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HomeMy WebLinkAbout13712 (1076) r' �� CTTY OF DIAMOND BAR DEPARTMENT OF COMMUNTfY dc DEVELOPMENT SERVICES � , xi�o E.copi�y n,zy�s,�u i90 PRESS (909)660-3195 Fex(909)861-3117 '�^'��� BUUJDING PERNIIT APP'LICATION FIRMLY � ADDRIESS �I�r� I�c�tlC+/(1�� �_�� DATE CAT10 � NUMB q� ��� �v $ ISSUE TYPE OCC APN LOT TEtACT DATE CONST. GROUP OWNER p ADDRESS `� ZONING SETRACKS CITY � ZIP���TEL.�I,�3�G�-�� FRONT RW ❑ APPLICANT (��Lt f TEL. REAR p SIDFISIDE STREET RW ❑ CONTRACTOR SI�E ❑ g CDDRESS ZIP TEL PROPOSED USE / y � � ARCH/ENG/ �Idl3� �X Y1 Y1?,�. r� DESIGNER NO.DWEL. . NO. � CrtDRESS ZIP TEL. UNRS STORIES BEDROOMS rn DESCRIPTION Sa.FT. FACTOR PSF AW.AREANALUATION p� O R-BUILDER DECLARATION SFFVADDAiEM O 1 NE(E9Y AfFXW UNDER PENK7Y OF PEf WRY F4NT I AM FXEMPT FPOM ME CONTMCTORS L� Qef9�CeI�Of[ CElISEUWFOqTHEFOLl01W1NGREA80N�9EG709i.6BUSINE59ANDiROFE55qNSCOD@ANVCI7YOR (n - COINiiYNT9CHREOIARESAPERMRTOCONSTRUCT,AI,TERMAPROVE,DEMOUSH,ORREMIH11NY9TRUC- w pell0/DOCk TURE,YRqR i0 ITS IBSUANCE,IILSO RE�l11RES TFIE APPLM.�W7 FOR SUCH PERMIT TO FlLE A SIONED liATEMENT 7FNT HE DII SME IS UCENSEU PURSUMlT TO THE PROVISIONS OF iNE OONiR�CfORB U- CENSE UW(WMTER Y(COMMENCINO WITH SECTION 7000)OF OIVISION]OF 7HE BUSINESS ANO Dpp- � POOVSpB FEBSbNSCOOE)ORTNATXEORSHE44EXEMPTTHEREFROMANDiNE8A419FORTHEALlEOEDE%EA1P- (' TION.ANVVIOLATIONOFSECTION708/.6BYANYAPPLICANT�ORAPERMITSU&IECT6THEAPPLICANTiG Z Re-Roof A CML PENALTY OF NOT MOHE 7}1AN FIVE HUNDH W DOLURS(iSWF): OI,ASOMMEROFTIiEPROPERTY,ORMYEMPIOVEE8MATHWAGESASTHEIHSOLECOMPENS�7pN, COrt1TBrC191 � MBl 00 7/1E WOiiK AND TNE STiiUCTURE IS NOT INiENDED OR OFFEFlEO FIXi SiILE(SEC.70u,8U51- � � PRiDPERTYWFpBUNDSORIMPRWE3�ERE0M,/NIDUWHO00ES3UCHYYORKXI SEL ORHERSEEFM = � 1HAOVGHWSOqMEROWNFMPLOYEES.PROVIDEDTHATEUCHhIPROVEYENTSARENOTWTEN0E00R LI� � , OFFEREDFORSAIE.K.NOWEVE0.7MEBULdNCiORIMPqOVE4FNT5SOLOWITNWONEYEAROFCOMPLE 4^'. 1qN,1ME OWNER$UItDER WILL NAVE 15�E BUROEN OF PROVINO TSMT NE OR SHE OIO NO7 BUIID OR IMPfiOVE FOR7HE WRP06E OF 6AL�. � 04�q`�NEROFTHEPROPER'TY,AME7(q.USNELYCONTMCTINOWfT11UCEN3EDCONTRAC70q5 � TO OONSTRUGT T}1E�R61ECT(BEC.iOM,SU91NE59 ANO iROFE39pN5 CODE:TME OONTiUCTORS ll• V81U8T1011 ADJ.AREA CENSE tAW DOES NOT APPLYTO AN OVMER OF A YROPERTYYYIIO BUIlD5 Op W PROVES TMEREIXI.AH] N1iDGOHiRACiSFORBUCHPROJECT9YYITIACON�RACiDR(9)LICENSmPURBUIWfTOTHECONffUC� pUAN17TY DESCRIPTION �E `_ lORS UCENSE IAW.I. i O I AM E%EMCT U�DER BEC. &i P.G FOR 7HI5 HEASON Q T V �= DATE OWNEA �� V � LICENSEO CONTRACTORS DECLARATION W � I HEfiEBYAFF6IM lINOER PENKTY OF PEfWRY 7NAT I AM LICENSE�UNDER PHOVISIONS OFCHAPTER � �(CONMENCINOYATHSECTION7000JOFDIVISIDN]OFTHEBUSINESSANDCIiOFFSSIONSC�E.AND Z � W LICENSE IS IN FUl FOpCE ANO EFFEC7. m 0 LICENSE CU35 LIC ND. � � DATE CONTRACTOR � � WORKERS'COMPENSATION OECLARATIUN Q � I HEREBV�1fFf W UNGER PENALTY OF iEiUURY ONE OF TME FOLLAYANG DECLAMTNDNS: Z � _IMAVEANDN'ILLh1AIN��INACEATIFICATEOFCONSENTTOSELF•INSUREFONWORKERS' 2 Qp,IP�lSATION,AS PFONDED BY SECiION]7000F THE LABOR CODE,FOP TNE PERFORIAMlCE W Q OF TIE WOHK FOR Vh11GT1 tN18 PERMIT IS I66UED. � � �_I NAVE AND WILLMAINTNN WOfiKE115 OOMPENSA7KKJ INSUHANCE,AS REOUIRED BY BECTION Q 97000FTHELABORCWE.fORTMEPERFORMANCEOFTHEWORKFORWHICH7HI5VERMRIS � ISSUE0.W WOqKERS'COMPENSATpN INSURNJCE CARRIER AND OOLICY NUMBER AAE: CONSTRUCTION � CAWYER PLAN REVIEW POLICYANMBER � ELECTRIC 6 , 0 (fH66E+.'iqNNEEDNO'TBECOhIPI.E7IDOFiHEPEiiAfBiOROr1EH.XOREo0dlAFtsft•ml0atP55l MBING Z I CFR7ILYTNAT MTHE PERFORAIANCE OF 7H6 WOqK FOR WHlqi TMIS PERMI7 W ISSVED,I MECHANICAL � 6HALL NOT EMPIAY M1Y PERSON W ANY MIWNER SD/S TO BECOME SU&IECT TO THE � WORKERS'COMPEN9ATqN�AW90FCALIPoRMIAANDAGREETXATIFI6HOUlDBECOME INSPECTIONFEE S SUHJ[CTNTNEWORKERS'COMPENS�TqNPROVI510NSOFSECTIONS70DOF7MELABOR WOE,1 SHALL FOR71iYY1TH COMPIY WITN 7HOSE PROVISIONS. ISSUANCE rl f„ O p ppTE: _ qppUapl�ri SMIP "1 e � WARNINO:F/1RA1RE TO SECURE WORKERS'COAIPENSATION COVERAl3E IS I1NlAWFUL AND SNALlBE ENERGY P/C f} �m � � +�1 e.�.. SUB.IECTANFMPLOYERTOCRIMINALPENM.TIESANOCIVILFWESl1PTODNENUNOREDTFqUSAND �st L '¢' LL' ENEHC3V PERMIT .. ��' ` '� ' '°'r" '�.TT � OOLLARS(it00.000),W AODITION TO THE COST OF COMPENSRpN,DAMA(iE6 AS PROVIDED FOR IN ,,, 1 - c_ J� SECTqN770�OFTHEU1BOIqCODE.INTERESLANDATTONNEY'SFEES. RETENTIONFEE: �� 4 CONSTRUCTION LENDING AGENCY PRE•AlT FEE: O � 1 MEREBYAFFIRM UNOER PENALTY OF PERIURY THAT h1ERE IS ACONSTRUCTION IENDWO AOENCY 2 FOR iHE iERWRAIANCE OF THE WORK FOH 4VHICH 1HI5 PERM�T I5155UE015EG 3oi7.GV.GI. W .c� LENDERS NNAE 3 1— LENDERSADDRE35 � I CERTIFY 7MAT I NAYE PEAD THIS MPLIGTION AND 9TA7E TFiAT TNE ABOVE INFORM�TION IS CORRECL TOTAL F EES � � d 1 A(3REE TO COAIP�Y W(f}i ALL CRY M1D COUNTY OR�INANCES ANO STATE UWS REtA71N0 TO BURDINO v � CONSTRUCTION,AND NEREBV AUiViORIZE NEPRESENTATIVES OF THIS COIINTY i[7 ENTER UPON h1E �180VE-MEMqNEDOqOPERTVFOR WSPECf10N VURPOSES. COMMENTS � � J � QPE M E NAM (PRI ` � � ��a � ��� ��- ���I�� (/) 816NATURE PERA{ITTEE � RECPT.NO. PAID BY VALIOATION WHRE-0epartment Copy.YELLDIN--Fiience Copy,PINK—Asaessar Copy,GOLDENROD—File Copy,GREEN—IlpplicaM's Copy , •• . • .. , . .r. , .. � I'. �. ...� .i.. . . . va . . � � .. . .� • . . .. . 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