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HomeMy WebLinkAbout13658 (16) --,�y ��, _u �. � CITY OF DIAMOND BAI� ' � ��--��'- DEPARTMENT OF COMMUNITY&DE`VEI.OPMENT SERVICES � 1/ .; 21660 E.Copley Drive Smte 190. , ;.; PR�$s � (909)8G0-3195 Fax(909)8613117 '�° BUII.DING PER1MfIT AP]PI.ICATION FIRMLrI( � ,,. � JOBSITE � � p pPPLICATION �j `7 ERMIT �j �P/ o ADDRESS v���� Hs"G�1/3��'�.�� DATE �-^' UMBE�✓ � �`-'# � � � c� ISSUE • . PE^�� OCC APN " , LOT TRACT DATE CONST. GROUP p OWNE�C 2.. � ��� �&'ie' S�r'� � ADDRESS C`s' �' t-oG2t"'S ZONING SETBACKS �w CIIY � �.�c ZIP y,�]�S 7EL. ��I .3 REART ' RW O APPLICANI"�-e�de.t E�c��:> .::c :s� TE�. ' -�' �_ SIDEJSIQESTREET RW ❑ � CCINTRACTOR�!'<��efe_E�rr�.':�.2�(`�:t>�:+1k�e( �•weEa�y�wn�t��"- SIDE O �:•.. AGDRESS 'l �'— PROPOSED USE �« �? �'�-- G»'#°z� `'' :d�sb '��r> � r � CI�fY F' - ZIP �il?�L? .�.�`.�-��`i$„�_ �' a.:s ! a_ 3,+y.F-t� .. w� ARCH/ENG! � DESIGNER � d �k'� �- NO.DWEL. NO. NO. 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DATE S�""Z�"( �--�Ld CONTRACTOR CC �t' ' - � � 4� � -� W�r�d$�<r��.:t=tc,�ar^Arr� ��",Vc + � WORKERS'COMPENSATION DECIARATION y —� . � _. � I HEREBYAFFIRM UNOER PENAL7Y OF PE0.IURV ONE OF THE FOLLOWING DECLARATICNS: �� U � Z Q � ,tHAVEANDWILIMAINTPINACERTIFICATEOFCONSENTTOSELFdNSL1REFOPVJORKERS' _ CUMPENSATIqN,ASPROVIDEDBYS[CYION3lo00FTHELA.eOftCODE,FORYHEPERFORMANCE C.) Q OF THE WOFK FOR WHICN THIS PERA/IT IS ISSUED. � W _,,.�1 HAVF_M/D WILL MAIN7AIN WOAKER5 COMPENS0.TION INSU4iANCE.AS REQUIRED BY SECTION ."� /"\ 4�/p Q37000F7HELABORCODE,FORTHEPERFORMANCEOFTHEWORHFORWHICHTHW'PERMIT!S C,✓ C.� � ISSUEO.MYWORi(ERS'CAMPENSATIONINSURANCECARRIERANDPOLICYNUMBFR.4�9E: CONSTRUCTION - j C�RRIER �~��'a''��t'-- r��'' � PLAN REVIEW ' �+ ��" � POI.ICYNUMBER ��- -.�l� � ` �l� '' ELECTRIC �c� 2"� ^ • o � � (iHISSECiKNJNE�NOTBE�LEfFDOFh�PEFiMf1'ISiOt70NEERNJDAEDGa.�A11S(5100}ORLE . PLUMHING �r�L ��_.�__ llJ � I CERTIFVTW.T INTHE FERFORMANCEOFTHE WORK FOR WHICH THIS FlA�IT IS ISSUED,1 MECHANICAL �. SHALL NOT F.MPl,OY AIVY PERSON IN ANY MANNER AS TO B�CAM� ll.'EC7 T4 THE � WORKERS'C[kAPENSATiCNlAWSOFCALIFORNI , AGR THkYIF NOULDk7ECOME INSPECTIONFEE � SUBJECTTOTHEWORKERS'COMPLNSATIONP OV NS� F�G�TIO 37000FTHELA80R cooE.is�winicoMv�rw,n+r sE —vi � ISSUANCE p OATE:'7� z c APPLICANT. ______ SMIP � � � ENEFIGY P/C � WARNINGFAILURETOSECUqEWORKcRS'COMPENSATIONCAVERAGE�SUNLAWNL,AI�SHALLBE — — � SUBJECTANEMPLOYER70CRIM!NALPENALTIESANDCIVILFINESUPTOONENUN�REOTHOUSANO ENERGY.,PE.H�dLt — DOLLARS(5700.000).IN ADOITION TO THE COST OF COMPEN3ATION,DAMAGES AS PIiOYI�ED FOR IN J SECTION37080FTHELABORCODE,INTEREST,AN�ATTORNEYSFEE5. R�€,NTIONFEE: � oCONSTRUCTION LENDING AGENCY P'�R'F!�ALT F � � INEREBYAFFIRMUNDERPENALTYOFPERJURVTHATTHEREISACONSTRUCTIONLENDINGAGENCY y , � a- FOR THE PERFORMPNCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC 3081,qV.C.). � W �..r � LENOER'S NAME _ F— LENDEH'SADOFlE55_ � ICEaTIFYTHATlHAVEREADTHISAPPLICA710NANDSTATETHATTHEABOVEINfORMATIONISCORRECT. 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