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��� CITY OF DIAMOND BAR
DEPARTMENT OF COMMUMTY &DEVELOPMENT SERVICES
21825 Copley Drive,Diamond Bar,CA 91765
� (909)839-7020 Fax(909)861-3117 Building Inspection Hotline(909)839-7027 PRESS
���� BUILDING PERMIT APPLICATION F RMLY
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� LICENSED CONTRACTORS DECLARATION � � � �
� I HEREBV AFFlRAA UNOER PENALTY OF PERAIRY THAT I AM UCENSED UNDER PflOVI510N5 OF CHAPTER � .
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� WORKERS'COMPENSATION DECIAAATION � ��� �G
� I HEREBY AFFIRM UNDER PENALTY OF PERriJRY ONE OF THE FOILOWING�ECUi7ATqN5:
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� _I HAVE AND WIIL MAINTAM A CERTIFICATE OF CANSEM TO SELF�INSURE FOR WOiiKERS' _
� COM9ENSATpN,AS PROVIDED BY SECTION 3100 Of TNE 1A80R CODE.FOR 7ME PERFORAUNCE W
OF THE N'ORK FOR WHICH THIS PERMIT IS ISSUED. �
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w __I HAVE/WD WILL MAUfTAM WORKERS'COMPENSATION INSURANCE,AS REOUIRED BV SECTION
Q 370o OF THE LABOR CODE.FOR THE PERFOFMANGE OF THE WORK FOR MMlpi THIS PERMIT IS ' � �]
ISSUm.MV VJO�PENS INSU CE CARRIER AND POLICY NUMBER ARE: I ��II:I-�
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Z I CERTIFY THAT Pl h1E PERFORNANCE Of THE WORK FOR wHICN 7HI5 PERI.�iT IS ISSUED.I ECHANLC � V
• (} $HALL NOT EMPLOV ANY PERSON IN ANY MANNER$O AS TO BECOME�1BJECT TO THE •
Uj WORKERS'COMPENSATION LAWS Or'CALIiOFN1I,AND AOREE TMAT tF I SHOIAD BECOME tNSPECTION FEE
SU&IECT TO THE WOANERS'COMPENSA710N PRONSqNS OF SECTION 7700 OF THE UBOR
s CODE.I SHALL FORTHWITM C0IAPLY WI7H TFIOS VISIONS. SUANCE L
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--� WAfWING:FAI�UR TO SEQIRE WORNERS'COMPENSATION COVERAGE IS UNLAWFUL AND BE
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� DOlURS(f100.000�.W ADDITION TO THE COST OF CAMVENSATION.DNAAGES�5 7ROVIOED FOR IN ERGY PE • �
J SEGTION 37oe OF T11E UBOR COOE IH7ERE57,�NO A770RNEv5 fEES. � ETEr1T1 N F ? �
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d CONSTRUCTION LENDING AGENCY � P EQA,�LT FEjyJC � J�
CC I HEAEBY AFFIRAI UNDER PENALTY OF GERIURV THAT THERE IS A CONSTRUCiION LENDING AOENCY �/-]J/"�/ �,(J�
� f-0R THE PERFOfU1ANCE OF THE WORK FOR WHICFI THIS PERMIT IS ISSUED(SEC.7041.ClV.C.�.
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' � LENDER'S NAME
F- LENDERS�DDR[55 /� �/
� 1 CERTIFY THAT 1 HAVE RE/�A 7HI5 APP�ICATION AND STATE THAT THE ABOVE WFORMATpN IS CARRECT. TOTA L FE ES ��� �� • �� / (• I'
w I AGREE TO CAA/PLV WITH ALL CT'AND COUNTY ORDWANCES ANO STATE LAWS REUTWq TO BUILDING
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CANSTRUCTION.ANO HEREBY AU7HORIZE REPRESENTATNES OF THIS COUNTV TO EHTER UPON THE 1
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