TEL.`i[�)At,[�-S�/ FRONT RW O APPLICANT TEL�T--- SIDFJSIDE STREET RW ❑ � CONTRACTOR SIDE p � ADDRESS PflOPOSEDUSE iZ-ra,�� ,r>�/iiJ�; r c� .�o[�,� CfTY ZIP TEL � ARCHlENGI DESIGNER NO.DWEL NO. NO. ADDRESS UNITS 1 STORIES I EiEDROOMS�_ � CIN ZIP TEL. N OESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION N � OWNER-BUILDER DECLAHATION SFR/ADD/FiEM � 1 MEREBY�FFlRM UNDER iEN�1TY OF PEIWRY 7H�T I MI E%EMPT FROA1 iME CONTMCTqiS LI• G3fTgB/CE1p011 � W CENSEUWFORiNEFOLLOWPI0REA50NISEC.7001.SBU5NE55NVOYROFE55�OK5CO0E:ANYLINOH (n S,2 COI,MYMRACHREOUWESAGERM�TTOCONSTAUCT,I�L7E0.MPHOVE,OEMOLISH,ORPEDA;f1ANYSTRUC• W pg�i07DBCk � � LL� ll/iiE,VNIOR TO rt4 L"SUANCE.AL50 REOUIRES ME APP�ICANT FOR SUC/1 VERAIiT TO FILE A SIGNEO W � ETATEMENT iHAT ME OR SHE IS LICEHSED WIRSUANT TO TME VROVISICNS OC THE CONTRACTORS U� � CENS[UW(CNAPTER Y(CWIMCNCNC MATH SECTION 7ooa)OF DIVISION]OF TME BUSINE55 AN7 PkO� u' POOVSPe fESSqNS OOOE)OR TNAT NE Oi15HE IS E%EMPT 7HE RCFROAI AND THE B�lSlS FOR 7ME ALLEOED EXCMP- 710M.A71YV�OLATIONOF6ECTION7071.6BYMIYAPVUCJIMFORAPEAMITSUBJEGTSiHEAVPLICANTTO Z Re-Rool '„_, A VENALT/OF NOT MORE 71UN FIVE HVNORED DOILA(LS�t5o0��� � �hSOWNEROFiHEPFOPFRTY,ORMYFMDLOYEESWITHWAGCSASTNEIR50lECOMPENSATION, � COR1mOtCi11 ' YIILL 0o THE WORK.AN�iHE STRUCfURE IS NOT INTENOED OR OFiERED fOR SALE(SEG 7a�,BU51• J N NE54 AHD OqOFES51d1.4 COOC.TME CONTtUCTORS LICCNSE lAW DOES NOT AVVLV 70 AN OWHCR Of ? 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J V DATE corrrw�cTOa a � WORKERS'COMP[NSATION DECLARATION a N 1 HEREHY AiFIRM UNDER PENALTY OF PE0.IURY ONE OF ME fOLLOMrtNG�ECUA�TGWS: U � Z Q � _IIIAVE/NDM'iLLMANTAINACERT�FICATEOFOJNSENTTOSELFaNSUREiORKVqKERS' _ � COUPEN5AT1oN,ti5 PROVIDED BY SECP.ON 77ao OF 7ME lAlfOq CODE.FOR THE VE�FORMtiYCE W OF TNE WOHN FOR WNICN TNIS CERY�T LS ISSUED. 2 � �I MAVE MID WILL W�NTAN WORKERS'WMPE>/SATION INSUMNCE,�5 R[OUIRED BY SECTION ��.I O O �70o OF ME LAUOq COOf.fOR iHE GERFORMANCE Oi TME WONK FOR WHICH iHiS PERMR IS 155UED.WWDPoCERS'f�u7EN5A7qNIH5l1MNCECARRIERM�DPOl1CYNVIJBERAF.E:� CONSTRUCTION jGwwEq PUW REVIEW � POIICYNUMBER ELECTRIC ' � Q �nass[crcx�res�rooreeaY.vtEr[�ocncv[n.irswr+a::rarn�smmLrsmm�oa�[ss� PLUn7BtNG � 1 CERTIFY THAT W T1E PEPFOAMlJJCF:OF THE WORK FOR WHICN 1NI5 PEfUAIT IS tSSL'ED.I MECHANICAL � SMALLNOTEMYLOYMIYFERSONNMI'IMANNERSOASTOBECONESIAJCCTTOTIE • j� N YARKERS'LOMVENSATIONUWSOFCALIFOfi++1A,INJAGAEETHATIrI5�10ULD0CCOME INSPECTIONFEE 1,.�1/ S SUOJELTTO THE YIO�lKEFS'CONPEN".+ATqN PFi0Y15qN5 OF SECTION�100 0�inE IABOR �$$VAVL,E CITv n *m 7)A T ��'v v CODE.I SHALL FOqTfM'ITN WA�PIY W�TH TMOSE PRONSIONS. n1 �}A��ALR7�7-jj�- p DATE: APPIICANi: SMIP n l ITI-�����r,�(�1� • l� ❑ W ENER3Y P/C WARN'N0:iA1LURE TO SEQ:AE WOW(ERS'COMPENSATION COVERAGE IS UNUwFUI.M!D SHML BE �y StIB1ECfANE1APLOYENTOCR:A/INALFENALTI[SANOCrv:LFWESUPTOONEHUNDnCDTMOUSAND ENERGYPERMIT DOlU1R5(f t00.0o0).N ADDITION TO THE COST OF LdAFEN5AT10N.D�IAAGES AS PROVIOED FOH IN � SECTION]�OeOFT1GlABORCODE,MTEREST,ANDATTOPNEYSFEES. RETENTIONFEE: � CONSTRUCTION LENDING AG[NCY pqE-ALT FEE: O � INER[BV/�F�iauUNOEFGENAiivOFDERAIRYT1UiTHEREISACONSTRUCTIONLENDINGAGCNCV FOR TME PEFFORIAANCE OF TNE WORK FON W1n01 THIS PEiUAIT IS ISSUED(SEC.7077.CIV C.7. Z w � �EuoEas r+�v+¢ � lEN0Ef�5AOORE55 wICER7IFYTMATIHAVERF1DT115APVLICATIONANDSTATETMATTNEIBOVEINFONAATIDNISCORRECL TOTAL FEES I O I��O � I�GFCLTOCOMPLYYATHALLCITY/�NDCOUrRVORDINANCESINDSTATEUNSPELATNC708110.01NC CONSTRVLTION,AND M[REBV AUTHORIZE REFRESENTATIVES OF TNIS COUNTY TO EMFR UPON THE Z /�gOVE�MEN710NCD PR07ERT'/FOR WSPECTION WFV09E5. COMMC-NTS � ��[.ZS'� /1 l�dcr+n n .c.c� m PEM.nifEE N � �:. /d-�C�a d _ SMa �1TUR DATE RECPT.NO. O � PAID BY � VALIDATION W}iITE--0opertment Copy,YELLOY!—Financa Copy,PINK—Assessor Copy.GOLDENROD—File Copy,GREEN—Applicant's Copy CITY OF DI/�PJIOND BAR . - � � IPtiS��C i IOfv i�EC�i�D . , "'._ �(�`�:j�;a�e-'�r'r'l►`i '��ri'= �ji�� j-y�e?�j�o r;. � xilF` '7:�;c;'��Ir:'Ii�R�^ *� + 'n)��:-!'= T_�I��F=1.�=i'^�c)' � F_. �!'._?..� �, ! 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