HomeMy WebLinkAbout13372 _�rt� CITY OF DIAMOND BAR �
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190 '
(909)86Q3195 Faz(909)861-3117 PRESS
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� I HEREBY AFFIRM UNDER PENALTY OF PERIURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER � �r''"""
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N I HEREBY AFFIRM UNDER PENALTY OF PERIUHY ONE OF THE FOLLAWING DECURA710N5: � �✓�
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Z 1 CERTIFV THAT IN hiE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
(} SHALL NOT EMPLOV ANY PERSON IN M!Y MANNER SO AS TO BECAME SUBJECT TO THE
�/j WORKERS'COMPENSATION UWS OF CALIFORNIA M1D AGREE THAT IF I SHOULD BECOME INSPECTION FEE
S SUBJECTTO THE WORKERS'COM7ENSATION PROVISIONS OF SEC710N 37000F THE IABOR ISSUANCE O
CODE,I SHALL FOiiTMYITH COMPLV WITH THOSE PROVISIONS. �
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J WARNINO:FAILURE TO SECURE KORKERS'COMPENSATION COVERAGE IS UNUWFUL,AND SHALL BE
� SU&IECTAN EMPLOVER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND ENERGY PERMIT
DOLLARS(i100.000).IN ADDI710N TO7HE COST OF COMPENSATION,DAMAGES AS PROVIDED WR IN
J SECTION 3708 OF hiE LABOR CODE,INTEREST,AND ATfORNE1"S FEES. � RETENTION FEE: S���
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a CONSTRUCTION LENDING AGENCY P ALT FEE: n/� �
Q I HEREBY AFFIRM UNDER PENALTY OF PERIURV iHAT THERE IS A CONSTRUCTION LENDING AGENCY ���,�((..�
d FOR 7HE PER WRMANCE OF 7HE WORN FOR NRiICH THIS PERMI7IS ISSUED(SEC.3097,CIV.C.). �
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� LENDER'S NAME !�� D
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W I CERTIFY THAT I HAVE READ THIS APPLICATION AND STA7E THATTNE ABOVE INFORMATION�S CORREC7. TOTAL FE ES
� I AGREF 70 COMPLV WITH ALL CITY AND COUNTV OHDINANCES AND STATE UWS RELA71N0 70 BUILOING
� CONSTRUCTION,AND HEREBV AUTFIORIZE REPRESENTATIVES OF THIS COUNTV TO ENTER UPON THE � .
Z ABOVE•MENTIONED PROPERTY FOR INSPECTION PURPOSES. COMMENTS ��
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WHITE—DepeAment Copy,YELLOW�inance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanYs Copy
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ROOF�S}-NEA HEI�G'.;•.�°'� - • ' � 8 FT. BOND BEAM
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