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HomeMy WebLinkAbout17153 (44) CITY OF DIAMOND BAR � -�� - � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21660 E.Copley Drive Suite 190 ~� (909)86Q3195 Fax(909)861-3117 PRE$$ ��^�� BiJII.DING PERMIT APPLICATION FIRMLY � JOBSITE /7 ,��r Mn n��' APPLICATIO PERMIT P/Cr 2 o ADDRESS /_Cl r� ���I�v�l"' f�+' DATE - -� NUMBER ��15�N_�L)(-./�� g issuE , �� TYPE occ Q APN LOT�TRACT DATE CONST. �_ I N� GROUP u p OWNER < < " ADDflESS ZONING SETBACKS � CITY ZIP,���p TEL. • � FRONT RW ❑ APPLICANT w TEL. A�R ❑ � SIDE/SIDE STREET RW ❑ CONTAACTOR SIDE O � ADDRESS PROPOSED USE CITY ZIP TEL ►��+ ARCHlENG/ L�p '� � . 1 � DESIGNER LC/ , N-v ''- � ADDRESS NO.DWEL NO. NO. UNITS STORIES I E3EDROOMS� � CITY ZIP TEL� � DESCRIPTION �S�.FT. FACTOR PSF AW.AREANALUATION � Q OWNER-BUILDER DECLAHATION SFR/ADO/FiEM O p I HEREBY AFFlRM UNDER PEN�LTf OF VEiWNV TMAT 1 AM E%EMPT FROM THE COMMCTORS LI- G8t9{JB/CBIpOR W CENSEU�MFOflh1EFOLLOWNOHEA50N�5EG7071.68U5WES411ND7ROFE5510N5000E:AN1'GITVOR (f� � ODU!lTYNMIQ1REOlI1RESAPERIARTOCONSTRUCT,�ITER,MPROVE,DEMOLISH,ORREPAIRAHYSTRUC• W patio/Deck TUR�VRIOR TO RS ISSUANGE I�LSO REOUIRES TM[APRIGWT FOp SUdI VERMIT TO FILE A SIGNED w � STATEYEM 711AT ME OR SME IS LICENSED M10.511A17T TO iHE VROVISIONS OF TME CONiMCT00.5 L4 � CENSE U�M(QNPTER Y(GDAIMENCpW N1TN SECTqN 7000)OF DMSiON]Oi THE BUSINE55 MMJ OR0. V- PooVSpa FE5510N4 OODE)OR iF1AT HE ORSHE IS ExEMPT7NEREFRdA JWDTHE BASiS FORTHEALLEGfD E%EMP- TIDN.M(YY�OIATqNOFSECTION7a77.6BYAHYAGPLIGWTFORAPEiwIT5U61ECT5Tl1EAPVLICMffTO Z RB-R001 � ACIVIL PENALTT OF NOT►qRE TW1 FNE MlNDFEO DOIURS I35oo)�� p ❑l���EROFTHEPROPERTY,ORYYEMP�OYEESwITHwAGESIISiMEiRSOLECOIAPENSATqN, � COmmBfGiel . 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FEE � TpiS UCENSE Uw). \ 0 O INA O(EMPTUNDER SEG B.�P.G FOR TMIS PUSON U 3 ¢ LL" DATE OwNER f' "� W F UCENSED CONTAACTORS DECLAAATION —� _ � w IHEFEBYAFiIM1UNDERVENALTYOFVERJURYTNAiIAMIICENSEDUHDERORONSqHSOFCHAPTEq � � •(WEIMENClqWITMSECTION70aa)OFDMSION]OFTMEBUSINE59ANDPROFE5510NSCODE,AND Z X W LICENSE IS M FULL FORCEAND EFFEGL m u� � � LICENSE CLASS LIC.NO. �� /��� J V DATE �� CONTMCP�^-��-�. iSe^r a W ��1 � WORKEFS'COMPENSATION DECLAFIATION �+►/G a N U y IHEREBVAFFlRuIM�ERCENALTYOFCE0.NR'/ONEOFTHEFOLLDWwGDECLAM710N5: Z � Q G _IHAVEANOWILLAWNTAINIICEHTIFICATEOFCONSEMTOSELF-INSUREiORMqHKERS' _ � OOMPENSATION,ASP1i0V�DEDBYSECTON77000FTMEUBOi1LO0E,FORTMEPERFOfW�NCE 1U OF t/1E WORK FOi1 Nn11C11 THIS VERMIT IS ISSUEO. � L Q �IHAVEAND WILLMARRNN WORKERS'C01A7ENSATqN INSVq�WCE,AS REWIREDBV SECTqN /-� �7000F THE U80R COOE fOR TN[PERWPfAM10E OFTNE WORK FOR WMICH THIS FERMIT 15 � � ISSUED.WVMDNKERS�WVFENSATIONINSUR/WCECMPiERAND70LICYMIMBENARE: CONSTRUCTION � �a��a�T A T�c FtJ N� PLAN HEVIEVY _ o POLICY HUTABER�Z9 �-p I�J���—�DZ _ ELECTRIC I � a � �aSs�erpaKmr.qje�m.s�t�pacn[peqr.�rswnor¢��pociUresR+oo;ontFss� PLUM6ING w ` Z ICLRTIFYTNATNTNfFERid11IANCEOFTMEWOpKFORWHICHTHISPERA1R51.JED.1 MECHANICAL •�7- � 511ALLNOTEIAGLOY/JJYFERSGNYdAM'YANN[RSOASTOBECOAI[5� '�" � L _____—� -'�: - . � WORKER5COYPENSATqNlAW50FGLIFOR1.tA,AND�GFEETMnTIF �B ' IAE INSPECTIONFEE , S SUOJECTTOTNEYIONCER5COMOENS PROVIS OFSECT 77 F cIABOFt -I �-•' " � � cooe.i wnnemm cornv�r m na rno�s Ns. ISSUANCE ^ �� O Q DATE: +Z �O� MPIIGM �. � SMIP -p—i1�L� !1'1 01. W ENERGY PfC �� ' WMNItq:FALURETOSECUREWORNERS' JMPENS�TqNCOYEHAGEISVNUYK _ SWILLBE � SIAJECfANEMPLOYERTOCR:MPIAIPENALilE5M10CMLFPiESUPTOONEHU � TKK151W0 ENERGYPERMIT DOIUFU[f IOO.Oool.N OD�I710H TO iME COST OF C0IAPENS�TqN,DMUGES AS cmDED FOFt RI � � SECTnN�7oeOFiNEUBORCODE.N7EREST,/�NOATTORNEYSFEES. p�NTIONFEE: pW_, CONSTRUCTION LENDING AGENCY PRE•ALT FEE: � � � O .� INEREBYAFFlRAIUHDERGENAITYOFFEM1f7YTNAT711EREISACONSTRUCT10NlENDINGl1GENGY �Z- FO(i TNE PERFORMANCE OF 1HE WORN FOR WMIGi iH15 VERM7TIS ISSUEO(SEC.]00�.GV.C.). W ,.�Z LEMJERSNAME r � LENDERSADORESS WICEHTIiVTHATIWIVEREADTM5A7PLIGTIONANDSTATEiHATTHEl�80VENFON.�A7qNI5CORAECi. TOTAL FEES 7� ( .��. �3L�• � O � IAGREETOCd/7LYMnTMl1LLCrtVAHOCOUNiYORDP7ANLESANOSTATEUWSNEUi�NGTOBURDiNO CONSTRUCiION,/WD MEREBY AUf1qR12E REVRESENT�TNES Of TWS COUNTY 70 ENiER UPON iHE Ov ' ZABOVE�AEHT%1NEOPROPERTVFORINSPECTqNVUR705E5. 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