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HomeMy WebLinkAbout10627 (5) �-- C1TY OF DIAMOND BAR ' COMMUNITY DEVELOPMENT DEPARTMENT ;,,� 21660 E.Copley Drive Suite 190 PRESS (909)860-3195 Fax(909)861•3117 . �'^�'� BUILDING PERMITAPPLICATION FIRMLY � JOBSITE �J � �� {� APPUCATION �' —L PERMIT a— P/C o ADDRES y �Q`��` y ���✓ DATE NUMBER M � ISSUE lYPE OCC APN LOT TRACT DATE CONST. GROUP . p OWNER f GL'��.� �-� ADDRESS O � � ZONING SETBACKS � CITY ZIP / �o TEL7/ 72/ FRONT RW O APPUCA L CJ�6� TEL. << REAR O � SIDEISIDE STREET HW O CONTRACTOR SIDE ❑ � ADDRESS PROPOSED USE � CfTY ZIP TEL � ARCH/ENG/ DESIGNER NO.DWEL NO. NO. n. ADDRESS UNITS STORIES BEDROOMS � CI7Y ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BL'ILDER DECLARATION SFR/ADDIREM O p 1 MEREBY AFFIRM UNOER iENAITY OF PEfWRY THAT 1 AY F%EIA7T FRdA THE CONTMCTORS LF Gef8Q6/(.AfpOR � � W CENSEUWFORMEfOLLOWINnREA50N�SEC.7mt.6BUSNE55/NOVROFESSIONSCOOEANYGTYOR (n C� Cq1N7YWHICHRE0UIRESAVERMtTTOCONSTRUCi,ILLTER.IMPROVE,DEAIOIISH,OqREPA1RAN'lSTRIIG W PetIdDBCk . . bTUHE.VRIOR TO ITS ISSUANCE.ILLS�fiEWiRES 7HE APVIICAM FOR SUGI PERMR i0 fllE A SIGNED � 'STATEUEM TNAT HE OR SME 6 L�CENSED PURSl1ANf TO iHE VHOWSIONS OF THE CONTMCTORb L4 � . . , . . � CEHSE UW(dNPTER��COMMENCW6 VIITN SECTION 7000)OF DMSION!OF T11E BUSMESS ANO DR6 LL' POOUSpB FESSqNS COOE�OR TW�T HE OR SHE IS E%EMPT T1IEREFHOM ANDTME BA319 FOR iHE IllLEOED E%EMP• TION.ANVVqUiIONOF5ECT10N70]1.6fiYANVMPLIC.MITFORAVERMITSUBIECTSTHEMPIICANTTO Z pe-Roof � ApNIfEN+LLTYOFNOTMOFiETIWJiNENU�DREDDOLVJ1Sp5oo).): � ��i,A50NNEROFiMEVROPERTY,ORMYEYPLOYEESWIMWMESASTME111501ECOMVEN5ATi0N, � COf11TBfClel � VALL Da7HE WORK,/ND THE STRUClUPE LS NOT INTENDED OR OFFEHE�fOR SALE(SEC.70N.BUSI• J � HESS AN�VROFESSIONS COOE:THE COHTMCTORS LICENSE UW DOES NOTAPCLY TO AN OWNER OF ? , PRDPERTY WI�O BUIDS OR W 7ROVES MEREON.AND YR10 OOES SUCH WORK MIMSELF OR ME0.5ELF Ofi � T11ROlMHWSOi1HER04N�lEMPLOVEES,VRONDEDTHATSUGIWPROVEMENTSMENOTMRENDEDOq m � OFFEREDFORSALEIF,lIOV/EYER711EBUILDIN60RIMPROVEMEMISSOIDWRHNONEVEMOFCOYRE Z 710N,iME OWNER-0UttDER WILL MAVE TNE BUPDEN OF PROYIN�THAT HE OR SNE DID NOT BUIID OR = IEICROVEFORT11ER1ROOSEOFSALEI. ❑4�OWNER OF iHE�ROPERTY.A4 E%CLUSNELY CONtMCTINO N7TH IICENSED CONTMCTORS Q TOOONSTRUCTTHEPNOJECT�SE47W�,BUSINESSMIDPROFESSqNSCODE:711ECONTMGTORSLI� 318111BI1011 ADJ.AREA W CENSEUWDOESNOTAPPLYTOANOA4NENOFAVROVENiYN?iOBUILDSOR►IPROVE9TNEREON.IWO � WHOCONiMCT5iOR9UCHPNGIECTSWI7HACOM�MCTOR(S)IICEN5f0iURSVANTTOTHECONTMG pUANTfTY DESCRIPTION � FEE .I TORS LICENSE UW} /}� � OIAME%EAIPTUNDERSEC. B.IV.C.FONTNISpEhSON U V V � � DATE OMMER � � Z W F¢ UCENSED CONTRACTORS DECLARATION W 2 IHERfBYAFFIRMUNDERVENALTVOf0E0.A1RYTUiIAMLICEHSEUUNDERVROVISqN30FG1APTER� Z . , - " •. �` � p„ �(COhWENCN6NrtTH5ECTiON7000)OfDM5lON70FTHEBUSINE391WDVROFESSqN5CO0E,AND X L1Y UCENSE 6 W FULL PoRGE M!0 FFFECT. m � UCENSECLASS UC.NO. � 1�-� V DATE CONTMCTOR � . . � W � WORKERS'COMPENSATION DECU4RATION � N IHEREBV/�FIRA1lINDERVENA�TVOFGE0.ri1RYONEOFiHEiOLLOMANODECUMTIONS: U � � C� Q � _I NAVE AND WILI►UINiAINACERTIFICATE OF CONSEHT TO SELfaNSURE FOR W'OqICER3' _ COMFEHSATqN,ASPROVIDEOBYSECTION77oo0fTHEUBORCOOE,FORiHEPERFOPAUWGE W � O�iNEWOPJCFORNMICIITMISiERMITISI55UEU. ,� O ' _I MIWE M10 WILL MAINTIUN WORKERS COMVENSATqN MISUAANLE,AS REOUIREO BV SEGTION Ql700 OF THE LABOH CODf,FOiI THE PERFORAIANCE OF THE WORK FON NM�dI TM�S OERAI?IS � ISSUED.IAYN9RKER5'COL�PENSATqNINSUiiANGECARRIERPHDPOUCYMIMBERARE: CONSTRUCTION � CARq1ER PLAN REVIEW , - � POIIGY NUA1B[R . . . � ELECTRIC � �t1�s�crqrr�mrq7e[pp►s�rEppFncvfp,rtsroqp�EKrpun0.7turtspiao�at� PLUMBINO Z ICERTIFYTNATIN7TIEPERFORMANCEOFTHEWONKFORWFIICHTHISPEN.1IT6155UE0,1 MECHANICAL (.�J 6HALL NOT EMPLOY ANY PERSON W ANY M►NNER 50 AS TO BECOME SU&IECT TO TM[ . vJ M/ORKEi15COUPENSATqNUWSOFCALIFOiWItiANbAGREETM�TIFISHOULD8EOD4E iNSPECTIONFEE � S SUBJEGTTOTHEWORKERS'COAIVENSATqNPROVISqNSOFSECTION]70pOFTHEI/�BOR caoe,i swul�oarHvnrH eouc�r wm�nase vAowsar+s. ISSUANCE � SMIP p OATE: APPLICANT: LL� ENERGY P!C � WAqNIN�:fAILUNE TO SEWRE WOIIKERS COMVENSATpN COVERAOE IS UNU�MFU.AND SHILLBE �ry SUBJECfJWEMPLOYFRMCRMUULifN�U.TIE3MACMliNESUPTOONEMINDREDT/OUSAN� ENERGYPERMIT �1��1 � I pOLLAitS(I100,00a),INADD1710NTOTMECOSTOFCOMPENS�TqN,OAMADESASPqOVIDEDFORW i t�„Z��•'�- J SECi10Nf70lOiTMELABOi1CO0E,N7FREST.IND�TTOqNEYSFEE3. � RETENTIDNFEE: � � � � CONSTRUCT�ON LENDING AGENCY PRE•ALT FEE � � INEREBYAFFIRMUWERVENALTYOFPEiWRYTXATTHEREI5A00N5TfiUCT10NlENDiNOAGENCV ' Z fOR TME PERiORMANCE DF TIE WOi1K FOR NM1IICH iMIS PEIIMIT IS ISSUED ISEG]oi7,CN,G). , W � LENOER'S NwE � � IENDER'9/�DDRE55 .� � ICERTIiYilUT111�VEREMTMtSAiVUCATIONANDSTATETHATiHEABOVENFORMATIJNISCORRECT. TOTAL FEES , � -� d IAOREETOWMPLYVATHALLdTYANDCOUNTYOPDWIWLE5IWOSTATEUVYSREU7NGTOBUILDINO CON5TRUCTION,AND HENEBV AUfV10RRE RE7RESENTATIVE3 OF TW S COUNT7 TO ENTER UDON THE S�. ABOVE�MENTIONEDiROOERTYFORWSPECTI0NGl1HP0'ES� � COMMENTS � .✓t" �-r t( � ' m PE E G��- O I 9 . . 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