HomeMy WebLinkAbout18-10646• CITT OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21810 Copley Drive, Diamond Bar, CA 91765 PRESS
(909) 839-7020 Fa:: (909) 861-3U7 Badding In3peetion Hotline (909) 839.7027 FIRMLY
WELDING PERMIT APPLICATION wwweltyoldiamondbareom boddmg@dumoodbarea.gov
JOSSITEADDRESS 21645 $rA4 TO-'tkerl-, Ni'Bwanw rL,Bnr
APN LOT TRACT
OWRNER
ADDRESS
CrrY LP TEL
APPLICANT TEL
CONTRACTOR
ADDRESS
CITY ZIP TEL
ARCH/ENG/
DESIGNER
ADDRESS
CrrY ZIP TEL
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MOM CONfMCTOR'S DECLARATION
I hereby affirm under paraW of PoW qN Ion tiwlmE Leader ;vAslons of Omar 0 Omen" wed Bmaw 70M
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LICENSE CLASS LIC NO_
DATE Ed'_ CONTRACTOR
WORKER'S COMPS nON DECLARATION
I NFREBY AFFIRM UNDER PENALTY' OF PERM ONE OFTNE FOLLOWING Dm '110115.
_ I Nit pad WN melmW a Certificate of Cana b Sek-0mn for Workers Compensation, a pmNded by
Semen 3/00 of the Labor Code. for the "r,now of In, work braNw Ole permit be bored
_ Inow W we nslnbm WmWsCuemammn Insurance, a reaWred by Enloe 3700 of the Labor Cookbr
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CAFORS
POLICY NUMBER
MIS SEIDON NEED NOTBE WfRLDTD FTIE PHROTS FOR ONE KUMOOUM ORLEM
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mmammn pmwffip m Seam 3700 m qe labor Code, I eM bmamh mnbb war d®poriwlpn
DATE APPIIANY
WAnala Failure um m cWmtrfa mmpmws.w corm W Is unlawful, ad es1 wblw a anpbya b cran rW
wmnn and dA bur rib to on bp0ed Reamed mare MOO.0001 In ammn b the cow of the mmpamlYsa
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CONSTIWC LMMAMM
I boreby affirm under penalty of whey Vet Into, be a Cm rUtx*n Lers.rq Agar M the parbrmanca of the wmrt for
wNrA qg P.Wt1, issued pet 3097, Ch, W
LENDERS WALE.
LENDER'S ADDREBS
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munb ormnmpn and OW mane mbar b buNRnp m WjLmft , and hamw autladw npmenmem of qm county b
enter upon qe aborw vIloned property for hwpemon purwo.
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PERMM NAME IPW
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APPLICATION DATE
ISSUE DATE �EAMITa
TYPE CONST.
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RETENTION FEE
PRE-ALT FEE
BASF
PLOT PLAN
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TOTAL FEES
COMMENTS
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Pro PAID BY
RECBPTI PAID BY
VALIDATION
VAUDATON
W'11rTE—DepnmmYtCopy, YELLOW —Finance Copy, PWK—Ameanur Copy