HomeMy WebLinkAbout13-263 �� _ CITY OF DIAMOND BAR �" �
• � DEPARTMENT OF CONIII4UNITY&DEVELOPMENT SERVICES
. 21810 Copley Drive,Diamond Bar,CA 91765
� (909)839-7020 Fax(909)861-3117 Building Inspection Hotline(909)839-7027 PRESS
, ,'°^'� BUa.DING PERMIT APPLICATION FIRMLY I
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STA7EAIEHT THAT HE OR SHE LS UCEtISED PU0.5UANT 70 THE PROY45ION5 OF THE CANiMCTOILS l!-
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� FESSIONS CAOE�Oq THA7 HE Ofl SHE IS F7(FAIPTTHEREFROM ANO 7HE B/�515 FOH THE ALLEGED EXEMP- (� �
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� _INAVEANOWILLAWHTIVNACFATFlCATEOFCANSENTTOSELHNAIHEFOHWORKEAS =
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��W _I MAYE ANO Y/ILL MNPRAW WORKERS'COMPENSATION INSURANCE,AS REOUIHED BY SECTION
Q`"� ]7ao OF THE UBOH COOE.FOH THE PERFOfiM/WCE OF THE WOW(FOH WMO/THIS PERA/IT IS
ISSUED.A/Y WORNEAS COMPETlSATION IHSURANCE GRA�ER AND POIIC/NUMBER ARE CONSTRUCTION
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� CARRIEA PLAN REVIEW �
� 70lICY NUMBER ELECTRIC �
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z I CER7IFY iHAT IN THE PERFOfU1MlCE OF THE WORK FOR VA11Ui THIS PERMfT IS LSSUEU.1 MECHANICAL
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J WARNIN6:FA011RE TO SEGLHE WOHICFAS COMPENSATIOH CAVEMGE IS UNUWFUL AND SHILL BE �ERGY P/C
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� I HEREBY AFFlFM UNOER PENPLTY Of PE0.NiiY THAT 7NERE LS A CAKSTRUC�ON LENO WG AGFNCY �
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¢ 1 CERTIFY 7HAT I/UVE REJ�THIS A➢PLICATION ANO STATE TUT THE I�HOVE INFQAMATION IS CARRECi. TOTAL F E E S � �• �
w I AGREE TO CAMPIY N77H ALL tlTV ANO COUNiY ORD WANCES ANO STATE UWS FE7.ATWG TO BUILDING
� CONSTRUCTION,AND HEHFBYAUh10fiIZE REPRESENTATIYES Oi 7HI5 COUNTY TO EMEA UPON TNE
� ABOVE-MEMIONED VROPERTY FOR INSPECTION PURPOSES. �
Z COMMENTS
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