HomeMy WebLinkAbout13-623� - -- - -- - - - -
�� CTI'Y OF DIAMOND BAR
� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �
21810 Copley.Drive,Diamond Bar,CA 91765
� (909)839-7020 Fax(909)861-3117 Building Inspection Hotline(909)839-702 �� �RESS
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I HEREBYAFFIRM UNDER PENAl7Y OF PERIUM THAT IAIA IICENSED UNDER PROVISIONS Of CHAVTER �
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� _I HAVE ANO WILL MAINTAIN A CERTIFICATE OF CONSEIff TO SELFINSURE FOR WORKER$' _
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Z I CERTIFY THAT IN iHE PERFOFMANCE OF THE WORN FOR WHICH THIS PEiU/1T IS ISSUEO,1 MECHANICAL
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N WORKERS'COMPENSATION UN5 OF CAIIFOfiNI�AND AGREE THAT IF I SFIOUID BECOME INSPECTION FEE �
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� LENDERS NAME . . .
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¢ 'I LERTIFV THAT I HAVE RFJ�D THIS APPl1CATpN AND STATE 7HAT h1E ABOVE PIFOfWATION IS OORqECT. TOTAL FEES � ��Q
w 1 AOREE TO COMPLY N7TH ALL CRY AND COUNfY ORDINANCES AND STATE UN5 qELATINO TO BUq.DINO
� CONSTf7UCTION,AND HEREBY AUTHORIZE REPRESENTATNES OF iH15 COUHTy TO ENTER UPON 7HE
Z A00VE-MEMIONED VROFEiiTY FOR INSPECTION OURVOSES. .
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