HomeMy WebLinkAbout1155 DIAMOND BAR BL (8) i .
_�� _ CITY OF DIAMOND BAR
DEPARTIv1ENT OF COIvIIvIUNTI'Y&DEVELOPMENT SERVICES
21825 E.Copley Drive
- (909)860-3195 Fax(909)861-3117 �������� PRESS
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�Z _I HAVE M1D WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF�INSURE FOR WORKERS' a
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Q 3700 0F TNE LABOR CADE,FOR THE PERFORMANCE OF THE WORK FOR WHICH TFIIS PERMIT IS J�
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(/� WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AOREE THAT IF 1 SHOULD BECOME INSPECTION FEE
= SU&IECT TO THE WORNERS'COM7ENSATION PROVISIONS OF SECTION 3700 OF THE LABOR ,
CODE,I SHALL FORT}IWITH COMPLV WITH THOSE PROVISIONS. ISSUANCE
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J SECTION 37oe OF THE LABOFi CADE.INTEREST,AND ATTORNEV'S FEES. '
OC RETENTION FEE:
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� 1 HEREBV AFFIRM�UNDEH PENALTV OF PENURV THATTHERE IS ACONSTRUCTION LENDINa AGENCV
FOR 7HE PERFORMANCE OF THE WORN FOR WHIG1 THIS PERMIT IS ISSUED(SEC.3087,CIV.C.).
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� IENDER'S NAME '
� LENDER'SADDRESS
w I CERTIFV THAT I HAVE READ THIS APPUCATION AND STATE THAT 7HE ABOVE INFORMATION IS CORRECT. TOTAL FE ES �• � U I` /I I '
� I AGREE TO COMPLV N7TH ALL CfTV AND COUNTV ORDINMlCES AND STATE LAWS REUTINO TO BUILDING I V v
� CONSTRUCTION,AND HEREBV AUTHORRE REPRESENTATNES OF THIS COUNTY TO ENTER UPON THE D�� O�
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