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HomeMy WebLinkAbout12642 (13) 1� CITY OF DIAMOND BAI+t � DEPARTMENT OF COMMUNITY&DEVEL4PMENT SERVICES �/' �� 21660 E.Coplcy Drive 5uite 190 L (909)860-3195 Fsx(9(19)861-3117 1 PRESS �"w' BUII,DING PERMIT APPLICATION FIRMLY o QDR'ESS /�4 I I']�F.�-Y ��1�---�� OATECATION� ' 13� NUMBE � P/C � ISSUE TYPE QCC APN LOT TRACT DATE CONST. GRiOUP p QWNER 1 o AODRESS (_,. ZONING SETSACK�u �W CITY � ZIP L.��I�e��� REAHT RW ❑ APPLlCANT TEL. 3�6,,Qg S SIDFJSIDE STREET RW ❑ a� CONTRACTOR M � Pt— SIDE ❑ � ADDRESS CITY ZIP TEL. PROPOSED USE � ARCFUENG/ DESIGNER NO.DWEL. NO. NO. 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Z LLJ m � UCENSECUSS LIC.NO. � V D11TE CONT0.4CTOR ¢ W � � WORKERS'COMPENSATION DECLARATION � � � IHERFBVAFiIRMUM�FRPEN/�17YOFPERIIIRYONEOFTiEFOUAWINQOECLAMTIONS: � � 0 _IHAVEAHOri7LLMJMTAINACERTIfiCA7EOFCON^uENTTOSELF-INSUAEFORWORKEqS' � COMPENBATION.AS�FW`ADE�8Y SECTION 3700 OF THE UBOP CODE,FOfl THE PERFORMANCE OF THE WOAK FOR WHIGH THIS PERUR IS ISSUED. W � �_IH�VEANDYALLMAMTAINWOFKERS'COMPENSIITIONINSURANCE,RSREWIREDBVSECTION Q �7000FTHEUPOFCODE,FORTNEPERWRMAHCEOFT}iEWORKFORWHICHTHISPERM1T15 Q ISSUED.MY WORKEFS'COMPENSATION INSURANCE CARRIERAND POLICY NUMBERARE: CONSTRUCTION � CMRIER PLAN REVIEW � va�crranaeen ELECTRIC � �nass�crnN�rqr2�mr.s�rmoFnfre�rrarsfoRa�MrioaEoOai.ws[stooloq�, IUMBI t � I CERTIFY T}UT M7HE PEflFORMANCE OF THE WORK FOfl WHiql THIS PERMIT IS ISSVED.� HANICAL � ('3 SHALL NOT EMPIOY MIY PERSON�N ANY MIINNEN 50 AS TO BECOME SU&1ECT TO THE � WpRNERS'COMPENSATION LAWSOF CALIFORNIA,AND AGREE THAT IF i 5Fi0ULD BECOME INSPECTION FEE S SUBJECTTO THE NK»RI(ERS'CWPENS�TION VFOVISIONS pF SECTION 3]O�Of THE LA60P CODE.ISHALLFORTH'MTHCWPLYWITHTHOSEPROVISIONS. ISSUANCE L r a 0 SMIP p DATE: APPLICANT. W ENERGY P/C J W�RNINO:FMLURENSEWREWORKERS'COIAPEN3ATIONfAVERAGEISVNLAWFUL,ANObHMLBE � SUB,IECTANEMPLOYEHTOCHIMMhLPENKTIESM'DCNILFMESUPTOONEHUNDFEUTFKK!$ANO ENERGYPERMIT 19gg DOU.AAS(flao.o00).W ADDIT70N TO THE COST OF COMFENSATION,DAMAGES AS PROVIDED FOR IN � SECTI�N 370BOF THE LABOR CWE,INTEREST.MIDATTORNEY'S FEES. 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