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HomeMy WebLinkAbout15622 (1103) J� CITY OF DIAMOND BAR � DEPARTMENT OF COMMUNITY 8z DEVELOPMENT SERVICES 21660 E.Copley Drive Suite 190 (��a6o-s i9s r����sbt.3i i� PRESS • ��^� BUILDING PERMIT APPLICATION PIRMLY y�, JOBSITE �y�s� APPLICATIO�( —QV PERMfT p/C��]� o ADDRESS Z �7 DATE ` NUMBER�� �� �1 " � ! � � ISSUE TYPE. OCC APN LOT�3 ZTRACT V� 8�O DATE CONST. GROUP g OWNER � ADDRESS t u � D(i, ZONING SEfBACKS w CITY a//A'rDr�D Ii7�'R ZIP� TEL. • O • FRONT ��� flW ❑ � APPLICAN7 $Ri� SGI-F..s�� TEL.q�'19•//l0 � � REAR ❑ � SIDE/SIDESTAEET RW ❑ CONTRACTOA 'Z�D r �S G' SIDE r p ADDRESS W. Gt� J}v _ /r g CfTY s�ai.�!�'1J ZIP y�7 3 TEL Ta!• �/7•/Iie PROPOSED USE_ ��l'1 D �'�(� V� � ARCH/ENG/ — DESIGNER_B��1Mi4 G. ,!4'O�MS NO.DWEL. NO. NO. ADDRESS— J J e ZZ Iq'G Glrf' PrLµ1. S UNITS STORIES BEDROOMS � CfTY��'Rr0!90 GR�d JIF ZIP���OTEL.`��• cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER•BUILDER DECLARATION SFH/A�DlREM O p 1 HERFBY AFi1RM UlAER PEHALTY OF PERUIIY THAT 1 AM F%EIAPT iROA1 ME COMMLT00.5 LL GareOa�CarpoA � CENSEUWFDRiHEfOL10wNOREA50H�SEG7Wi.SBUS�NESSANO7ROFE5510NSCO0E:/N'ICITYOA (n CAl)fT`lYN11CHNEOUIRESAVEfiMfTTOGONSTRUCL/LLTERMVPOYE,DENOLISM.ORREPNRANYS7AUG W PaliO/DBCI( Z 1L1RE,VNOft TO RS ISSUANCE.ALSO f1E0UIRE5 THC AVP��/,NT FOR SUpI PEiLA1T TO FILE A SICNED w � BTA7EMEM i/NT HE OR SME IS UCENSED►UFiSUNiT TO TME PROYISiONS OF TME CONiRAGT0R5 LF � � CENSE UW(dUPTEH 0�COYYENCPlO 1MTN SECTIDN 7000)OF DNISION]OF 7HE BUSINESS FN'J VRO• POOUSp� . FESSqNSCaOE)ORiNATHEOR5HEISF%CMPTiMEREFRqAANpTHEBA515FpR7HEALLECEDEXEMP• (r} TqN.ANVVI0LAT10NOFSECT10N1071.6BYANVAPDIN'JIMiOiiAPERMITSUAIECTSTNEAPCl1CANTTO Z qp-{�pp� �,,,, A dNl OENALTV OF NOT MORE 7NAN FNE HU'ARED DOLLAHS(f soo).1: O �lASOIM�EROFTHEPHOPERTY.ORMVEMVLOYEESWITMW�GE5A5THE1R50lECOMPENSATqN, O COrt1R10fCI01 � Z YIILL DO TI[WOpK,AND THE STRUCTURE IS NOT NTENDED OR OFFERED FOR SILE(SEC.7D1t.BUSi- _1 N NESS N1D YROFESSIONS OOOE'THE COHTMLiOFS UCENSE UW DOES NOT A7P11 TO AN OWNER OF � PROPENTV 1M�0 BUR.DS OR YPppVES 71/ERCON..WD Wlq DOES SUCH WORK H�IISELF OR HERSEIG OR � 7HROUGHWSpiMEROMMEMPIOYEES,YROVIDCCTUTSUCMIMPROVEMEtfTSARENOTMENDED0�1 m � OiFEREDGOR5KE6,/10WEVERIME&RDNUORM%iOVEIAEHiLS50LOWfTMWONEYEAROFCDYRE� Z T�dl.iHE OWNER�BVIIDER WIL:NAVE THE BUi1DCN OF PRpVWO TH�T NE OR SNE DiD NOT BUI�p Of1 = MPNOVE FOR TME PUHPOiEOF SitlE4 W Ol�3�WMEi10FTNFPROVER7`/,AME%QUSNE�YCOHTFACTNOWRH�IC(NSEDCOHTMCTORS � N Cd�STAUCT iNC PRUIELT(SEG)OM,BUSiNE55 M1D iiqFE5510N5 CODE THE GONTMCTORS U- �IglUalidl ApJAFlEA CENSE Uw DOES NOT AVRY TO Ml OVMER OF A VIIOPERTY W!q BUILDS OR IUPROVL9 THEHEON,AND � YnqOOrfTMCTSFORSUCHGRO.lECT9WITHACONiRACTOR(S�LICENSEDPURSUURTOTH[CONTMG pUANTITY [SCRIPi 4 � FEE � mAsuc�sEuw�. O IMI EXEMPT UNDER SEG B,t F.C.FOR TMIS REASON Q U LL F DATE OYMER U , � UCENSED CONTRACTORS DECLARATION W J � INEREBYAFi1RYtM!7ERPEIULT'IOFp[0.R1RYTIUTIMIUCENSEDUNDERDROYISIONSOFCMAVTER V. � � s �(QOMMENCWOYA7HSECTqN7aoo1�DM5i0N]OFTMCBUSINESSM+DPROFESS�ONSLODE,M'D Z X W 110EN5E IS N iLLL FOiiCE AKD EFFECi. LLl /' p�/ m � tICENS[CUSS ��►� LIC.NO._Q_Z,�� FJ j . �"j o,aE 7• /�• 0O conrr�ucro��R.iTFrf_fG� a � WORKERS'COMFENSATION DECLARATION a = U N1 n CIq1A�NCERVENALTYOFVERNNYON[OFTME�OLLOWINCDECLIlRAT10N5: _ Z �• . � , � � INAVEANDIYLLMANTAINACEHTiFICATEOFCONSENTiOSELFaNSURGiORNORKCRS' _ ' ' , C�DNPEHS�TqN,ASPROVUCD9YSECT10N77GOOFTMEUBORGOOE,iONTMEPERfORMANCE W /dF THE WORN iORV7111CH THIS PER411T IS I55U[�. �• � � ' ' � ., � •/ � , V 1 HAVEAND WILL MAIMAN WOitKERS'LOYPENSATqN INSUqhNCE,A$REOUIRCD BV SECTION � Q TOOOFTMEUIBORCOOE,PoRiH[VENFORIIANCEOFTNCWORKFORWMIdiTHISVERMITIS ' " � ' t . . ' . - �SSUED.A/YriOFlKF CdAVENSATGNWSURANCECARR�ERANDPOLICYNLMBERAR[; CONST{�IUCTION � �� y crwwcA�✓��r`T � PUWR[VIEW 1 � POUCYNW!!ER � �' OO�I Dn f Cf! r [1J ELECTRIC ' � (MSSECTOHnEmNOTB[C�EETC)o�MVEa�Ri6fOnULH1117i1m0aUlsR�ac)d1lEi.1 PLUMFSING Z 1 CERTIFY iNAT N THC PERLppuANCE OF TME NORK FOR WMICH TIIS iER1AR IS LSSUE0.1 MECHANICA� U' SFuILNOTEMiLOYIWYiER50NNANY4ANNEq50A5TOBECOlAESV&IECTTOTHE --f . � VpRKERSCOIAVENSAT10NlAWSOFGtLIfdiNIA/�NOAGREETNATIFISNDUI�BECA1.lE INSPECTIONFEE SUIiIEGT TO TME WORKERS'LdAPENSATION PROY:510N5 OF SECTION 77o00F TME IAUOR '�• �- �.�..�. s CODE.I6HAI.LFOR7MVITHCOMVLVWIMTMOSEPROV15qN5. ISSUANCE � SMIP DA7E: APPIICANT: � WARNINO:FARURE TO SEdJRE WORNEIIS'COUVENSATpN COVCRAGE LS UNUN?Ill,AND SHALLBE ENERGY P/C 1��1 (� �� I I i i!I �y„ SUBJECTANEMPLOYERTOLR1MiNALiENAlTIESANDCMLi1HE5lJPTOONEMIHOFEDTMGISMlp ENERGYPERI�AIT - ^ � AT� pOl1ARS({t00.000�.INA�DITIONTOTMECOSTOFCOMPENSATqN.OAMAGE3A5PROYIDEDFORW ' ' ��� � 5[LTqN77oeOFiHELAB00.CO0E,INTEREST,ANOATTOPNEY5FEE5. RETEhITIONFEE: �j 1 1 U� ��� � � .. �---•-!•-+' o • w 11^ LIJILL..��',.; t.t.L..�...�.a a O CONSTRUCTION LENDING AGENCY PR AL FEE: -r� � IMEREBYAFFIRMUNOERPENALTYOFPERM1JfiYTMATIHEAE{SACONSTRUCTIqi{,ENDINOAGENCY FOR THE PER�ORMANCE OF THE WO{iN FOR WF11CH 7Mi5 VERMIT I5155UEO(SEC.70V1.CIY.C.�. � �� � . � LENOER'S rIM�F C LENDEASADOR[55 W ICERTIFYTNATIXAVEREAD7H�SAPPL1GTqN�7+D5TATETYUTiMEABOVENFOAYATIONISCORRECT. TOTAL FEES � � p., IAIiREETOCOMPLYNTTMIiLLCT'ANDCOVNTYORDINANLESANDS7ATEUWSREU�INOiOBURDINO CONSTRUCTION.AI:OHEREBYAUTqP11ERE�NESENTATNE50FTMI5WU1/7YTOENTERUPONTNE r ' � ABOVE��/EHTIONE07ROPERTVFORMSPERIONPUHPOSCS. COMME TS � '��r 17gi'1� ��i 1'�C7 � �p Il� 'Z v-' � m ¢ o6a�l�r— a� � �_ � �� �• l-�•D�— y SiGNANREO�FENMiiTEE DATE , � R[CPT.NO. PAID BY VAIJDATION WHITE—Depurtment Copy.YELLOW—Fnence Copy,PINK—Assessar Copy.GOIDENRO�File Copy,GREEN—ApphcanCs Copy .. . . ' ' ^ .. . , , .d = .. , . . ,. . _. ..�ti . . .. , ., . . .. .. . ... - . � , ... . . . . . . . .- , . � . CITY OF DIAf►�OC�dD BAR . � • It�!SPECTIO��: F�ECOFD � _....._. _ .,.�_...__ ..�.` �:.�" �_ . `.li�.�i.:-�=G�.rI�1!°&...�__ _���4!'= _ �►���' �'�E".�0.�'�:_ . ....�....�.��F'j;i�.,.,���n����... . . _.� ,���C:�Y ''+ ,I e=7�c , �.. . _ . . _ . _.... .. � .. . . . .T_ ��-.--�-�-r -„�� �SEi 6ACY ...I��—� .:. . ( � FLO�R���Js,i��.:._ . . I , •, '. - � , I -'��,,1.-5-%':�-•-��.---:Y-�y-i4.-1*'i-t � . 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