HomeMy WebLinkAbout13644 CITY OF DIAMOND BAR '
� --� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICE
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(909)860-3195 Fax(909)861-3117 PRESS
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LJCENSED CONTFiACTORS DECLARATION �
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I HEREBYAFFlHM UHDER PENALT'OF PERIURY ilUT I AA1 LICENSED UNDER PROV1510N5 oF CHAP7ER � � N ,
� i(COAIMENCOlO WITH SEC710N l000)OF DMSION 3 OF THE BUSINESS M1D PROfESSIONS CODE,AND Z
MY LICEHSE IS IN FULL FORCE AND EFFECT. m
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� WORKERS'COMPENSATION DECLARATION � 3 (LN� O O oo O s'J `-'
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Q COMPENSATqN,AS VROVIDED BV$EC710N]7000F iHE LABOR CODE,FOR THE PERFORMANCE W '
Q OF hIE WORK FOR WHICH THIS PERMIT 19 ISSUED. . � ,
_1 HAVE AND WILL MAINTAIN WORNERS'COMPENSA710N�INSURANCE,As REOUIRED Bv 9EC710N `� �/ j /�
Q 97000F THE LABOR CODE,FOR TME PERFORMMICE OF THE WORK WR WHICH THIS PERMIT 15 ` / [y �. /N�
ISSUm.MY WORlCERS'CWIP@ISATION INSURANCE CARRIER AND POLICV NUMBER ME: CONSTRUCTION c �, '-�1, lYJ{.J
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Z 1 CERTIFV THAT W THE PERFORMANCE OF 7HE WORK FOR WHICH THIS VEHMIT IS LSSUED,I MECHANICAL 1 2�' a �
� SH/LLl NOT EMPLOY/JIY PERSON M ANY MANNER 50 AS TO BECOME SU&IECT TO THE �
(A WORKERS'COMPENSATION UY/S OF CALIFORNIA,AND AOFEE TMAT IF 1 SNOl1LD BECOME INSPECTION FEE '
S SU&IECTTO THE WORKERS COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR � � .
CODE,1 SHALL PoRTMWRM COMPLV WITH TFIOSE PROVISIONS. ISSUANCE
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DATE: APPIICANT:
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� WARNINO:FMURE TO SEWRE NORlCERS'COMPENSATION COVERAGE IS UNUWFUL,M1D SHALL BE
� SU&IECT AN EMPLOVER TO CRIMMAL PEIULTIE9 ANU CIVIL FWES UP TO ONE HUNDRED h10USAND ENERGY PERMIT
DOILMS(i100,000).W ADDITION TO THE COST OF COMPENSATION,DAMAOES AS PROVIDED FOR IN
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, � 1 HEREBV AFFIRM UNDER PENALTY OF PERIURY THAT THERE IS�CONSTRUCTION LENDINO ADENCV �p$�p�'��d�.1N1�tl(V 1}1 1„Y IjA14 I
FOR THE VEHFORMANCE OF THE WORK FOR M?iICH THIS 7ERMR IS ISSUEO(SEC.30W.CIV.C.). --�
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� TOTAL FEES � '�O, � � �
I CERTIFY TiAT I HAVE RFJ�D THIS MPUCATION M1U STATE THAT TiE ABOVE INFORMATION IS CORRECT.
� 1 AOREE TO COMPLV WfTH ALl CrtV AND COUNTI'ORDINANCES MID STATE Uw5 REUTwO TO BUILDINO
� CONSTRUCTION,/�ND MEREBY AUTHORIZE REPRESENTATIVES OF TMIS COUNTV TO ENTEH UPON THE ^ //��
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DA7E RECPT.NO. PPJD BY VALIDATION .
� � ' WHITE—DepeRmeM Copy,VELLOW—Flnance CoVY,PINK—Aaseseor Copy,GOLDENROD—File C.opy.GREEN—Applicant's Copy
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ROOF SHEATHING �5 J � 8 FT. BOND BEAM
FRAMINGNENTILIATION G� r °�� .�-! .L ' FINAL BOND BEAM
ROOF C�VER. ".�--- PRE-GRADING
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ROtJGH ELECTRIC � � ROUGH GRADING
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