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CITY OF DIAMOND BAR �
DEPARTIvIENT OF CONARiJN1TY 8c DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 F�(909)861-3117 PRESS
,�'"'" BUILDING PERNIIT APPLICATION . FIRMLY
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� WORKERS'COMPENSATION DECLAAATION � �
� I HEREBV AFFlRM UNDER PENALTY OF PERAIRV ONE OF THE FOLLOWWO DECIAfiATIONS: Z
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Q COMPEN3A710N.AS PROVfDED BV SECTION 3700 OF THE 1A80R CODE,FOR THE PEHFORM�WCE V
Q OF THE WORK FOR NM1i1CN TNIS PERMIT 19 ISSUED. �
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(/� WOPo(ERS'COMPENSATqNUW50FCALIFORNIA,MIDAQREETHATIFISNOULDBECOME INSPECTIONFEE
SU&IECT TO THE WORKERS'COMPENSATION PqOVISIONS OF SECTqN 3700 OF THE LABOR
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� SU&IECTMI EMPLOVER TO CRIMINAL PENALTIES AND CML FWES UP TO ONE HUNDRED T}KK15AND ENERGY PERMIT
OOLURS(it00,00D),W ADDITON 70 THE C0.5T OF COMPENSATION,DAMAOES AS PROVIDED FOR IN
J SECTqN�7oe OF THE LABOR CODE,INTEREST,AND ATTORNEV'S FEES. �
oC RETENTION FEE: I-
OCONSTRUCTION LENDING AGENCY � PRE-ALT FEE:
� 1 MEREBV AFFIRM UNDER PENALTV OF PERNRV THAT THERE IS A CONSTHUCTION LENDINCi AGENCV
FOR THE PERFORMANCE OF THE WORN FOR WHlpi THIS PERMIT IS ISSUED(SEC.30W,CIV.C.�. �
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� LEPIDER'S NAME
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� I CERTIFY THAT I HAVE REM THIS MPLICATION AND STATE THAT T1E ABOVE WFORIIATION IS CORRECT. TOTAL FE ES �
� I A(iREE TO COMPLV W17H ALL CITV AND COUNTV ORDINANCES AND STATE UWS REUTINO TO BUIDINO y
� CONSTRUCTION,AND HEREBV AUTHORI2E REPRESENTATIVES OF THIS COUNTV TO ENTER UPON THE '
Z ABOVE-MENTIONED PROVERTV f-0R INSPEC710N PURPQSES. COMMENTS '
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" WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENRO�File Copy,OREEN—Applicant's Copy
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SLAB GRADE FIREPLACE FOUNDATION
TEMP POWER FIREPLACE BOND BEAM
WATER SERVICE MID HT. BOND BEAM
ROOF SHEATHING S FT. BOND BEAM
FRAMING/VENTILIATION FINAL BOND BEAM
ROOF COVER PRE-GRADING
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WALL INSULATION POOL FINAL
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DRYWALL NAILING DEDICATIONS
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SEPTIC TANK LANDSCAPE/IRRIG.
SEEP PIT/L.L. ON SITE IMPS. �
GAS AIR TEST � FINAL ZONING
FINAL CONST. FIRE QEPT. FINAI
FINAL HEATIAIG HEALTH DEPT.'FINAL
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