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HomeMy WebLinkAbout13589 (11) �� CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �` 21660 E.Copley Drive Suite 190 . � (909)86Q�3195Faa(909)861-3117 PAESS ����� BUII.DING PE APPLICATION FIRMLY � JOBSITE APPUCATION PERMR P/C o ADDRESS � ' � DATE NUMBER �� M $ ISSUE �! TYPE OCC APN �CT DATE "J ��� CONST. GROUP p OWNER "" ADDRES ZONING SETBACKS Z CITY ZIP TEL � R�R RW � g APPLI T SIDE/SIDE STREET RW ❑ � CONTR/1C � SIDE ❑ � ADDRESS C IP TEL PROPOSED USE � ARCH/ENG/ ��(� DESIGNER �`� '� t S NO.DWEL NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCHIPTION SO.FT. 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J O I AM EXEMPTUNDER SEG B.t P.C.FOR THIS REASON U 3 � LL' DATE ONMER � . . � W � � UCENSED CONTF7ACTORS�ECIARATION W � 1 MEREBY IFFIRM UNDER PENKTY 7EiilUM THAT I I�M LICENSED UNDEA PROVIS�ONS OF CNAPTER Ur � � �(COMMENCrlO YrtTH SECTqH OF Om510N i 'HE VSINE55 YD PROFESS:ONS COCE,AND Z �� W LICENSE IS M FUII FORCE FFECi m � � �� LICENSE CUSS LIC.NO. J . . � OATE CONTfUCTOR a I WORKERS'COMPENSATION DECLARATION ¢ � � U � INEHEBVAFFWEIUNDENVENALTYOFVEiWMONEOFTHEFOILOV�IN00ELlAMT10N5: � Z 4 � _IIUVEANDMALLI.IA,MAINAC£RTIFlCATEOFCONSENTTOSEIF-1NSUREFORNtX3KER5' � S Q COMPENSATION,ASVfiOViDEDBY5ECT10Na�000FTMEV.BORCCDE,FORTMEDERFORMdNCE W OF 7HE WORK FOR VRIICH TMIS VERMIT�3 ISSVEO. � � O �I IUVE�ND MALL AWMAIN WOAKEPS'C0IAVENSATION P15URANCE.0.S REWIRE�BV SECTION a70aCFTHEIABORGOOE,FORTHEPERFORMN:CEOFTHCWORKFORWH:CHiMISPERM1T15 �� O� = 55UED.I.fYWONKERSCOMPENSAT10NW5URANC£G1RR�ERFNDPOIICYNUAIBERARE: CONSTRUCTION � � j uaa�a � PLAN REVIEW � Z pa�crauuaEn ELECTRIC Y .��'' ¢ � �ntss[crontu�r+oreEca.c�?[DaF7r�vcaMrarona�wwt¢ooaU,zs6�m�oatEssl PLUMBIN� � ICFRTIFYTHATNTHEVERiORMA4CE0FTMEWONKFORNMIpITH15PERMi715155UED,1 MECHANICAL SWiLLNOTEUPLOYANYVER50NNANYMANNERSOASTOBECAMESUBJECTTOTHE INSPECTIONFEE •�« � 1`�w � WORNERS'CdAPENSA710NLAW50FGLLiLO(1NI�ANDACREETHATIFISHOULDBECOME ,., L SUBJECTTOTHEMCXif(ERS'COIAPENSAiqNDROVI510N50F5ECTK7N97a00FTMElABOR �SSUANCE +i ,' ���� `��tl 7 CODE,1 SHALL FORTTA417N COMPIY WITH h10°E PROVISqNS. • � O �, SMIP ('1T`I ��� i�!r•. - f. �j:Yl � � p DATE: '� APPLICANP. � _ .. � . � ENERC�Y P/C !:T T"7 ��!4 i't�-� WApNIN@ FNLURE TO SEWHEMOfiKERS'COMPENSATION COVERAGE IS Ul6AWNL M1D SHALLBE � SU&1ECilWEMPLOYEHTOCfL�A�NALPENALIIESANOCN�IFNESUOTOONEMINDPEDTHOUSAND ENERGYPERMIT DOILAFiS(i700.000).Pl h�D�710N TO TME COST OF COMPENSATqN,O�ACES AS VROhDED FOR IN J SECTION'!70lOFT}1EUBORCOOE,MTEREST.ANDATTORNEYSFEES. RETENTIONFEE: Q W ' CONSTRUCTION LENDING AGENCY PREALT FEE: O /'� � IHEREBYAFFIRMUNDERPENALNOFPEiWRYTHATiHERE15ACONSTRUCT10NlFNDWGACENCV `���� �- FONTMEPERWFMANCEOFi11EWORKFORNM1IICNTMI57ERM171SI55UED�5EC.M97,CIV.C.). � I .�Z LENDERS wVAE � ' C LENDERSAODHE55 � ` WICEiiTIFYTNTINAV ADT ISAPPLILATqNM1D3TATETUTTMEABOVE FO ATIONISCARREM. TOTAL FEES �~-^ � I AGREE TO COMP 7M GRY ANO COUNIY ORD WANCES AND S 'NS LAT�NO TO BNlDINO . . ���� � .y � � �pN$TqUCT ' M VAUTMONREREVRESENTATNESOF S NTYTOENTERyPONTHE � �`� A[iOVE�AIE ERTY RINSPECTiONGURFOSE / �//�0-1 � COMMENT � � /�is J ��,%�% m � Q EWAITTEE WVAE�? (!J N bIGNANREOFPERM�TTEE OATE � � RECFT.NO. PAID BY VALIDATION � . WHITE-0epartment Copy.YELLOW�henca Copy,PINK—Assessor Copy.GOLOENROD—File Copy,GREEN—ApplicanCs Copy , CITY OF DIA�J�OND BAR , <: :::�•,,, , :� �fdSPECTIO�� RECORD '. . . : ' , - � ;1�i+F�i_:?���K�,�i!� 1Cli��� . 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