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�` CITY OF DIAMOND BAR
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Z TURE.PRIOR TO ITS ISSUANCE,ALSO REQUIflES THE APPLICANT FOR SUCH PERMIT TO FIIE A SIGNED w
w STATEMENT THAT HE OR SHE IS IICENSED PUPSl1ANT TO THE PHOVISIONS OF THE CONTRACTORS LI�
� CENSE LAW(CHAPTER B(COMMENCING W�TN SECTION 1000)OF�IVISI(N13 nF THE BUSINESS AND PRO- LL POOUSpB
FESSIONS CODE)OR THAT HE OR SHE IS E%E MPT THEREFROM ANO THE BASIS FOR THE ALLEGED EXEMV� Y,
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� I MEREBV RFFIRM UNOER PENNI.TY OF PERJURV THAT I AM LICENSED UNDER PRO\'ISIONS OF GMAPTEIl �
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Z I CEfiTIFV THAT IN THE.PEftFORMANCE OF TME WORK FOR WHICH THIS PERMIT IS ISSUED,I _
� SHALL NOT EMPLOY ANY PEflSON IN ANY MANNER SOAS TO 6ECOM[SUBJEf:T TO THE
� WORKERS'GOMPEN5�4TION LAWS OF GALIFORNIA,AND AGFEE TMAT IF I SHOULD BECOME INS?ECTION FEE
� SUBJEGTTO THE WOHKERS'GOMPENSATION PROVISIONS OF ScGTION 3�o00FTHE LABOR �.�—
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� SUBJECTANEMPLOVERTOCHIM'�NALPENALTIESAN�GIVILFINESl1PTOONEMUNDREOTMOU5AN0 ENERGVPERMIT
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zABOVE�MENTIONED PROPERI'V FOR WSPECTION PUi1PD5E5. COMMENTS
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CITY OF DIAMOND BAR
DEPARTIvIE'VT OF COMMUNITY&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT_APPLICATION
PRESS
FIRMLY
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