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DEPARTMENT OF COMML]NIT'Y&bEVELOPIv�NT SERVICES � I ti�j
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(909)8603195 Fax(909)861-3117 PRESS
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w STATEMENT THRT HE OR SHE I:i LICENSED PURSUANT TO THE VROVISIOM1S OF THE CONTRACTOftS LI�
� CENSE LAW(CMAPTER 9(COMhIENGING W�TM SEGTION�000)OF DNISION 3 OF THE BUSINESS AN�PRO- LL POOVSPB
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� 1 HEREBY AFFIRM UNDER PENALTV OF PERIURY THAT IAM LICENSED UN�ER PROVISIONS OFCHAPTER �
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w I HAVE AND WILL MAIN'"AIN WORKERS'COMPENSATION INSURANGE,FS RF_QUIRED BY SECTION
Q 970o OF THE LABOR C()DE,FOR THE P'eRFORMANCE OF THC WORK FOR WHIGH THIS PERMII 15 A `.,
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Z I CE�TIFv THAT IN TNE PERFORMANCE OFTHE WORN FOR WHICH THIS PERMIT IS ISSUED,I —
Lj' SHALL NOT EMPLOV AIJV PERSON IN ANY MANNER SOAS TO BECOME SIIBJECT'O THE
� WORHERS'COMPENSNTION IAWS Of CALIFORNIA,AND AGREE TMAT IF I SHOU'�D 6ECOME INS'ECTION FEE _ _� �
SUBJECT TO THE WOP.KERS'COMaENSATION PROVISIONS OF SECTION J]OOOF THE lABOl7
� CODE,I SHALL FORTM'NITH GOMFIY WITH THOSE PROVISIONS. �� ISSUANCE _ _
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� 1 MEREBV AFFIRM UNDER PENALTV OF PEiJURV THATTHERE IS ACONSTC,UCTION LENDING AGENf.V
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� I CERTIFY THAT I 11AVE READ 1'HIS APPLICATIONAND STATE THAT THE ABOVE WFORMATION IS COPRECT TOTAL FEES i �...�'�� ���
w I AGREE TO CAMPLY WITH ALI.CITYAND COUNTV OFiDINANCES AND STATE L4WS NELATING TO 9UILDING �
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CITY OF DIAMOND BAR
DEPARTME';�iT OF COMMUNITY&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
PRESS
FIRMLY
APPLICATION
PERMIT r�/C
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DATE
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