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�� CITY OF DIAMONU BAR �- �
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
° 21660 E.Copley Drive Suite 190
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���A�'� BUILDING PERMIT APPLICATION FIRMLY
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a� ADDRESS DATE NUMBER �-� #
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oOWNER-BUILDER DECIARATION SFWADDlREM
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Cl I,AS OV.7JEROF THE PROPERTY,AM EXCLU514ELY CONTflACTMC.Wi7H LICENSED CONTRACTOflS
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� LiCENSED CONTRACTORS DECLARATION �j
� IHEREBYAFFIFGIUNDEflPEN1LLTYQFPERJURYTNATIAMLICENSEDUNDtRPRUVI5lON50FCIi�PiER �
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Z I CEHTIFVTHAT INTHE PEflFOFMANLE Of TNE WOflK FOfl WHICHTHiS PEfiM17'IS ISSUED,I MEGHANICAL :.i F'l1 iI ..�,.'S�i ._.,___ —___._—.___._
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� WORKERS'COMPENSATION LRWS OF CALIFOflNIA,AND AGREE THPT IF 1 SHOULD BECOMF: INSPEC iIUN FEE .� � .,.__.._.—__ __
SUBJECTTO TNE WORKERS'COMVF.NSATION PHOVISIONS OF SECTION 3]0o OF THG l.AUOl1 � ' ��wp�����qc�T t;� �
j ISSUANCE 4.�`�s.d_.5,��,��— - �.___—___
CODF:,I SHALL KORTN W ITH f:OMPLY WITN THOSE PRUVISIONS.
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p DATE:__.._"—__"_ APPLICANT: __.— -- _._—_._._ __.___— �:_
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� I H[REOY AFFIRM UNDER P[NALTV OF PERJURY THATTHEflE ISACONSTRUCTION LENDING ACE�CV __ _____
FOR THE PERFOPMANCE OF THE WORK FOR WHICH THIS PEFMIT IS ISSUED�SEC.3097,CIY.C.).
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