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HomeMy WebLinkAbout16855 _�� CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOP�`'�ENT SERVICES � u�oE.c���yn�;��s�c�i90 C lq„SS j C S � C � PRESS � (909)860-3195 Fax(909)861-3117 ���s�� SUII.DING PERMIT APPLICATION FIRMLY o� JOBSITE ��D S��i I� n�'�p APPLICATION � � PERMIT I p[` Pl� � - �D ADDRESS �/ L� DATE NUMBER �o (�3J »V � APN LOT� TRACT �7�L�O� DATE � ��-`rU I CONST. GAOUP p OWNER PUI Le NOI��'S _ " ADDRESS Jt3�l I IO�? K(.�kL1"�")QYl ' 20NING SETBACKS w CfTY JIZVfrIP ZIP ��'f7G11 TEL JS,4�!-��f7-4� � FRONT '� '� '.RW ❑ APPLICANT 'Sp1'1'U2_ TEL. /��'1'iP_ REAR p 'SIDFJSIDE STREET RW O CONTFiACTOR • SIDE p g ADDRESS _ - CIIY TEL PROPOSED USE--' - � DESIGNER U U , i S I 7 � ADDRESS ' PI") 'C'- �'7 C��VG NO.DWEL NO. NO. � cmr N enn�1- i',P�l rl1 _ip A'�1n TEL. -7(N� UNITS STORIES BEDROOMS � DESCRIPTION SO.FT: FACTOR PSF ADJ.AREANALUATION � � OWNER-BUILDER OECLARATION SFRlADD/HEM � O � .� p 1 HEHEBY AFFlRM UNDER iEN�1,TY OF PE(WRV THAT I MI EXEIIPT FRdA iHE CON7RACTORS LI- Gdfe96/CefpJR ` t1J CE/14EUWFORTIEFOILOWNHIRFA,ON(SEG7WI.SBUSWESSANOPROFESSIONSCOOE:PNYCTVOR (n ZCO4INTYMMIGIREOUIRESAiEAMHTTOCON57RUCi,ALTER�PROVE.DEMOlJSH,ORREiNRANY3TRUG W P8ti0/DBtk..__.�._._ . `��'�... �j� TURE,PRqq TO RS RSUANCE/LL50 REWIRES T11E APPUClJR GOR SUG7 VERMIT TO FlLE A SIGNED W • • � STATEMENT h1AT HE OR SHE IS LICENSED WRSUAHT TO h1E PROVISIONS OF TFIE CONTMCfOHS LI• � . CEIISEUWICFUPTFR9�COMMENCPlOWIMSECTION7D0010FCIVISqN70FTHEBUS�NESSANUPRO- � POOUSpe \�� FESfiqNS[OOE�OR TNA7 HE OR SHE IS E%EYPi MEREFRdA AND THE BASIS FOiI THE ILLLE6ED E%EIAV• TION.ANVVIOlAT10NOFSECT10N7a�1.6BYANVA➢DLICMlTFORADEiWITSU61ECT5THEAPPLIGWiTO z Re-Root ..r � �avw.Pa+�u.nocHorr�oacnuwvn+EHu+oacooauws�ssoo�.�: _ � 04�+^�M�EAOFTHE7POPERTY.OPMYEAIPIOYEE5WI7NWAGESASiHEIRSOIECOMPENSATqN, 0 Cpmm0tCI3I . _ �� � �♦ �.," ' MLL DO iNE WORK,AND THE STRUC7URE IS NOT INTENDED OR OFFERED POR S�LE(SEG'lON.BU56 , J NESS IVW Y/qFES510NS Ca�E:TIIE CONTMCT00.S UCENSE UW DOES NOT APPLY TO AN OWNEH OF -- - � ._ . --:\�`"� . � PROPENTYMFIDBUILDSORMPROVE5711EREON.ANDN}10DOESSUCHWORKMIMSELFORMERSEIFOR = � THROUGHMSORHEROIN�EMPLOYEES,PROVIDEOhUTSUCHIMPROVEMEMSMENOTINTENOEDOH m LL1 .OFFERED iOR SILE F.lION�EVER THE BU�LDMO OR MPfiOVEMEHT IS SOID WITMN ONE YEAR OF WMPLE• ,. � �TqN,7ME OWNERAUIIDER NnLL MAVE iNE BURDEN OF VPOVNO THAT HE Ofi SNE DI�NOT BURD OR MPIqVE FOR TNE PURPOSE OF SitLEI. �y ❑LA40VMEROFh1EPROPERlV,MIfXCIUSNELVCOMMCTPI6WITMUCENSEDCOMMCTOii3 (= TO CONSTRUCT THE PRO.IECT�SEC loa�.BUSINESS AND VROFESSIq:S ODOE:THE CONTMCTORS LL V81U21I0n � AD,I.AREA LL) CElISEUWDOESNOiMPLYTOANOW4EROFAPflOPERTYW1qBUM50Rp.1PR0YE57HERE0N.AHD � WFqCOHiHACi5FOR5UCHVROJECT5WITIACONfMCTOR�S�I�CENSEDWRSUNrtTOTMECONTMG QUANTITY OESCRIPTION �� FEE }� TOR4 UCENSE UW.}� � � ��'�'�' S _ . . _. . . --� f . . 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B.i V.C.FOH THIS REA50N Q ` li+ 1 • U OC �� • u' DATE � ONMER V w 1 � L� � � UCENSED CONTRACTORS DECLARATION -� +L W � w IHEREBVAFFIRYU.DERV[NALTYOFVERXIRYTHATIMILICENSEDUNO[NPROVISIONSOFCHA7TER Vr l � �(COM4ENCPWWfT/15ECTION70001OFOM510N]O�iHEBUS:NESSANOPROFESSIONSCODC.IWO Z �� W UCENSE IS W FUIl iORGE AND f FFECT. lL /� �� �t Q � { � � ^� � � � UCENSE CUSs � r1 uC.No. /� J � J �— r � � p�� �"�'�/ corrraacror+ PUI C� O%Y�PS a o, � 1 S /' � e xP. yyORKERS'COMPENSATION DECUIRATION J � a < c � I MEREB AFFlRM UNOEH PENAl.TY OF VEIUURY ONE OF THE fOLLOWINOOEttMAT1DNS: ¢ T v N � HAVEANDWILLl1AINTAINACERTIFICATEOFCONSEMTOSEtFaNSUREFORWORKERS' = i � . � � COAIPENSATpN.AS OROVIOED BY SECTON f7oo OF iHE UBOR COOE.FOR 7HE VSRFORMANCE W iHEYNRK FOR WHlpl THIS VERMR I31.^.SUED. .� tMAYEM101MLLIM�MANMlOP10ER5'COIAPENSATIONWSURANCE,ASREWIREDBYSECTION ^ ,( � 77ooOFTMElABOliCOOE,iORiHEVERFORMANCEOFTHEWORKFORWHICHTHISPERM1iIS � fSSUED.MYWORKERS'COMPENSATIONWSI'MNCECMRiERIWD70LICVM!1�MeERME: CONSTRUCTION _ , O� U � Cr�NUER U f ,� �h'1��� �ei � 5 i l.d. 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RETEPtTIONFEE: ��S �r` W4O CONSTRUCTION LENDING AGENCY PRE-ALT FEE: / �- IHEREBVAFFIPAIUNDEROENAITYOFPERNRYTF1ATiHERE15ACON5TRUCTiONLENOWCAGENCY � �- FOR771E7ERFORMANGEOFTHEWORKFORWMICHTHI{PERMITISISSUEUISEC.]OW,CN.C.} 'NUY�D—�' Pv��e Hc?�� � ' � IEN�ER'SNAME � � LENOER'SADDNE55 . � � � ICEPTIFYINATIHAVEREIDTNI3ADOl1CAT10NANOSTATETHATTHEABOVENFORMATpNIStOFRECT. TOTAL FEES � , � I AOREE TO COAIPLY wRN/LL CrtY ANO COUNTY ORD�NANCES AN�STATE UwS REUTiNO TO BUILDINO � � CONSTRUCTION,AMD HEREBV 11UTFIORRE REDRESENTATNES OC 1N�S COUNTV TO ENTER UVON THE S� ABOYE�MENTIONEO OR07ERTY FOR INSPECTION PUiiPOSES. COMMENTS o ,�� a, h� _ _ � PERIAITTE WWE(PWNT) a S��.5�"�1� � N SIO EOFPEPIA� - OA�E / � RECPT.NO. PAID BY _VALJDATION . WHITE—Department Copy.YELLOW--Finance Copy,PINK—Assessa Copy,GOLDENROD--file Copy,GREEN--AppicanYs Copy _ . ,. . ....._ ._ . ... . . ., ... _.: . . ,,.-• . . , , . -- . . _ � ,.. � CITY OF DIi4MOND BAR . , . _ It�SPEC�IORI RECO 1:� . }�p� . ? r J � .� ' J • .. .. 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