HomeMy WebLinkAbout17754 CITY OF DiAMONi3 BAR �
i�� DEPARTMENT QF CUMA�f[JNITY&.DEVELOPMENT SERVICES
� 21825 E.Copley Drive
(909)860-3195 Fax(909)861•3119 PRESS
��"�4�y $UILDING PERMIT APPLICATION
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LY I HEREBY AFFIRM UrvDER f'ENA4TY OF PERJURV THAT I AM LICEN5E0 UNDER PqOVISIONS OF CHAPTER � �\
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� I NEREBV AFFIRM UNDEft PEIJALTY pF PERJURY ONE OF THE FOLLOWlNG DEGtARATIONS Z 3 Z""�i �M F.
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� oF THE WOFK FQR WHICH THIS PERMIT IS iSSUED. � �
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W .__t HAVE AN6 WILLMh�NTAiN WORKERS'CAMPENSA710N INSURANGE.AS REOUIREO BY SECTiON �
� 3]Od OF THE LA9qR CODE,FOR THE pERFOFMANGE�f 7HE WORK FOR WHICH THIS PEfIM1T IS
iSSUEQ.MK W4RlCF;RS'GOMPENSATION 7NSURANCE'LARftiER ANQ POIICY NUMBEH ARE�. CONSTRUCTION
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Z I CEflTEFY THAT IN THE PERFOHMANGE OF iHE W6RK FOR WNICH TNiS?ERMR i5IS5UE0,i ._ ,,, ,,,.___` A L� . ,
(,�J SMA4L NOT EMPI.01'ANY PERSON IN ANV MANNER SO A$TO BECOME SUBJEf.T TO THE �
� WO(iKERS'GOMPENSATION LAWS OF CALIFORNtA.ANDAG0.EE THAT If I SNOULD OGCOME �NSPECTION FEE .
= SVBJECTSO TME WORKERS'GOMPENS0.TiON PROViSKINS OF SEC7IQN 37660F THE lA6(7P
CODE.I SHALL FORTHWITH CpMPLV WITH TFIOSE PROVI&IONS. �SSUANCE �� ! �
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J WARNING.FRIIURE TO SECURE W{7RKEA$'COMPENSATIQPI CDVERAGF IS UNtAWFUI,AND SHAtlBE ENERGY PIC „_
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pW.. GONSTRUGTION IEND�NG AGENCY PAE-A�7 FEE:
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� I HEREBY AFFIRM UNDER PENAITY OF PERJURY THAT THFRE IS A CONSTPUCTfON LENOI4G AGENCY �`
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� !CERTIFY iHAT I NAVE REAC�THISAPRLICATION AND STATE TH4T THF ABOVE INFORMATION IS COftRECT. TO�AL I�E GS r��,����
� i AGREE TO C6M%.Y WITN AI_lCtTY AND CAUNTY OR6ENANCES AND STATE tAWS PEtATMG TO BVIIDINp
� CON5TRUCTION,ANDHEREI3VAUThORIZERFPRESENTATNESOFTHISCOUN7VTOENTEflUPONTHE
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
WHITE-Department Copy. YELL9W-Finance Copy, PIN
PRESS
FIRMLY