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HomeMy WebLinkAbout13115 CITY OF DIAMOND BAR �� " DEPARTMENT OF COMMUNITY dt DEVELOPMENT SERVICES � 21660 E.Coplcy Drive Suite 190 (909)86(�3195 Fax(909)861-3117 PRESS �'�"� BUII.DING PERMIT APPLICA�'IUN FIRMLY � JOBSITE APPLICATION PERMIT �P/C < ADDRESS ��� 8�t�Ry �R, �DIPMcw'� ;�r. p DATE NUMBER # � APN LOT TRACT �SSUE TYPE OCC DATE CONST. GROUP p OWNER C7c►.r��! �EAE'�a� X3A�K " ADDRESS Ih�S PAW 'ScN dAK�S $��D -�'Sp ZONfNG SETBACKS � CITY Pp4N �N ZIP��OITEL R�RT RW o APPLICANT __Rds N�ut2 TEL. SIDE/SIQE STREET FiW ❑ � CONTflACTOR KARCNE� �NVi¢ONMEN'I�,aL iNC. StDE ❑ � ADDRESS 2 �� a "'� w E ' pROPOSED USE b�'hoL��a,.i ��illE �InCE� R1 S/7jf�!c!' arv A�pNa,M Zlp C�_ TEL. 'e-8 o aRcwer�c,� ,.z, OESIGNER NO.DWEL. NO. NO. y ADDRESS UNITS STORIES BEDROOMS � ClTY ZIP 7EL. N DESCRIPTION SQ.FT. 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B.8 P.C.FOQ THIS RFASON J U � � DATE ONMER f" � W LICENSED CANTRACTOflS DECLARATION � � W INEHEBYAFFIFtlAU1VDEflPEN�LTYOFPEpJUFi1'T/U7IAMUCENSEDUNDERPROYISiON50FCHAPTER � Y(COWEIiCNO WITH SECT�ON 7000)OF DmSpN 7 OF TNE BUSINE55 AND PROFESSIONS CODE,AND Z X W LICENSE IS P!FULL FORGEAN�EFFECT. � LICEI�ISE CLASS LIC.NO. `T•I�/G � � a� 3• I�'4 coNrAncroa a � WORKERS'COMPENSATION DECIARATION a N IHEREBYAFFIRMUNDERPENALTYOFPENURYONEOFTHEPoLLOWPJGDECLAMTKKJS: U � Z a � _INAVEMI�WLLIIMNJTNNIICER�IFICATEOFWNSENTTOSELNNSUHEKOflYVORKERS' _ COAApEM$RTpN,�SPfWVIDEDBYSECT10NT7000FTHEUBORCODE,FORTHEPERWRMANCE W Q pF TNE WOPoC FOiI WHICH THIS PERMIT I$ISSUEO. g w ✓ 1 HIWEAND WILL M11Nfl1W WORI(EflS'COMPENSATKKi INSUMNC�AS REQUIRED BY SECTqN � 37oaOFTrrtLA80H�00E.FORhiEPERFOHMANCEOF'�-�EWOFiKFOFWHICH7HI5PEFMITIS I�� �/r� � GSgU�,►ryNpRKER3'COMPENSATIONINSUMNCECARRIERANDVOLICVNUM6ERARE: CONSTRUCTION ,����_ � �yEp � ZJ.�KfCN AMf�tICA hl PLAN REVIEW � POLICYlMW�EH W C 2�2.'L��3 O 7 ELEC7RIC Q (I1iS5ECfpNHE�NDT6EWMPLEf�OF7}fPEiMTI5FL7RCNEM1t�DF'IDOOLLARS(StOD)ORLESS} PWMBING W Z 1 CENTIFY THIR W 7NE PERfORA/M10E OF THE WORK FOR WHICH 7NI5 PERMIT IS ISSUED,1 MECHANICAL '�. — CJ SMAL�NOT EMPLOY AM(PEpSON W INY MMNER 50 AS TO BECOME SU&IECT TO THE �, (n WUHNE(i5'COMPENSATION UWS OF GLLIFORNIA,ANO�GREE TNAT IF I SMOULU BECOAIE IN ECTION FEE S SUBJECTTO7HEWORKERS'COIAPEN9ATpNPROYISqNSOFSECTION37000FTNELABOR ISSUAN P:i� S` COOE,I SF7ML FOfTiNWITi COMPLY WITH TFIOSE PROVISIONS. y�—��y�— � 3•r�•9q SMIP Wpp7E; APRIG.4NT. y � L — . � WARNING:FA0.URE TO 5ECURE WOPKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE ENERGY P/C .�\-}�\�'�ti l,°:. �~ — � SUBJECT M1 EMPLOVER TO CRW WAL PENALTIES ANO CIV�L FP/ES UP TO ONE HUNDRED THOUSANO ENERGY PERMIT `�--� �( a — � pp��{$({1Co,0oo�,WADDITIONTOIHECOSTOFCOMPENSATION,DAMAGESASPROVIDmF�i1N ����p �b� J� SECTION970EOFTHElA90RO�DE,iNTEREST,ANDATfOPNEY'SFEES. 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