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HomeMy WebLinkAbout12339 (11) �� CITY OF DIAMOND BAA _ - DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � � „ 21660 E.Copley Drive Suite 190 �� . (909)860-3195 Fax(909)861-311'! �� PRESS �"eN"�� BUII,DING PERMIT APPLICATION. FIRMLY . : .:.:. .... : : , ,. o� JOBSITE � � �''� �� " APPLICATION� C^ (�PERMIT /� a�y P/C ADDRESS--��-�-� - DATE �U__�.'- � J NUMBER �'G�� � #_ r ISSUE � APN__ LOT TRACT� i a ,.:�'' � TMPE OCC � _�- DATE__��_�CONST. GROUP p OWNER �,J -f3-'�-1.,s:a ' f-y� o ADDRESS L�• ��[6�d ZONING SETBACKS FRONT _ Z CIT`! `' ' ZIP TEL.�=i�`f(�'�,Z_ REAR RW L_ SAPPLICAf�T __ TEL.__ ��- SIDFJSIDE STREET RW f-:: � CONTRACTOR _ _ SIDE _ �- ADDRESS o CI``! ZIP_ TEL. PROPOSED USE t � �'" Q ARCH/ENG/ z DESIGNER ua NO.DWEL. NO. NO. � ADDRESS u� UNITS_ STORIES BEDROOMS � ClTY ZIP TEL._ cn DESCAIPTIOR SQ.FT. 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""_"'.___.___'_'._— Ia — tLl � 4NORKERS'CPMPENSATIGN DECLARATION a � IHEREBYAFFIRMUNDERPF.NALTYOFDERJUP.YONEOFTHEFO.;OW7JGOFfIARATIONS: z} '1 IHAVEANDWILLMAINTAINACERT:FICATEOFCONSENTTOSc'tF-�NSURF.F(;HWOflNERS' _ % � COMPENSA710N,ASPROVIDEDBYSEC?ION37ooOFTViELAf30RCCDE,FORTNF'EPFOFlMANCF I�G —_._T_ _J Q OF THE WOFK FOR WHICH THIS PERMI'IS ISSl1E� � i � � I NA4E AND YdILL MAINTAIM WORKERS'COMPENSA'IDY!NSURANCE,AS REOL!IFED B"SEGTAN � Q 37000FiHELA90RCODE,FORTHEPEAFORMANCEOFTNEWORKFORWH:CHTHISPERMlTiS . ISSUED.MY WORKF.R�CAMPFNSA710N INSURANCE CARRIEfl.1ND PCI.ICV NUMOER ARE CONSTRUCTIO�V � '_--_' ' _—__ j caaRien _ PLAN REVIEVJ .� , j O PeLIcvNUMBER_____ ___-_"""'__._—_—___"'"— ELECTFIC .._____.__. _ _ �1 3 t : a __—_---'—"_'_ ' _._— '_ � �iri:5secr�wN�noreecor�t�r:oaFn-�r�w�nr�s�ot�auGr+���waE000c:�xsis�aa��oa��s). PLUMBING ---- — -- ,,� Z I CERTIFV THAT IN THE PFPFORMANCE OF T6�'E MlORK FOR WH;CeV THIS PERMIT IS�SSt:ff1,I PAECHA�ICAL �� � SNALL NOT EMPLOV ANY PF.RSON IM1 ANV MANNc9 SO AS'O BECOMF SUBJCC'Tb TI IE ,3 �} WORKEi1c•�pMPENSRTIONLAWSOFCALIFORNIA,FNDA(;REETHATIF;SHOULDP.fCOA!E IfJSPEC-CIONFEE ___ - SU�JECT TO TF?E YlORKERS'COMPENS,4TION PROV!SIONS OF SEC710:J 3�00 OF TI�IE:J�BOR � CODF,I SISALL'rO�HWITH COMPLY WITH THOSE PRC`/ISIONS. ISSUANCE _ _ � p DATE: __ APPLICANT: __.___""'__"____' SMIP _____ r. J WARNING.FAILUSYE TO SECURE WORXERS'GOMPENSATION f.OVERAGF�S UNLAWFUi,AND SNRLL BE NERGI'P/C _________________ __ � SU&IEGTANEMPLOYEftTOCRIMINALPENALTIESANOCIVILFlNESUPTOONEHUNDREOTHCl1�AN0 �oy'��'GY?F_RMIT �OLURS(5700,000�,I�AODITION'D THE COSTOF COMPCNSAT;OP:,DAfdAGF_S AS PROVIDF.D FOR IN � SECTIDN37DBOFTHLLABORCCDE.IN?EREST.ANDATTORNEY'SFEES. 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