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HomeMy WebLinkAbout16564 (23) � / ! CITY OF DIAMOND BAR -- �� -- DEPARTMENT OF COMMiJNITY&DEVELOPMENT SERVICES / 21660 E,Copley Drivc Suite 190 (909)860-3195 Faa(909)861-3117 PRESS ''M'�� UQ.DING PERMIT APPLICATION FIRMLY fl � JOBSITE ) � � y� l APPLICATION_ �. /) �'_� PERMIT � P/C� `- � h �s / o ADDRESS � �- DATE �f' NUMBER x.�✓ � ISSUE - `'�:�;�\,NPE OCC APN LOT T ACT A :� �-�' � CONST. GROUP � OWNER / '� � wl s! _ "' ADDRES t - ? '/ NING .SEfBACKS` �= _ ��'� , • PL _ �h7 . �AONT-_ ._ _.�.. ,RW ❑ � CITY � K ZIP TEL > >- ,/ APPLICANT TEL-�?-`1r1�'0 } REAR " p � . SIDE/SIDE STREEf RW O CONTRACTOR SIDE ❑ � CID�DfRESS ZIP TEL PROPOSED USE _ O�'SY �,• �,- . .. ,._'rt;, �, � ARCFVENGJ � -- _,._ DESIGNER NO.DWEL NO. NO. ADDRESS UNITS � STORIES BEDROOMS `� CITY ZIP TEL � y DESCRIPTION Q.FT.' FACTOR PSF ADJ.AREANALUATION Q OWNER-BUILDER DECLAFlATION � . 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Fd UCENSED CONTRACTORS DECIARATION W , [t iNEREBYAFiIM1UN0ERPENALTYOFGERRJRYTNATIA4LMENSEDUNDERVROVISqNSOFCHAVTER p (� ��COMMENCNqWITHSECTI0N7000)OFDMSIONJOF7HEBUSMESSANU7ROFESSIONSCOOE,ANO Z • � i - .- �X� MY LICENSE IS PI FiJLL FORCE AIA EFFECL m � O ./�- "'"`".'. �r—a � LICENSE CLASS LIC.ND. j \ � .� ��tjl OATE CqJTRACTOFI d w � t� WORKERS'COMPENSATION DECLAHATION t Q a C� NIHEREBYPFFlRIAUNOERVENACT'OFPERNfiYONEOF7H[FOLLOWINOOEGUM7iONS z �� , � �IN�VEN/DIMLLIMMNNAGERTIfICATEOFCONSENTTOSELF•INSVREFORWORKERS' _ (1I\ COYPENSATION,ASVNOVIDEDBYSECiION]7000FTHELABORCOOE,FOqiHEPERFORMANCE W Vv OF ME WOfVC F00.WHIW 7HI5 iERMR IS ISSUED. � O — Q �IHAVEANO WILL WUNTAl1N�ON1(ERS'CdAPENSATION INSUiUNCE.A9 REWIRED BV SECTION 77VOOfT1iEVBORO00E,FORTMEPERiORMANCEOFiHEWOflKFORN7/1CHTl113PERAIRIS �5,c� J 4SSUE0.4YV�piiKERS'COAI7ENSATIONINSl1RANCEGRRIERANDPOLICYNUMBERARE: CONSTRUCTION j unweA ' PllW REVIEW �1„ Z vo��cYr�weEA ELECTRIC ..'�O. Q Q �sEcnorar�mNorefm.r�hooFt��tswnor+E�uc�ooau�s6+aoloAtessF PWMBING � ICERTIFYTHATNiHEPERFOFlMANCEOFh1EYfORKFOitWHICNTH15PERMiTISI55UED,1 �+1ECHANICAL (.�' SHALINOTEMPLOYANYPEli50NNANYIMNNER50145TOBECOMESUBJECTTOTHE / N NqRKERS'CpACEN5AT10NUW50FCAUFORNIA,AlI�AGREETMATIFISHOIADBECOME INSPECTIONFEE S SU6IECT TO THE WWIKERS'CdACENSATION GRONS�ONS OF SECTION�70o OF ME UBOii ' eaoE,i sw�t�Foarnwm�caav�r win�nase Paowsior+s. ISSUANCE �%`' � SMIP � `p OATE: APPLICANT: . � ENERGY P/C � WAiW INU:FAILURf TO SE W RE WORKERS'COMPENSATIDN COVEMCE IS UNUWFUL,AND SMALLBE rl � SU6IECTANEMPLOTERTOGRUAIWILVENALTIESMIDCMLi1NE5UPMONEMINDREOTMOU5hN0 ENERGYPERMIT �'� OOLURSIf1ao.Do%,Y�IADDRIONTOTHECOSTOFCOMPENSATIDN.OMIAOESIISPROV10EDFORN '.\ / /� � SECT10N97oeOFT/EUB�RCODE,MEREST./urDATtOiWEYSFEES RETENTIONFEE: v V nW.. CONSTqUCTION LENDING AGENCY PRE-ALT FEE: � 1 MERE9V AiFlRM UNDER PENALTV OF PE0.IURV TN�TTHERE lS ACONSTRUCTION LENDWO AGENCY FOR TNE VERiORMANCE OF TME WORK FOR WMN]17M�S VERIAR IS ISSUED�SEC.�oW,CIV.C.). �1 � � LEN�ER'SNM�E � � lEN0ER5ADDRE3S � ICERTIi`/THATIHAVERUDTMSMPLMATIONANOSiATEhUTTMEABOVENFOR1AATpNISCOHRECT. TOTAL FEES W IAGREETOCOMVLVWI7MALLCrtYANDCOVNTYOROWANCE5ANO3TATEUWSRElA77NUTOBUIIDINf7 � � � Cd1STRUCTION.ANDHEREBYAUTYIORIZEREVRESENTATIVF50FTHI5GOUN7YTOENTEflUPONTHE � ��i��� Z �BOVEJAEMIONEDPRO�ERT`IFORINSPECTIONPUROOSES. COMMENTS � 1� µ1� <<l��G _ ¢ VERui7TEEWWE �Nn . 1 N .� � /.� 1 y SIfiNATUREOFDEPAIITiEE DATE � RECPT.NO. PAID 9Y VAUDA710N WHITE—Department Copy,YELLOW—Finar�ce Copy,PINK—�Aasessor Copy,GOLOENRO�Fite Copy,GREEN—ApplicanCa Copy CITY OF DIAh1iOND BAR _ . _. ., � -:. 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