HomeMy WebLinkAbout17603 (42) CITY OF DIAMOND BAR �
^---��`---- DEPARTMENT OF COIvA�UNITY&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117 PRESS
�'%���� BUILDING PERMIT APPLICATION FIRMLY
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w NRE,PRqR TO ITS ISSUANCE,/�LSO REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIONED w Patio/Deck �
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� I HEREBY AFFIRM UNOER PENALTY OF PERJURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER �
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_I HAVE M1D WILL MAIMAIN WORNERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTION
O 37000F THE LABOR CODE.FOR THE PERFORMANCE OF THE WORK FOq WHICH THIS PERMIT IS
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C.�} SHALL NOT EMPLOV ANV PERSON IN ANV MANNER 50 AS TO BECAME Sll&IECT TO THE
(n WORICERS'COMPENSATION LAWS OF CALIFORNIq AND AOREE THAT IF I SHOULD BECOME INSPECTION FEE
S SU&IECT TO THE WORICERS'CAMPENSATION PROVISqNS OF SECTION 37000F THE IABOR
CODE,I SHALL FORTHWITH COMPLV WITH THOSE PROVISIONS. ISSUANCE
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� SU6IECTMlEMPLOVEFTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT
DOlLARS(5100.oao�.IN ADDITION TO THE C0.5T OF COMPENSATqN,DNAAGES AS PROVIDED FOR IN
J SECTION37080FTHELABORCODE,INTEREST,ANDATTORNEV'SFEES.
OC RETENTION FEE:
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBV AFFIqM UNDER PENALTY OF PERIURV THATTHERE IS A CANSTRUCTION LENDING AGENCV
� FOq THE PERFORMANCE OF THE WORK FOq WHICH THIS PERMIT IS ISSUED(SEC.30G7,CIV.CJ.
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� LENDER'S NAME
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w I CERTIFV THAT I HAVE READ THIS APPLICATION AND STATE TIiAT THE ABOVE INFORMATION IS CORRECT. TOTAL F E ES ���, �
� I AGREE TO COMPLV WITH ALL CITY AND COUNTV ORDINNICES AND STATE LAWS REUTINO TO BUILDINQ �
� CANSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF THIS CWNTY TO ENTER UPON THE
Z ABOVE-MENTIONED PROPERTV FOR INSPECTION PURPOSES. COMMENTS
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WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENRO�File Copy,GREEN—Applicant's Copy
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