HomeMy WebLinkAbout17528 CITY OF DIAMOND BAR EX P I R ED
----��-- DEPARTMENT OF COIvIIv1UNTI'Y&DEVELOPMENT SERVICES
21825 E.Copley Drive MAY 0 9 2003 PRESS
"'`" (909)860-3195 Fa�c(909)861-3117
"':»;�'' BUILDING PERMIT APPLICATION FIRMLY
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w TURE,PRIOR TO ITS ISSUANCE.AL50 RE�UIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIdNED w
g STATEMENi THAT ME OR SHE IS LICENSED PUflSU1JJT TO 1HE PROVIS10N5 OF THE CONTMCTORS LI- � POOVSPB
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� WORKERS'COMPENSATION DECLARATION -�
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� _I HAVE AND WILL MlJNTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WOHKERS' 2
Q COMPENSATION,/S PROVIDED BY SECTION 3700 OF TME UBOR CODE,FOR THE PERFORMANCE w
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. �
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w I HAVEAND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE.AS REWIRED BV SECTION l
Q 37000F 7HE LABOF CODE,FOR THE PERFORMANCE OF 7HE WOH1C FOR WHICH 7HI5 PERMIT IS
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Z I CEFTIFV THAT IN THE PERFORMANCE OF THE WORN FOR WHICH THIS PEPMIT IS ISSUED,1
(r} SHALL NOT EMPLOV ANV PERSON W ANV MANNER 50 AS TO BECOME SUBJECT TOTHE
� WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME INSPEC710N FEE
SU&IECTTO THE WORKERS'CAMPENSATKKJ PFOVISIONS OF SECTION 37000F TME V�BOR ISSUANCE ��O
CODE.I SHN.L FORTHWITH COMPLV WITH TFIO E PROVISIONS. /�� Y�--�
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DOLURS(f100.000I,IN ADDITION TO THE COST OF CAMPENSATION,DAMA�ES AS PROVIDED FOR IN
J SECTION 37oB OF THE LABOR CODE,INTEFEST,AND ATTORNEY'S FEES. RETENTION FEE: ��
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w CONSTRUCT�OtJ LENDING AGENCY PRE-ALT FEE:
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� I HEREBV AFFIqM UNDER PENALTV OF PERIURV THAT THERE IS A CONSTRUCTION LEND�NO AGENCV --
0- FOR 7NE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED�SEG.308�,CIV.C.). �
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� LENDER'S NAME
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� I CERTIFV THAT I HAVE READ TNIS APPUCATION AND STATE THAT THE ABOVE INFORMATION IS CARRECT. TOTAL FE ES �
� I AGREE TO COMPL�WITH ALl CITY AND COUNTV ORDINANCES AND STATE UWS RELATING TO BUILDING
� CONSTRUCTION,AND HEREBVAUTTN)RIZE REP{iESEN7A71VES OF 7HI5 CWNTV 70 ENTER UPON THE
Z AHOYEyENT10NE0 PflOP R1Y FOR INSPECTI�N PURPOSES. COMMENTS
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