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• 1�� CTTY OF DIAMOND BAR .
� DEPARTMENT OF COMMUNTI'Y&DEVELOPMENT SERVICES
21810 Copley Drive,Diamond Bar,CA 91965 ,
(909)839-7020 Fax(909)861-3117 Building Inspection Hotline(909)839-7027 PRESS
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_�`_ CITY O�DIA BAR �
DEPARTMEN�OMMUNITY&DEVELOPMENT SERVIC�
21825 Copley Drive,Diamond Bar,CA 91765
(909)839-7020 Fax(909)861-3117 Building Inspection Hotline(909)839-7027 � PRESS
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I HEREBY AFFIRAI UNDER PENALTY OF PEiiJURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER �
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� I HEREBV AFFIfiM UNDER PENALTV OF PERIURV ONE OF THE FOLLOWINC DECLARATIONS: Z
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Z 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TNIS PERMIT IS ISSUED.I MECHANICAL
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SU&IECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 370o OF THE UBOR n �
S CODE,I SHALL FORTHWITN COMPLV WITH THOSE PROVISIONS. ISSUANCE q�, �
`p DATE:�_ APPLICANT:7� SMIP �� �a,
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� WARNINO:FPJLURE TO SECURE M/ORKERS'COMPENSATION CAVERAOE IS UNLAWFUL,AND SHALI BE ENERGY P/C �
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� LENDER'S NAME
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w I CERTIFY THAT I HAVE READ THIS�PPLICATION AND STATE THAT THE ABOVE INFORMATION IS C-0RRECT. TOTAL F E ES �.✓�
� I A6REE TO COMPLV WITH ALL CITV AND COUNTV OqDINANCES AND STATE LAWS RELATINO TO BUILDING
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