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_ � CITY OF DIAMOND BAR 1 '
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21825 Copley Drive,Diamond Bar,CA 91765 ' �
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� CENSE L�W(CHAPTER Y(COMMENCWO WIh1 SECTION 7000)OF DIVISION 3 OF iHE BUSINESS AND PRO- POOUSPB
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� Y(COMMENCWOWRHSECTION7000)OFDIVISION30FTHEBUSINESSANDPROFESSIONSCODE,AND Z
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NI HEREBY AFFIRM UNDER VENALTY OF PERIURY ONE OF THE FOLLOWING DECIARATIONS: � Z ' � I
� I NAVE M1D WILL AWNTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WOHNERS' _
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Z I CERTIFV THAT IN THE PERFOpMANCE OF THE WO{L(FOR WHICH THIS PERMIT IS ISSUED,1 MECHANICAL � �Z.•
C3 SHALL NOT EMPLOV ANV FERSON IN ANY MANNER SOAS TO BECOME SU&IECT TO THE
[/J WORNERS'COMPENSATIONUWSOFCAI.IFORNIqANDAOREETHATIFI ULDBECOME INSPECTIONFEE
SU&IECTTOTHEWORKERS'COA/PENSATIO OVISIONSOFSECT 77 OF HELABOR
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p DATE: :�...�,LJP=c...�/ppLICANT. ` ` SMIP � ,,�
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� WAHNINO:FAILURETO SECURE WORKERS'C EN qN CAVERAOE IS LAWFUL,AND SHALL BE ENERGY P/C
� SUBJECTANEMPLOVERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSMID ENERGYPERMIT
DOLLAAS(5700,000),IN ADDITION TO THE COST OF COMPENSATION,DAMA�ES AS PROVIDED FOR IN
J SECTION 37oe OF THE LABOR CODE.INTEREST,AND ATTORNEV'S FEES. � �
OC RETENTION FEE:
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBYAFFIqM UNDER PENALTV OF PERJURV THAT THERE IS ACONSTRUCTION LENDINO AOENCV
FOR THE PERFORMANCE OF THE WORK f-0R WHICH THIS PERMIT IS ISSUED(SEC.3087,CIV.C.).
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� I AGREE TO CAMPLV WITH ALL CfTY AND COUNTV ORDINANCES AND STATE UWS REUTINQ TO WILDINO
CANSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF THIS CWNTY TO ENTER UPON THE ' .�/-�---
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