HomeMy WebLinkAbout15041 (20) J� _ CITY OF DIAMOND BAR � i DEPARTMENT OF COMMiJ1�TITY 8t DEVELOPMENT SERVICES 21660 E.Copley Drive Suite 190 (909)860-3195 Fac(909)861-3117 PRESS ����� BUILDING PERMIT APPLICATION FIRMLY o ADDRESS���v v E•�'r/"�^,J �R"i�/�s,1�^ APPLICATION � ' -�,\ PERMR r— P/C 7 W" DATE �" NUMBER7��1 � ISSUE TYPE OCC APN LOT TR CT �ATE CONST. GROUP p OWNER '` " ADDRESS �� it'i ZONING SETBACKS Z CITY � ZIP 9Z�� TEL FRONT RW ❑ g APPLICANT TEL REAR ❑ � SIDE151DE STREET HW ❑ CONTRACTOR ��� � � � q � . SIDE p � ADDR S • L R^ PROPOSED USE�� 5.���t� CfTY�l�+'f�n� ZIP�C TEL.7NSyL[19/�I � ARCH/ENG/ DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. y DESCRIPTION S�.Ff. . 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DATE OWNEA V � J � LICENSED CONTRACTORS OECLAFlATION W � IMENEBYAFFGiMUNDERPENKTYOFGEM1tiYTNAT�NAULENSEDUM1OEflPflOVI510NSOFC/UPTER � � ��COMYENCINOWITMSECTION7000)OFDMSION70FiN�8U51NE55MlDPROFESSIONSCOCE,hND Z W LILENSE R N FUI.L FOflCE M10 EFFECT. m �,(� � � LICENSE US `' LIC.NO. ��"'�S� J V DATE � � COMMCTORrrlr r� �14 a W � WORKERS'COMP[NSATIONOECLAFIPTION U �� ��� � � 1 HEREBVAFFtRM U1:DER CENALTY OF iEiiJURY ONE OFTNE FOLLOWIhC DECUnA71oN5: y Z Q G �INAVEANDWILLMANTAINACERTIFICATEOFCONSEMTOSEIF-INSUREFORWORKEPS' 2 � C0IIPENSATIDN,ASVROY•DEDBVSELRION]7ooOFiHEU80RCCOE,FORTXEFEPfORMN10E 'U OFiME WORK FOR MR1:CM7Hi5 VERM�T SISSUED. � G �I NAVE AND WILL�7�'TAIN WOpNERS C0IAOENSATqH INSURANCE,AS RE�VIRCD BY SECTION Q 77000Fh1[lAlfORCODEfORTHEFFRFD�MANLEOFTHEINURKFORWMICMTHISPERMRIS ISSUE0.MYWOPKERS'CO�PENSATIONWSURtiYCECA RiER POL�CV OERARE: CONSTRUCTION � CARRIER C/YZ(F��a..,^'� l� �S. �U• PUW REVIEW —�, �.._, � voucrr+uuoca ELECTRiC �_�� k "� � fn+sstcrnNr[mr+ore[mti+r�rIDoci�vearerbwnaaeMrrn[�ocuu�,piayantEss� PLUMBING Z ICERTIFV TNAT INT/G FERFOqMM'CE OF T1E WORK FOR Nh11C}I THIS CERIIIT 5 LSSIlEO,I MECHANICAL • � � �n (, SYULLHOTEIAPLOYMlVYERSONM AIANNEFSOASTOBEWrAE5U0JECTTOTHE �J�y .L V vj UWW(EAS'COMPF.NSATIONUWSOF ORVI^ANDAGREE7 �TIFISHOV�OBECAAIE INSPECTIONFEE SUfiJELTTOTHEWOfiKCRSCpAPNS �CNYROVIS�ONSOFSE 7TOOOFTHEVDOR T� T ��, � S cao.i uL poanrvnn+corav�ti � '+ose vno�sans. ISSUANCE �ITv nr.PT n n'\�.i r. � _ 0 SMIP TT 7�T�tr �.\'�Tl l'�T'r=�:Y p DA7E:�� APPI �U�.Y7�.�C - . � ENERGY P�C WARfJINO:FAILURE TO SECURE YAORKfR4 COAIPENSATION COVENAGE IS UMAWFUL.AND SHALL BE �y, SUOJECT/NEMVLOVERTOCRIM;NALPEIULTIE511NDCM�FWESUitOONEHUNORCDTHOUSA4D ENERGYPERMIT � DOLLAFtS�floo,o00).NIDDIT.ON TO7HE COST OF COuvENSATICN,DAIAACESAS DqOV10FD FOq IN J SECiY]N77oeOFTMElA00RCODE.NTERE5LAN0ATfORYE7'SFEES. RETENTIONFEE: � pW. CONSTRUC710N LENDING AGENCY PRE-ALT FEE: � INERCBYAFflHMUNDEHOENALTVOFPEFWRViNATTHEREISACONSTPUC710NLFNDINGACCNCY a- FOH iHE VCRWaAANCE OF iHE WORK iOR WHIq1 THIS VENMIT I5I55UED�5EC.70Y1.PV.W. � � IFNDERSWWE � IENDER'SADDRE54 � ICERTIFYTHATIHAVEREI�DTHISPPPL�CA7qN11ND5iATETW�TTMEABOVEMfOfWATIONISLOHRECT. TOTAL FEES W IACREETOCONPLYWI7M/�LLGRYANDOOIMTVOHD�NANCESUMJSTA7EUwSREUTINOTOBURDiNO � � CONSTRl1CT�ON.ANDNFpEBYAUf11OR2EREVNESENTITIVE50F1HISCOUNTYTOENTFflUPONTME Z /�WVE•MEN710NEOOROPERttFORWSPECT�PtlWFFOSES. COMMENTS _ �' ��y � m E EE NAME(PfllllT) ¢ � � S�G PERMITTEE ATE / � RECPT.NO. PAID BY VALIDATION WHITE—Depertment Copy.YELLOW—Finence Copy.PINK—Assessa Copy,GOLDENRO�File Copy,GRE N—ApplicanCs Copy