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CITY OF DIAMOND BAR
-- --���-- DEPARTMENT OF COMMUNITY&DEVELOPIvIENT SERVICES
21825 E.Copley Drive
- (909)860-3195 Fax(909)861-3117 PRESS
�%�M� BUILDING PERNaT APPLICATION FIRMLY
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W NRE,PRIOR TO ITS ISSUANCE,ALSO FEQUIHES THE APPLICANT FOR SUCH PERMIT TO FILE A SIONED �w Patlo/Deck
� STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CANTRACTORS LI�
� CENSE LAW(CHAPTER G(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO• � PooUSpa
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Z WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.70a�,BU51� J �
� NESS AND PqOFESSIONS CODE:THE CONTRACTORS UCENSE LAW DOES NOT APPLV TO AN OWNER OF �
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OF THE WORN FOR WFIICH THIS PERMIT IS ISSUED. W
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w I HAVE AND WILL MAIM�IN WORI(ERS'COMPENSATION INSURANCE,AS RE�UIRED BV SECTION
Q 3700 OF THE LABOR CODE,FOR 7HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMR IS ""�
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Z I CERTIFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PEFMIT IS ISSUED,I MECHANICAL
CJ SHALL NOT EMPLOV ANV PERSON IN ANV M/WNER SO AS TO BECOME SU&IECT TO THE �
(n WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME INSPECTION FEE
SU&IECT TO THE WORKERS'COMPENSATI OVISIONS OF SECTqN 3700 OF THE UBOR
S COOE,I S-C'r�WITH COMPLV WI MO E P IS 5. ISSUANCE
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p DATE: �� V APPLICANT: • SMIP
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� SU&IECTAN EMPLOVERTO CRIMINAL PENALTIES AND CML FINE UP TO HUNoaEo n�ousnwo � ENERGY PERMIT
DOLURS(f 100.000).W ADDIiION TO THE COST OF COMPENSAT AA/A ES AS PROVIDED FOR IN
� SECTqN 3708 OF THE LABOR CODE,INTEREST,ANDATfORNE1"S FEES. RETENTION FEE:
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBV AFFlRM UNOER PENALTV OF PERIURV THAT THERE IS A CONSTRUCTION LENOIN(3 AGENCV '
� FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3087,CIV.C.).
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� LENDEF'S NAME
F- LENDER'SADDRESS
w I CERTIFY THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORAIATION IS C-0RRECT. TOTAL FE ES �
� 1 AGREE TO CqMPLV N7TH ALL CITV AND COUNTV ORDINANCES AND STATE LAWS REUTINO TO BUILDING � ' ��'
� CONSTRUCTION,AND HEREBV AUTFIORIZE REPRESENTATIVES OF THIS CAUNTV TO ENTER UPON THE /• .�� »�
Z ABOVE-MENTIONED PROPERTV FOR INS7ECTION PUFPOSES. '1 ��
� COMMENTS��
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RE OF PERMITTEE DATE
� RECPT.NO. PAID BY � VALIDATION
WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Cqpy,�LDENROD—File Copy,GREEN—Applicant's Copy
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