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HomeMy WebLinkAbout10116 (9) - � CITY OF DIAMOND BAR � COMMUNITY DEVELOPMENT DEPARTMENT .,.� 21660 E.Copley Drive Suite 190 PRESS (909)860-3195 Fax(909)861-3117 '*"� BUILDING PERMITAPPWCATION FIRMLY � J08SffE APPLICATION � � PERMIT P/C ,..-/ o ADDRESS �.1�T 0 3 5�-�.��-�ti�� o y� DATE NUMBER r��+D r� ISSUE TYPE OCC APN LOT TRACT DATE CONST. GRdUP p OWNER I�nv1P_t� SI,��.,.��,n p ADDRESS '2-�'r�'3 `-�`�n'4-�+� C��.1 20NING SETBACKS ' W CITY ��,�..n�w���n,� ZIP TEL.�����1-f.R'� R�RT RW O � APPLICANT ��•tbrt ���-;,4�c..,� TEL. SI�E/SIDESTREET RW ❑ ' � CONTRACTOR��;�. �. Cnr1�}rttC��"�✓1 SIDE ❑ p� A�DRESS (6(7� "T'p�•+ c f .� � tr � � CITY M__ �s.� ZIPQ2�� TEL7� - - ROPOSED USE o AFiCWENG/ � z� DESIGNER NO.DWEL � = NO: =' � •< '� �.. NO. � � ADDRESS UNITS - - � �'STORIES � ' � BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BI:ILDER DECLAFATION SFR/ADO/REM O ' p I NEREBY 11FFIRM UHDEA PENALTY OF FERAIRY THAT 1 W IXEM7T iRdA T1E CONTMCTORS LF � GBfefld('el➢OR ��\ � � `� W CENSEUWFORTMEiOl10WINOREA50N(SEC.7a71.6BUSINE551WDViqfES5�ON5CD0E:ANYGrtYOR U tO(RfiYYMIp1qE0UIRE5AFERMITTOCONSiHUCT,/LLfERWPROVE,DEMOlISN,ORRECNRANYS7iK1G W patblDeek � TURE PRqq iOITS ISSU.wCE,ALSO REOUIRES iHE M�L�CAM FON SUCH VENYIT TO FILE A SIGNED W 67ATE4ENT TNAi NE OR SHE 6 UCENSED iU0.5UAHT 70 iHE iiiOVI510N5 OF THE CONTMLTWiS l4 � CENSE UW(f��PTER 0(COMYENC W6 MATH SECTION 70001�F DIVISION]OF iHE BU51NE55 ANO iR0. u' POOVSpi , FE3510H5 COOE)OR THAT NE OR SHE IS EXEMPTTHEREFROM AND THE BASiS iOH TME ILLLEGED EXEMR TION.ANYVIOl�T10NOF5ECT10N7D71.6fiYANVMVLIGANiFORAiEiWIT5U8.IEGTSTHEMPLICMliTO Z Re•Roof ` '�`'� •� � ACMLPENFLTYOFNOTMOfiET4NFiVE1MaDRED00LU0.S�f5o01.0 � � , � O4ASOWNEROFTMEVHOPENT`I.ORMYEMVLOIEESWIMWAGESASTHEIRSOIECOMPENSATqN, 0 Cammercial �.,1 I � '��' f„ • ',� •� NnLL DO TNE WONK.AND THE STRUC7URE IS NO7INTENDEO OR OFFER[D FOR SALE(SEG 7W�,BU54 J NESSANO VROFESS�ONS CODE:THE CONTNACTORS LILENSE UW OOES NOTAPPLY TO AN OWNEfl OF �.�\ • ' ' N PRDPERTV1Nq8UlD50qIMPROVE5iH6REd1ANDNM1�ODOESSUd11MDRKHIYSELFORHE0.5ELFOq � �\ � ' � W OFF�fR�EDiOR5ALE6,iqWEVER7HEES•BULDYMORMVpOVEY�C,NfISR50ltlyWfflaNDNEY�EAROFOOMPLE- m ��J '.�\` � TION.ME ONNER�BUILDER WKL FUVE TME BUROEN OF PROMNO T/NT ME Gi S+�E DD NOT BUIID Oq l = WVROVEfOpiNE7URPO5EOF3ALE1 �! 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B.1G.GFOqTWSREASON Q ' 3 �' � - LL, � ``J G — DATE OWNER V � , , � Z W ' �¢ LICENSED CONTRACTORS DECLARATION �j __ 2 I HEREBYAFFlRAI LNDER VENALTY OF PE0.JURY THA7IAM LICFNSED UNDCR VROVISqNS OF CMAVTEH Vr ... ," ' � � ;�� d 9(C�ENpNON1TH5ECTqN7000)OFDMSiOH�OFTME8U51NE55ANUPRDFE551pJ5CODE,AND Z X MY UCENSE IS N FlAl FOHCEAND EFFECi. m �• lLl (� � UCENSE CUSS 1•7-�-��^ LIC.N0. �y�G�S � ' F.. • � --. . . . .. v o���y_Q^_ corrra,�croa!Q r�,,, lu�.citia•d 5.' w � WORKERS'COMPENSATION OECLARATION � N IHEREBYAFFIWAUNDEHVENt1TYOFPEIUURVONEOFTI1FFOltAWWCDECUMT10N5: V `—" a � _111�VEAN�MItLLMA1NTAINACERTFICATEOFCONSEHTTOSELNIJSUREfORWdiKERS' _ r CdIPENSA7qN,A5VpOVDE0BY5ECTIONf7a00FTHELABORCO�E,FORTNEVERiORWWCE U d OF THE WORK FOR VM�C11 TMi4 PEf1A1lT IS ISSUED. � 0 W __I/I�VEIN�WILLIMMITAINWORKEPS'OOMPENSATIONINSUWNCF.ASREOUWEUBYSECTION /Q Q �70o OF iHE LABOH CODE.Fdi TNE PERFOIiMANCE OF THE NM17NK FOR NMICH iH13 PENAITIS U ISSUED.I/VN�ORKERSCOMPENSA710NINSURANCEGARIEN�U1DPOlICYNLYBERARE: CONSTRUCTION � � CARRIER PLAN REVIEW Z ra�cYrxn�sER ELECTAIC �' J ¢ 0 �nassEcnon��wreEm�renoFncrE�rswaartHuaamocuusa+ao�oR�l PLUMBIN� Z ICEqTIFYiHATNiMEPERFORAIMICEOFiHEWORKFORWNN71TH4PERY�TL5155UfD,1 MECHANICAL (7 SHALINOTEMVLOYNlYVE1i50NNANYYANNEH50�5TOBEC01AE3LBlECTTOTHE . (/� WOPofERS'LOYPENSATIONUN50FCALIFORNI/�NIDAGNEETHATIFISHOULDBECONE INSPECTIONFEE S SUBJECTTOTFIEIMORKERS'COMPENSA7qNPROY1510H50FSEG710N770aOFiHE�ABOA � caoe,i sruu�onnrvnrH couvir vnn� E vnansaNs. ISSUANCE � O ,/� � p WtiE: —� �I APPIIGINT./�tC 9� .5 L 4..✓ SMIP � ENERGY P/C WARNINO:FALUHE TO SECURE YIORKER5 COMFENSA710N COVEiUGE IS UNlAWi1.�,AND SHALL BE � SUfl1ECTANE4PLOYEFTOCRIMNALVENALTIESANUGVILFNE5UP70q1EMMlRCDTMOUSMrD ENERGYPERMIT pOlLARS({I00,000),N AOOITION TO iHE C0.5TOF COMPENSATIDN,Oµ�GES AS PROVOEO FOR IN � BECTION77wOFTHELABORCOOE,HTERF3T.ANDATIORNEY'SFEES. RETENTIONFEE: � �. qW.. CONSTRUCTION LENDING AGENCY o PFE-ALT FEE 0. 1 NEREBV AFFIRM LNDfR PENALTY OF PEFW0.V TIU7TMENE IS 11 GONSTRUCTION LEN01lq ACENCY ' Z iOq TME VENfORMMILE OF THE WOfiK FOR riHIG1 TH�S 7ERA1tT IS ISSUED(SEC.7oY7.pV.G�. 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