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HomeMy WebLinkAbout14097 a�— J� CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES „w 21660 E.Copley Drive Suite 190 (909)860-3195 Faz(909)861-3117 PRESS '"'N'� BUQ.DING PERMIT APPLICATION FIRMLY o DDflESS ��3�f'/O I �VOM/ rJ� DATECA�y ZS l,�_NUMBE � M/C $ ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP °� OWNER 'TIe+I���ceN C� c�� ADDRESS a'�91 [7 P�LON1/�'V (� ZONING SETBACKS � CITY��OM n.i� �� ZIP '��'TEL. - REAR RW ❑ APPLICANT TEL. SIDFJSIDE STREEi' RW ❑ � CONTRACTOR SIDE ❑ � ADDRESS P.o,f�oac L/�3 CffY Ile�fl��7 C d. ZIP / � TELR�'�A����JY PROPOSED USE��2 � � ARCHlENG/ • DESIGNER NO.DWEL PlO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL v�i DESCRIPTION S�.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADD/FaEM O p 1 HEREBY AFi1RM tllWER PENALTY OF PEiWRY THA71 M1 E7(EMV7 FROM iHE CONTRACiORS Ll• Ga�9���� llJ CENSELAWiOHTHEFOILOWtlJUNEA50N(SEG.70.71.68USINESSMIOPROFESSIONSCODE:MlYqTVOH (n Sy7 GDU!lTYM4YOIREOUIpESAiffWRTOCOPISTRUCi.ALTEFIIMPROVE.DEYOLISH.ORREPNRANYSTRUG W P8S10IDBCk C� 7URE.FRqR TO rt3 ISSUANGE.AL50 REOUIRES THE APDLICANT FOR SUd1 VERMR TO FlLE A SIGNED W 6TATEMEM if1Ai HE OR SME IS 110ENSED PU0.5UANT TO TFIE PROVISIONS OF iME CONTMCTO{7311� � C£tISE U�N(GNPTER 0(COMMCNpNO WRH SCCTIDN 7000)OF OMSqN]OF iHE BUSINE55 AND PRO � PooVSPa ' FESSqNS COO�OR iMAT HE Oft SME IS EXEMPT 711EHEFFIOMAND TME BA515 FOR TNE ALLEOED EXENP• TIOH.AM/VIRATqNOFSECilON7W1.6BYM7VMPLICA7lTFORAPERYITSUBJECTSTMEAPP�ICNITiO Z Re-Rxf � ACMLVENALTI'OFNOTMORETWIirvEM1NOREDDIXURS(5500).E � OL��WNEROFTHEPROPEfiTY.ORIAYE4PLOYEESWITHWAGESASTHEIRSOIECOAIPEN5AT10N. 0 �mmercial - MALL DO iNE M�OfYf.AND THE STiU1CTURE IS NOT INTENOED OR OFFERED iOH SALE(SEG 70u,BUSI• J NESS AND PfqFE4510NS COOE 7HE CONfMRORS UCENSE Uw DOES NOT ADFLV TO AN OwNER OF N Ci10PERTYW/pBULOSORIIAPIq1/ESTHEREON.MIDM'I�ODOESSUCHKOf1KNIM5ELFORHERSELFOfl � (r 1}1ROUGHNISDIiHEROWNEMPLOYEE3,iRONDEDTHATSUp7MPROVEMEMSARENOTWTENOEDOR m . Ll� OFFEREDFORSALEG,/qWEVERTMEeUIDINGDRIMPi10VEMENTIS50l➢WfTHNONEYEAROFCOMPIE Z TION,7ME ONNEREUIDER YALL W1VE THE BURDEH OF VpOYWO 7}UT HE Oq SHE DD NOT BUR.D Ofl = 4viqVEFORiHEPURPO5E0FSALEI. Ol�:OM�MEROFTMEPpO VEHiY.AYEXClVSNELYCOMMCfINOWRHLICENSEDOONTMCTORS � 70 CONSTRUCT TNE iAO.IECf(SEC 70N,BUSiNE54IN0 iROFE5510N5 CODE:TH[COrRRACTOFlS�4 VHIUeliOn ADJ.AREA W C[NSEUWDOE9NOTMPLYTO/WOWNEROFAPROPERTYWN06URDSORIMPROVESTH[RCON,AND � WIqCONTMCTSFORSUp1PRO.JEGTSY.ATHACONTMCTOry4JLICENSEDGURSUANTTOTHECON7RAC• pUANT1TY DESCRIPiIOt� FEE � 70RSUCENSEUW.} O IAA1 E%EYP7 LNDER SEC. B.t P.C.FOR THIS REASON Q 3 " LL. � DA7E OYrt1ER V � LICENSE�CONTRACTORS DECLARATION —� � w 1 HENEBY AFFIRY UNDER iENAITY OF PEMIRY TFUT I AM LICENSEO UNDEF VROVi510NS OF CHAPiER � •(Cd1uENCNOWIT15ECfION70o0)OfDM510N�OFTMEBUS:N[SSANDPROFESSIONSCODE,M70 z 2 � f �c W UCENSE IS N iLU FORCE AND EFFECT. /+ n m 0� LICENSEC�U+SS �` ��+ � LIC.NO. � ' 1 J t' DATE —I• 7��-�i CONTRACTON d Sl � WORKERS'COMPENSATION DECLARATION ���� U N INEREBYAFFlRMUN�ERiENALiYOFGERNHYONEOFiMEFOLLOWWGDECLAMTION �. Z • . . � . 4 � �IMAVEANDWI.LIMINTAINACfRTIFIGTEOFCONSENTTOSEtF•INSUREFORNURKERS' - 2 � ' . � . , , , _ , , , , S CdIPENS�TqN,ASPFlOViOEDBv5ECT10N�7oaOFTHELABOFlOODE,FOi1THEVERFONAANCE U RO Q Oi7MEWORKFONYM1G17M15iERMIT15155UED. � 0 �I HAVE AND WI�l YAMAIN WORI(ERS'COMPFNSATION P15UMNLE,AS PEOl11RED BV SECTIDN � 770o OFTNE UBOR CODE iORTH[GER�ORMANGE OF TFIE VIORK FOR WHiC11TN15 PERMiT IS ISSUED.MYWORI(ERSCOMVEN5ATI0NIN RANCEGARRIERANDPOLICYNUAIBERARE: � CONSTRUCTION j GRRIER VU1't"e,.S� ��G � PLANREVIEW � POLICY M1M0ER 1J1A7�P1�� � E�c� 0 (na55FCi�a+ht�HoiBL07.slFrIDofn[aEaMr6FORaE�ua�EDDOttNas(S�mloatESsF UM � Z I CERTIFYTHAT N THE iERFORMANCE OF 7HE WOPoC FOH HM1IICH THIS VENAIT IS ISSUE0,1 MECHANICAL (� SHALLNOTEMPLOYANYPERSONINANYMANNEHSOASiOBECOYESU0.IECTTOTHE � NONkERSCdJVE1JSAT10NUW50FCALIFORNI�AND�CREETMATIFISH0ULD8ECOM[ INSPECTIONFEE S 6VBIEGTTOTMEVIORNERSCOMPENSATqNPROVI510NSOF ECTION77000FTNEUBOR caoe,i sw�LL ronnm�n�caar�r vnn�nase rnrnnsar+s. ISSUANCE � � SMIP p DATE:_��j��APPLICANF. . � WARNINO:FA2URETOSEWREWOfL(ERS'C01aPEN5A710N EiSUtAA A�SH�41BE [NERGYPlC r b � SUBJEGTANEUPLOYERTOCRIMNALPENALTIESANDCMLFINE5UP700NEFM+DREDTHOU5�N0 ENERGYPERMIT DOILAFiS(ilao,000),W ADDITON TO iHE GOST OF COMPENSATqN,DAMAGES IS FHOVIDED FOR IN - ¢ SECi1DN77D10F7HEUBORCODE,INTEREST,AN�ATTORNEYSFEES. RETENTIONFEE: a CONSTpUCTION LENDING AGENCY PRE•ALT FEE: � O � IHERE9YAfFIRMUNOERPENALTVOFPERNHYTNATTMEREISACONSTRUCTIONLEND�N�AGENC'/ Z FOR iHE PCRFORMANCE OF 1HE YVORK WR WMICH 7MI5 PERIAITIS ISSUEO(SEG 7w7,qV.C.). W � LEFIDERSNAAIE � LEHDER'SADORESS W ICERTIFYTHATINAVEREADTHISAPVlICA710NAN�STATEiHAiTHEABOVENFOiL�1ATqNISLORRER TOTAL FEES 1 � IAGRCETOO]MDLVWrtHALLCrtV/JIDCOtMTYORDWANCESANDSTATEUWSREUTNGTOBUILDINO CONSTRUCTqN,AND NEREBY AUTNOfUZE REDRESEHTIITIVES OF TMIS COUNTY 70 ENiER UPON TME � ABOVE-MENTqNEDPROPEFlTVFORIN5PEM10NWNPOSES COMMENTS � � /•.1�/���.Y�'\ ._ ♦ m 6 GERMiTTEE WVAE(PN u� /1 _/ _ � (n S�GNATUREOFPERAIITfEE D�TE t� � RECPT.N0. PP1D BY _,�/ VALIDATION WHITE—Depa�ment Copy,YELLOW—Finence Copy.PINK—Assessor Copq,GOL�ENROD—File Copy,GiiEEN—Applicant's Copy . �.. .t•, . � .....�..:.;�... ,. .1 0. , �r,- .�... . .,�. ..y' • . � . .,..s��.�. � ._.. . .�, .�Y•;+:.,f.::e'�h'R�:J�, . ..r"'.. ...i�..... <�ii. 'f'•. . ' . � CITY OF DIAMOND BEiR , .., ._., ,. . . _ . .; �,�. IF,lSPEC i iC)!'�:RECO�;Q �.. .. . , • .; . 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