HomeMy WebLinkAbout14702 �rt� CITY OF DIAMOND BAR E��I R�D
DEPART?.RENT OF COMMUNITY&DEVELOPMENT SERVICES
� 21660 E.Copley Drive Suite 190 O C T �,5 ZOO2 �RESS
(909)860-3195 Fax(909)861-3117
�-�A�^�` BUII.DING PERMIT APPLICATION FIRMLY
� JOBSITE ` /� APPLICATION /�� PERMIT / P/C
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� I HEREBY AFFIIUI UNOER PENALTY OF PERIURV THAT I AM LICENSED UNOER PROVISIONS OF CHAPTER � .
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� WORKERS'COMPENSATION DECLARATION �
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� I HEREBY AFFIRM UNDER PENILL.TY OF PERIUIiY ONE OF T1E FOLLOWI ECURA7q
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� _IHAVEANDWILLAWNTAINACERTIFIGITEOFCONSENT70S F•INSUREFO WORKER'
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OF THE WORK FOR NMlpl THIS PERMIT IS ISSUED. �
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W _I HAVE AND VALL MAINTAIN WORKERS'COM7ENSATION INSUHANCE,AS REQUIRED BV SECTION
Q 3700 OF 7NE LABOP CODE,WR 7HE PERFOHMANCE OF TNE WORK FOR WHICH hi15 PERMIT IS
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(f SHALL NOT EMPIOV ANY PERSON IN ANY MMINER SO A TO BECOME SU&IECT TO TH
N WORKERS'COMPENSATION UWS OF CALIFORNIti AND A REE THAT�F I SHOULD BE INSPECTION FEE
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COOE,I SHALL FORTHWIT/COMPLV WITH THOSE PROVISIONS. ISSUANCE n
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� ENERGY P/C
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� SUBJECTANEMPLOVERTOCRIMINALPENALTIESANDCIVILFINESU7TOONEHUNOHEDTHOUSAND ENERGYPERMIT
DOLLARS(5100,000).IN ADDITION TO 7HE COST OF CAMPENSATION,DAMAGES AS PROVIDED FOP IN T�y�y'�7�7
� SEC71ON370BOFTHEUBORCODE.IN7EREST,PNDATfORNEV'SFEES. ' RETENTIONFEE: BUAIr1l11`�
a CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� 1 HEREBV AFFIRM UNDER PENALTY OF PERIURY THAT THERE IS A CANSTRUCTION LENDING AOENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS FERMIT IS ISSUED(SEC.3007,CIV.C.).
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� LENDER'SNAME
F= LENDER'SADDRESS
� 1 CEHTIFY THAT I HAVE READ T1IS APPLICATION AND STATE THATTHE ABOVE INFORMATION IS CORRECT. TOTAL FE ES � �
W I AOREE TO COMPLV N77H ALL CT'AND COUNTY ORDINANCES AND STATE UWS REUTINO TO BUILDING
� CONS7RUCTION,AND HEREBY AUTHORIZE REPRESENTA71VE5 OF THIS COUN7V TO ENTER UPON 7HE -
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