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HomeMy WebLinkAbout13151 (16) �� CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY 8c DEVELOPMENT SERVICES �� . 21660 E.Copley Drive Suite 190 � (909)86Q3195Fax(909)861-3117 . PRE$S ���'�� BUILDINGPERMITAPPLICATION FIRMLY o� JOBSITE .Z�G'a rl7. ��� �r APPLICATIO PERMR I ��yJ� �/C ^ � ADDRESS ��v V DATE NUMBER � ISSUE TYPE OCC APN LOT TRACT ZZ'� DATE CONST. GROUP p OWNER �� " ADDRESS L ZONING SEfBACKS �w CITY���- eS� ZIP��� EL7 '� REAR RW p APPLICANT TEL. SIDE/SIDE STREET RW O � CONTRACTOR �e ����L SIDE ❑ qC ADDRESS o CITY ZIP TEL PROPOSED USE� F I.�- � ARCH/ENG/ f} �„���t/�'1l� DESIGNER r��i'� NO.DWEL. NO. NO. ADDRESS UNRS STORIES BEDROOMS � CITY (d+ ZIP TEL cNi� DESCRIPTION SQ.FyT. FACTOR PSF ADJ.AREANALUATION p� ONMER-BUILDER DECLAFATION SFRlADD/REM Z7 O � 1 HEREBY AFFIRY Ul1DER PENALTY OF PERAIRY TNJR 1 AM E%EMPT FROM THE CONTfUCiORS U• GBrggB/C'spaT j CENSEUWFOR7HEFOLLVMNQREASON(SEC.7P71.6BUSINESSM10PfiOFESS10NSCODE:ANYCITYOR , (n COUNfYWMU/REOUIRESAVERYRTOCONSTRl1CLALTERUAVROVE,DE�IOLISH.ORREPAIRANYSTRUC• W �� +] '] 7UHE ORIOR TO RS 65UM10E ALSO REOUIRES TME APCLIGWf FOR SUpi VERIAIT TO F0.E A SICNED w L C. STATEMEHT TIAT HE OR 6HE 6 LICENSEO PURSUAN7 70 TH[PNOVISIONS OF THE CONTRACTORS LI- � CENSE Uw(qiAPTER 0(COMNENqNO H'IiH SECiqN 7ooD)OF DMSION a OF THE BUSiNESS AND PRO- � PooVSpa FESSIONSOODEIDRTW�7HEORSHEISE7cEMPTTTIEREFROMAND711EBA515FORTl1EALlEOEDExEMP• (� TION.IINYVIOLATIONOFSECTION7Wt.6BYANYMRICAMTFqilliEfiMi75U&1ECf5TME�PPLICANTTO Z F19-ROOf � A CIVIL PENAITY OF NOT►10HE 7HM1 FNE HUNDRED DOLLARS If So01.1: � OI�dJYNEROfTHEVROFERT/,ORWEYPLOYEESNIMWAOESiISiHEINSOLECOMPENSATION, 0 (�'OTTBfC�B� � ' WILL DO iHE WOR1(,ANO THE STRUCTURE IS NOT IMENDED OR OFFER[D FOR SALE(SEG 70u,BU54 J � NESSANO PROFESSIONS COOE:TME CONiMCT00.5 LICENSE UW DOES NOTAPPLY TO AN OWHER OF � � PROPEHiY MM1�O BULDS OR MVROVES TXEREON,AND MMO DOES SUCH WOPK HIMSELF OR MERSELF pR � TMROLkJ/MISORMEflOWNEMPLOYEES,iROYIDEDTMATSUGIIMPROVEMEMSARENOTINfENDCDOq m OFFFAEO fON SME IF,FqwEVER 7NE BULDINOORIMPROVEAIENT IS SOLD WITHN ONE YEAROF COMPLE- Z TION,7HE OVMER�BURDEH 1NLL W1VE iHE BURDEN OF PROVINO TNAT HE OR 6HE OIp NOT BURD Ofi = IAIVROVEFORTFIEPURPOSEOFsun {,y,� ❑4��wNEROFTNECROPEIiTY,AME%ClUSNEIY[ONTRACTN4WITFILICENSEDCONTiUCTOR4 � (r 70 CONSTRUR 1HE PRDJECT(SEC.70a�.BUSiNE55 AND PROFESSIONS CODC:THE CONTMCTORS l4 VBIUeU0f1 OC _ADJ.AREA LLI CENSEUWOOESNOTAFPLYTOANONNEROFAPROVERttMTGBUILDSOHMPi10VE5THEREON.AND � M'MOCONTMGTSiOHSUCHFRQIEGTSMATIACONTRACTOR(5)LICENSEDMIRSUNRTOTHEOOHfMC pUANTITY DESCRIPTION,, , �� , FEE � � 70R5 LICENSE UW.). - OIAIAEXEYPTUNDCRSEC. B.iP.C.fORTH15REASON U 3 ¢ . , DATE OriNER V � W � UCENSED CONTRACTORS DECLARATION �y � IHEREBYAFFIRYUNDERiENAL7YOfPERR1RYTHATIAMLILENSEDUND[RPHOVISiONSOFCHAPTEA V. � i(COA1MfNCPqWRNSECTqN70oo�OFON�SiON]OFTIEBUSiNE55ANDiROFESSqNSCOD�ItA Z L1V ��NSEISNFULLFOFiCEANDEFFECL ��I �� m < � LICENSECLASS UC.NO. J �j oah��lL• C��corrtancroa� a W � WORKERS'COMPENSATION DECLARATION Q NIHEREBYIFiWAIUNDERiENN.7YOFPERNRYONEOFTHEFOLLOWIN6DECU1RAT10NS. 2 � � �IHAVEANDWILLYANTARIACEPTIFlCATEOFCONSENTTOSELF�INSUREFORYVOqKE135 = �' COYPENSATION.ASVROVDEOBYSECTOH17ooOFTMEUeORC00E,FOHTHEGEFFORMANCE `U OFT1E WORN FOR W111GHTHIS PEHAIIT IS ISSUW. � � �IHAVEANOW:LLMNNTANWORKERS'COUPENSA770NM5URAHCE.ASREOUIREDBVSECTION ^ �+('� p� e Q �70oOFTHEtJBOR000E,FORTHEPER�ORMANCEOFTHEWORKiORNMICHiHISPERIAITIS / ly'� l \ V ._ISSUm.WM9 EflS'COAI7ENSA10NINSUfU1NC[CJ�RFUCRAVDPOLICYNUMOER�RE: CONSTFlUCTION V�vY� v (�"' -. _ —'� . .. 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TOTALFEES �ry�� ,� � Z�����N w IAC1tEEMCOM�LYM17HI11CITYANOCOUN7VORDiNANCE5M1�57ATEUwSRELATWOT09uILDINO ✓ l � CONSTRUCTICH,M1D HEREBYAUTFIDRIZE PEVRESENTATNES OF TMIS COUNiYTO EMER UVON iHE � � � IBOVE�IAENTIONEDVROFERTYFORINSPECf10NPURPO"E5. COMMENTS � L �V 5 m PERMfTTEE NAME NfJ Q N � BIGNATUREDFVERUITIEE OAiE � RECPT.NO. PAID 6Y VALIDATION WHITE—Dopartrnanl Copy,YELLOW—Flnante Copy.PINK—Aisassor Copy,GOLDENROD—File Copy,GREEN—ApplicanCs Copy . ,. . . � '.,: � , . . � , . , . .... . �. . ,. . ... , . . . .. . • . ,. . CITY OF DIANiOND.BAR . . _�� � �:.. R�SPECTIOh! RECORD � � -.. �l►`�7�;��=�"!i�����:� ����ifi :1.���� �'?�a �.t + ''�..�s�� ��� ��-� �.� ��cj�_ � ��o � �.., � f►� �.N� ���... I�`�-�:���_:�,..F1'f�" ._...a,..w-..�... -..—�a....� .� — -_ �� . ... �.....�.�w....�.� w..r...e.....�. .w...� w-. .. . k �.... 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