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1 �TY OF DIAMOND BAR
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DEPARTMENT OF COMMUNITY&DEVE�OPMENT SERVICES
21660 E.Copiey Drive Suite 190
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DATE OWNER
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LICENSED CONTRACTORS DEC�,4RATION w
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I HEREBY AFFIRM UNDER PENA�TY OF PER]URY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
0(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND Z
MY�ICENSE IS IN FUL�FORCE AND EFFECT
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LICENSE CLASS(�
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WORKERS'COMPENSATION DECLARATION Q
I HEREBY AFFIRM UNDER PENA�TY OF PER7URY ONE OF THE FO�LOWING DECLARA,TIONS: Z
I HAVE AND WIL�MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS' S
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE�ABOR CODE, FOR THE PERFORMANCE U
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. LU
I HAVE AND WIL�MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE IABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
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ISSUED
CONSTRUCTION
MY WORN ERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
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CARRIER UI/U00 �w'�-/
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PO�ICY NUMBER ZOU,)7'i.) L 4
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E�ECTRIC}�'V�rII-_7-
(THIS SECTrDNNEE)NOT BE�ONIP�ETEDOF THE PERMIT IS FOR ONE HUNDRED DOL.LARS($100}OR LESS).
P�UMBING•L
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
MECHANICAL
SHAL�NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
INSPECTION FEE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE'NORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE,I SHAL�FORTHWITH COMPLY WITH THOSE PROVISIONS. ISSUANCE
DATE:APPLICANT: SMIP
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WARNING: FAILURE TO SE-URE WORKERS'COMPENSATION COVERAGE IS UN�AWFU�,AND SHAL�BE
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SUBJECT AN EMPLOYER TO CRIMINA�PENA�TIES AND CIVIL FINES UP TOONE HUNDRED THOUSAND
ENERGY P/C_y
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DOLLARS($100,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
ENERGY PERMIT�/
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SECTION 3708 OF THE LAEOR CODE,INTEREST,AND AITORNEY
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S FEES. RETENTION FEE:V. .-i c•'6T
CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
I HEREBY AFFIRM UNDER PENA�TY OF PERJURY THAT THERE ISA CONSTRUCTION �ENDING AGENCY
FOR THE PERFORMANCE OF THE W
RK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV. C.}.
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LENDER'S NAME c�9
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LENDER'SADDRESS �1 U�///Yi C''Q/Vt/'I'/�'/V f•97&-66'
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
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I AGREE TO COMPLY WITH A��CITY AND COUNTY ORDINANCES AND STATE�AWS RE�ATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. COMMENTS
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PERMIITEE NAME(PRINT)
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SIGNATURE OF PERMII�'E DATE 7 7
RECPT-NO.
PAID BY VA�IDATION
WHITE-Department Copy,YE�LOW-Finance Copy, PINK-Assessor Copy,GO�DENROD-File Copy,GREEN-Applicant's Copy
CITY OF DIAMOND BAR
INSPECTION RECORD
INSPECTiC}N
DATI= INSPECTt�R'
INSPECTICIN
IIdSPECTpR
PROJECT TRACKING&TIME SHEET
Project No. Pian Ck. No.
Address Heurs Date
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