HomeMy WebLinkAbout18354 CITY OF DIAMOND BAR r '�
•- �''�'`` DEPARTMENT dF COMMUNIT'Y&DEVELOPMENT SERViCES
21825 E.Copley Drive
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.� CENSL LAW(CHAP7Efl 9(COMMENCiNG WITH SECTION 7Wo)OF DIVI540N]OF THE BUSINESS ANp PRO- � �OOIJSPB
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�+K[ �iCENSED CON7RAGT4RS DECLARATION �
CC 1 HEflEBY AFFIRM UND£R PfNALTY OF PEAJUHY THAT 1 AM LlCENSED UNDEA PFOVISIONS OF CHAPTER �
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� i HEREBYAffiRM UNDER P€NAITY Of fERJURY ON[Of TNE FOl.L4WiNG�ECIARATiONS: Z
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(� I HAVE AN�WILL MA.INTAIN ACERTIFICATE OF CONSENTTO SELF�INSURc FOR WORKERS' 2
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W I HAVE AND WILLMAINTAIN W6RKER5'COMPENSP710N INSUFANCE,AS REOUIRED BY SECTION
� 3To0OF THE LABOH CODE,FORTHE PERFORMANCE OFTHE WORK FOR WHICH THIS PEflM1T IS �pj
tSSUED,MY W6RKEFtS'COMPENSATION INSURANCE CARRIFRAN�P(aI�CY NUMBERARE: CONSTRl7CTION ZGJ""�?
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� (iFiI55EGT1C'N4NEELINOTBEOJMREfEDOFhEPERINiISFOHONEHUhOREDDIX,.lARS(5100)tlRLESS). PLUMBING �!
w i CERTtFV THkT IN THE FERF6flMANCE 4F TtiE WORK F6ft WF'IC}f THIS FERMFT is ISSUED,i NiECHANI�A� _
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SHALL NOT EMPL4�ANY PERSON IN.ANv MANNER Sn AS To BECOME SUBJECT TO THE INSPECTION FEE
� WOflKERS'COMPFNSATlC1N LAWS OF CALIfORNIA,ANJ AGREE THAT If i SNOULD 9ECOMG j�- /�-
SU&fECT TO THE WORK£RS COMGENSA7It7N PRLiViS�ONS OF SECTION 31D0 OF TN�tABOR '��
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� SECTIqN 37U9 OFTHELADOR CpDE,INTEREST.ANDATTORNEY'S FEE5. RETENTION FEE: _,.^._„ ��`���
d CONSTRUCTI6N LENDING AGENCY PRE-ALT FEE: _ -..
� i HEREBY AFfIflM 1JkCER PENAITY OF PERJURY TNAT THEFIE LS A CONSTRUCTIONl.END4YG AGENCY �yJIy � /� �/}�
n- FOR TH£GERWRAAANCE OF iHE WORK FOR WHICN THIS PERMiT�S ISSUED iSCC.309],CIY.C.j. ��R� t V V . `[./-,,,7 �4/' ••�ii.�*�
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� i AGREE TO COAIPIV WITH A._IGiTY AND CDUNTV 6ROW ANCES AND STATE tAWS RELAiWO TO BU�LDING , q"��
� CONSTRl1CT10N,ANDHEREI3VAUTHpRRE(iGPRESEN7ATNE50FTHISCOUNTYTOEMERUPONTHE �
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)8b1-3117
BUILDING PERMIT APPLICATION
PRESS
FIRMLY
APPLICATION� �//!� pERMIT� P/C
DATE /(0 NUMBER� #
ISSUE L-} ' TYPE OCC
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ZONING SETBACKS
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UNITS STORIES BEDROOMS
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SFR/ADD/REM
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QUANTITY DESCRIPTION FEE
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COMMENTS
RECPT N0. PAID BY�VALIDATION i
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy