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HomeMy WebLinkAbout16782 (37) J� C1TY OF DIAMOND BAR � � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES '" ��� -� 21825 E.Copley Drive (909)860.3195 Fax(909)861-3117 PRESS '-:�=� BUILDING PERM[T APPLICATION FIR LY o� JOBSITE /��� APPUCATION n I PERMIT I P!C ADDRESS 15Ll�� DATE / � I `D I NUME3ER ` � � ISSUE I'� TYPE CC � APN LO� TRACT DATE 1 I CONST. GROUP ¢ OWNER � ZONING SETE3ACKS o ADDRE� � z CITY ZIP �� TEL � ��� FRONT pW ❑❑ o APPL CANT TEL, SIDE/SIDE STREET RW ❑ ¢ CONTRACT SIDE ❑ oADDRESS � ��j'�� CITY ZIP TEL � O,�� ys 4 w ARC NG/ + z DESIGNER , w NO.DNJEL. O. NO. a ADDRESS � CITY ZIP TEL. UNITS STORIES �EDROOMS � cn DESCRIPTION SO.FT. 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B.6 C.C.FOR TMiS REASON Q � U ti. � DATE OWNER � Z W � LICENSED CONTRACTORS DECLARATION W I NEREBYAFFIRM UNDER PENALT/OF VERIURv THAT 1AM LKENSED UNDER FROV1510N5 0F CHAPTER � p„ !�COMMCNpNC W1TM SELTION 7000�OF DMSION]OF TME BVSINE55 ANO PROFESSqNS CACE,M:D Z X MY LFENSE IS W FULL FOqCE AND EFFECT. m LLI /' � UCENS(E�CUSS /'�� LIC.NO. ( j W DATE C1T��[Q_ CONTRACTO ��j�/1��/� a _ � � WORKERS'COMPENSATION DECLARATION a = U NIH[REBYAFFIRMUNDERVENALivOFPERRIRYON[OFiHEFOIIAW:NCDECIARAT�ONS: Z 0 _IHAVEANDWILLMAINT�tt�/110ERTIFICATEOFCANSENTTOSEIFaNSURCFORWORNERS' _ � LOM�PENSATqN,�SPROVI0E�9YSEC710N7�000FTHEUBORCOOE,FORiHEFER�ONaANCE w OF TME WORN FOR WHlpf TNIS CERNIT IS ISSUED. � � W _I HAVE AND WILL MAINTAM WORHERS'fAMPENSATqN INSURANCE,AS REW�RED BY SEC710N n � ,/� Q ]700 OF TME IABOfl COO[,fOfl iHE VERFOFMRNCE OF TME WOR1(FOR WMip1 iMIS PERMiT IS 1 �N, ��'y � ISSUEO.MYWOFN COAIPENSATIONINSUA' EGARH�ERANDPOIICYNUMBERME: CONSTRUCTION � ✓V d 7 CARRIER �� PLAN REVIEVJ Z valcrNUMB[R_� .�!�� - _- -______ - ELECTpIC ¢ � (MSSECTIOrdNCmwis[Cp.9'LF7mOfMPEitMf6PoROnENUL47[ODolUiL5R+a70RlFss1 PLUMBING Z 1 CEpTiFY THAT IN TME DEAFOaEAANCE OF THE WORK iOR WIIICH THIS VERAIIT IS ISSUED.I MECHANICAL (7 SHALLNOTEA��LOYANVDEASONWANYIAANNERSOASTOBECA�AESU0.1[CTiOTHE � WORKERS'COMPENSATqNUW50FG1LIFORNi�AN'�AGREETMATIFISMOl1LDBECOME INSPECTIONFEE S SU&1ECTTOTHENK7RKERS'CAMPENSATiONPROVI510NSOFSECT10N77000FTHElABOR `�� cooE,i swu.�FORrHvmn coMv�r win�nase vao�s�or+s. ISSUANCE � SMIP � p DATE: APPLICANT: � WARNINO:FARURETOSECUREM/ORNERS'COA�CENSATIDNCAVERAGEISUNUWRIL.MIDSHNIBE ENERGYP/C � SUBJECTANEMPLOYERTOCRIMINALPENALTIESMIOCMLFWESUPi00NEHVNDREDTFKKISAND ENERGYPERMIT OOlURS(f tOD,000),IN ADDiT1ON TO TME COST OF COMPENSAiION,DARUGES I15 YNOVIOED FOfl IN ¢ SECTION77oeOFTHELABORCODE.NTEREST,ANDATTORNEY'SFEES. RETENTIONFEE: � ow.. CONSTRUCTION LENDING AGENCY PRL-ALT FEE: O Q 1 HEREBV AFFIRM UNDER PENALTYOF PERIURV TNAT THERE IS A CONSTRVCTION LENDIHG AGENC'/ aZ- FOR THE GENFOHMANCE OF TM[WORK FOR WMICH THIS PERMIT IS ISSUED(SCC.70V1,GIV.G.). il.l �Z LENOER'S NIA�E � LENOERSADDR[SS W ICEflTIFYTHATIMAVEREADTHISMVUCATqNANDSTATETHATTMEA80VEP1FO1WATqN15CORRECT. TOTAL FEES F ��• d I�GREE TO COMPLY NnTH JLLL CRY AND COUNTY OfiDINANCES Ml�SiATE UN�S REUTINO i0 BU4DING � WNSTRl1CTIQV.ANDM[REBYAUTFIORIIEREVRESENTATNESOFTH�SCOUNTVTOENTERUPONiHE Z ABOVEMEN7qNE0P P TYFORINSPECTIONPURPOSES. 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