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HomeMy WebLinkAbout13551 �.� CITY OF DIAMOND BAR � -� DEPARTMENT OF COMMUMTY&DEVELOPMENT SERVICES 21660 E.Copley Drive Suice 190 (909)860.3195 Fax(909)861-3117 PRES$ ����^ BUII.DING PERMIT APPLICATION FIRMLY JOBSITE 1�r- e APPLICATION � 1 PERMIT `3�S P/C o ADDRESS �JSD ✓. Y.�t,1le� �sfaT�f' DA7E NUMBER M cab, ISSUE TYPE OCC APN LOT Z TRACT DATE CONST. GROUP p OWNER c ! e ADDRESS � M� II 1 ZONING SETE3ACKS "' CITY��v�[n� ZIP�{�Io TEL.�I ��� FRONT ` HW ❑ � APPLICANT TEL. REAR O SIDFJSIDE STREET RW O � r. �r- I�'� � SIDE O CONTRACTO� � ADDRE S � ' �� � PROPOSED USE CITY ZIP TEL z B ARCFUENG/ � DESIGNER NO.DWEL. NO. NO. AODRESS UP�ITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION Sa.FT. 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OIAME7cEM7TUNDERSEG B.iP.C.FORTHiSREASON a � 3 � � � � u" DATE OVINER � � � r , !� . W UCENSED COYTFiACTORS DECLAFiATION W � 1MERE8IAFFIRNUNDERPENKTYOFCEfiIUiT�i1UTIAAILICENSEDUNDERCROYISICNSOFCHACTER �. p� •(COYYENCTqYVITMSECTION70001��M510N�OFTMEBV51NE55ANDPfiOFE5410NSCOD[,AY� L x W LICENSE IS W MLFORCEAND EFFEC7. � m �i.� r „ � LICENSE CLASIS' y�V UC.N0.��a p3 S � b � � pqTE�/ 1� �� CONTMCTOR�•�1��� d -r� � WORKERS'COMPENSATION DECLAFiATION -' ¢ � U � 111EREBYAFFlRAIUNDERGENALTYOFOE0.IUR'�d:EOFT11EfOLLOWINGDECLAMTIONS: Z Q � �IIMVE/WOWiLLWhTNNACERTIFICATEOFCONSENTTOSELF-INSUREiORNORKERS' 2 � � C04PENSATqN.A5VF10ViDEDBVSECTION77000FTNEUBOfiCOOE,FOnT7�EVERiORMAN:E w OF ME WORK FOR MTIICH TNIS VERMIT IS�SSUE�. 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O SMIP ..... . �... p DATE: APVLICANT: IT11 . :` I,7..i^. � ENEHGY gJCd,�, WAHNINO�FMURE TO SE W RE WORKERS'LOMPENSATqN COVEMGE IS UNLAVKUL.AND SHA�y B[ () � �y SUBJECTANEMPLOYER70CRIM'NALVEN�LTIESANDCIVILFINESUPTOONEMUNDfiED7HOU5AND ENERGY ��{MITY `/•� 1J '��'� DOIURS(lt00.OW1.D1/�DIT10N i0 7HE CAST OF COMPCN5l1T10N,OAM�GES A5 PROV10ED FOH IN ��. J SECT%N177oeOFTNELAflORCOOEMTFREST.ANDATTORNEY5iEE5. FIETENTIONFE�'���'����' � 2 w CONSTRUCTION LENDING AGENCY PRE•AL7 FEE: d CL IHEREBVAfFlRMUNDCRCENALNOFPERNRViMATTHERF.ISACONSTRUCTIONlEN7WG�GENCY n- PoHTMEPERFOfiMAMCEOFiHEWW1NFORWHKHTH15iERMiTI5155UED(SEG.9oY1.pV.C.). Z W � IENOEHS NAME � LENDER'SADDRESS . O � 1 CERTIFY TUT I NAVE REAO THIS A�PLICATIOH MA STATETMAT THE/1BOVE NFORM�TION�5 CORRECT. 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