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—1-'"� CITY OF DIAMOND BAR
COMMUNITY DEVELOPMENT DEPARTMfiNT
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(909)860-3195 Fax(909)86t-3117
'""' BUILDING PERMIT APPLICATION FI RM LY
� JOBSITE 6 APPLICATION PERMIT P/C
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2 1 HEREBV AFFlRM UNDER PENpLN OF PERJURY THAi IAM UCENSED UN�EFl PROVISIONS OF CHAPTER � �
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� WORKERS'COMPENSATIONDECLARATION � � J �' ''� � . �� �
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Z 1 CERTIFY TMAT IN THF.PEfiFORMANCE OF THE WOPK FOR WHlpi THIS PERMIT IS ISSUED,I MECHANICAL __ �
(3 SHALL NOT EMPLOYANY PERSON IN ANY MANNER SOAS TO BECOME SUBJECTTO THE
� WORNERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGREE7HATIFISHOULUBF/COME INSPECTIONFEE ____
SU&IECT TO THE WORKERS'COMPENSATION GflOVISIONS OF SECT�N 9700 OF TNE LABOR
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CADE,ISHAIL�FO)RTHW%ITHCOMPLVWI7HTH ROVISIONS.
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W ENERGY P/C
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� SU&lEC7 AN EMPLOVEH TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDREO THOUSAND ENERGY PERMIT
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� SECTION 370d OFTNE LABOR CO�E,INTEREST,AND ATTOHNEYS FEES. RETENTION FEE:
� CONSTRUCTION LENDING AGENCY PRE•ALT FEE:
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� I HEPEBV PFFIRM l/NDER PENALTYOF PERIURY THAT THENE IS ACONSTRUCTION LENDING AGENCY ___ __
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� LENDER'SNAME _ __
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� IAGREETOCOMPLYWITHALLCITYANDCOUNTYORDINANCES/WDSTATELAWSflEIATINGTOBU1L01NG
� CONSTFUC ON,AND HER�`LJ�U7IiORIZE REPRESENTA7IVES OF THIS COUNTV TO ENTEH UPON THE
ABOVE E IONEOPRO �F qINSPECTIONPURPOSES. COMMENTS
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