HomeMy WebLinkAbout18125 (25) CITY OF DIAMOND BAR �
� ------��'--- DEPARTMENT OF COIvIIv1UNITY 8c DEVELOPMENT SERVICES /
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(909)8603195 Fax(909)861-3117 ,
"`:9��W BUILDING PERMIT APPLICATION FIRMLY
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� STATEAIENT 7HAT HE OR SHE 15 LICENSED PURSUANT TO h1E PFlOVISIONS OF THE CANTFIACTORS LI�
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I HEREBYAFFIRM UNDER PENALTY OF PERJURV THAT IAA1 LICENSED UNDER PROVISIONS OF CHAPTER V.
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c� WORKERS'COMPENSATION DECLAFATION J
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� I HEREB�AFFIRM UNDER PENALTV OF PERIURV ONE OF THE FOLLOWINO DECLARATIONS: Z
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G I MAVE AND N�ILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF�INSURE FOR WORKERS' _
¢ COMPENSATION,AS PFOVIDED BV SECTION��o00FTHE LABOR CODE,FOR THE PERFORMANCE w
OF WORN FOR WHICHTHIS PERMIT IS�SSUED. �
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w VE AND WILL MAWTNN WORKERS'COMPENSATION INSURANCE.AS REOUIRED BV SECTION
Q 3700 OF THE OR CODE,FOR 7HE PERFOHMANCE OF THE WORK FOR WMICH THIS PERMIT IS
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w I CEFTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
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(,r} SHALL NOT EMPLOV ANY PERSON IN ANV MANNER 50 AS TO BECAME$U&IECT TO THE
� WOqNERS'COMPENSATIONLAWSOFCALIFORNIA.ANDAGREETHATIFISFIOULDBECAME INSPECTIONFEE
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� SUBJECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTFqUSANO ENERGVPERMIT
DOLLARS(f100.000).IN ADDITION TO T1�E COST OF COAIPENSATION,DM/AOES AS PROVIDED fOR IN
J SECTION 37080F SHE LABOR CODE,WTEREST,AND ATTORNEY'S FEES. RETENTION FEE:
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, � CONSTRUCTION LENDING AGENCY � PRE-ALT FEE:
� I HEREBV AFFIRM UNDEF PENALTV OF PERIURV THAT THERE IS A CONSTRUCTION LENDING AGENCV
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� LENDER'S NAME
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� I�aHEE TO COMPL�WfTF�P1l GTV M1D CWNTY Ofi01NANCES ANO STATE UWS REUTINO TO BUILOING
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