HomeMy WebLinkAbout12-1424 �,`__ CITY OF DIAMOND BAR �
� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21810 Copley Drive,Diamond Bar,CA 91765
(909)839-7020 Fax(909)861-3117 Buiiding Inspection Notline(909)839-7027 PRESS
'�^'. BULLDING PERMIT APPLICATION FORMLY
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w ,� 1 HAVE AND NALL MAVfTAIN WORNERS'COMPENSATION INSUMNCE,AS REOUIHEO BY SECTION
� 770o OF THE LABOR CADE,FOR THE PERFOHIAANCE OF THE WORN FOR WHICH THIS PERMI715 , 'Q
ISSUED.MY WORKEAS'OOMGENSATION INSURANCE CARRIER AND POIICY NUMBER ARE: CONSTRUCTION /� `�S��
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Z I CERTIFY THAT IN THE PERFOflMANCE OF THE WOHI(FOR WHIG}f TH�S 7ERMIT IS ISSUED,I
(} SHALL NOT EMVLOY ANY PERSON W ANV MAtJNER 50 AS TO BECAME SU&IECT TO THE
� WOHNERS'COMPENSATION LAWS OF CnLIFORNI0.AND AGREE THAT IF I SHOULO BECAME INSPECTION FEE -
? SU&IECT TO THE WOFiKEFS'COM7ENSATION PROVISIONS OF SE �37a00F THE LABOR
CO�E,I SHALL FORTHWITH COMPLV WI7H THOSE PROVISIONS. ISSUANCE
p DATE:��I�IZ APPLICANT: �— �SMIP D
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� SUBIECT AN EMPLOYER 70 CRIMINAL PENALTIES D CIVIL FlNES OONE HUNDRED 7HOUSANU ENER('iY PERMIT
DOLURS(f10o,000),IN ADDI710N TO THE COST OF COMFENSA710N,DNAAGES AS PROVIDED fOR IN
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w I CERTIFY THAT I HAVE READ THIS A7PUCATION AND S7A7E THAT TiE ABOVE INFORMATION IS COHRECT. TOTAL F E ES ��� �� ���'�
� 1 AGREE TO C6MRY WITH ALl CITV AND CWNTY ORDINANCES AND STATE UWS RELATING TO BUILDING
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ZABOVE-MENTIDNED PROPERTY FOR INSPECTION 7UAVOSES. ' COMMENTS
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WHITE--Department Copy,YELLOW--Finance Copy,PINK—Assessor Copy,GOLDENRO ile Copy;GREEN--AppllcanYs Copy
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