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HomeMy WebLinkAbout12964 CITY OF DIAMOND BAR '' J� DEPARTMENT OF COMMUNITY&DEVBLOPMENT SERVICES ,���'"��� � 2]660 E.Copley Drive Suite 190 -° � (909)860-3195 Fax(909)861-3117 PRESS "� �_=' ,, ���'��� BUII.DINC PERMIT APPLICATION FIRMLY o� JOBSITE �, � �� DATE CATION NUMBER �1 b #�C -��� ADDRESS_ �Y7.�J� � r? PI��S� � ISSUE (� TYPE OCC F APN_ LOT TR CT DATE �-I�7 CONST. GROUP p OWNER n � �- " ADDRESS � � ZONING SETBACKS o � Z CITY L .> . .n ZIP f EL. REART RW _ � � APPLICAN� TEL. SIDEISIDE STREET _ RW Cl ¢ � CONTRACTOR � 'Y\ !� SIDE _ _ �.____�_ � ADDRESS ,� PROPOSED USE � 6 � � � ' � CITY� � - ZIP �� TEL. d L ' o ARCHIENG u� DESIGNER NO.DWEL. NO. NO. � p„ ADDRESS UNITS STORIES BEDROOMS k � CITY ZIP TEL. � � DESCRIPTION SQ.FT. 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LICENSED CON7RACTOPS DECL4RATION w ¢ �MEREOY RFFIHM 11NDER PENALTY OF P[RJUHY TH�T I A4 LICENSEO UNDER 9ROVI51045 OF CHAPTER � I (y 9�COMAIENCINOWITHSECTION7o0])OFDIVISKINJOFTHEBU51NE55ANDPROFE5510N5CODF,AND Z 7C MY UCENSE�S IN FULL FORGEAND EFFECT m d tICENSECLASS �f F�%� LIC.NO ���' C _____ � g i J � ~ DAYE__ .�`I��[ CONiRACYOR___ , �- ` � � WOPKERS'COMPENSATION pECLARATION a ! = U N iHEREBYAFfIPMUNDERPENAITVOFPERJURVONEOfTHEFOI.LOVhNCDCCLAqATI0N5 � � Z Q � ___IHAVEM'DWILLMAINTAINACEqTIFICATEOFCONSENTTOSELF-IN3UREFOHWORKFRS' S } COMPENSATION,ASVROVIDEDBYSECTION3i000FTHELF60RCq�E.FORTHEPERFORMANCF 'L � OF THE WORK FOF WHICH 1}i15 PFAMIT IS ISSUEO � & p Ep w _IHAVEAH[1WILLMAINTAINWORKEFlS'CAMPENSATIONINSURANCF.,ASFEOUIREDPYSECTION 9 Q 9'l0o OFTHE LABOq cOUE,FOR THE PERFORMANCE OF,kiE W�RK f"OR WHICHTHIS PERMIT IS -_ �'7 t� - - f ISSUED MY WORKEPS'CAMP NSATION INSIIRANCE d/f IER PND POLICY NUMBEq ARE CONSTRUCTION ___I_�C-U...� � _ /}_"_"_ " � CARRIER_.__�C �y�F �l/{�n ---- PLAN REVIEW _.I_V:'�*-� -- - .--- ------ ! 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