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� CITY OF DIAMOND BAR �
DEPARTMENT OF COMMiJDTITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)86Q3195 Fax(909)861-3117 PRESS
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OF 7HE WORK FOR WHICH THIS PERMI713 ISSUED. W
� �HAVE AND WILL MAINTAV!WONCERS'COMPENSATION INSURANCE,AS RC-0UIRED BY SECTION �
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Z I CERTIFY THAT W THE PERFOfUTANCE OF THE WORK FOq WMlpi 7HI5 PERMIT IS ISSUED,I MECHANICAL Y�C1LI1.
(,'} SHALL NOT EMPLOY ANY PERSON IN ANV MANNER SO AS TO BECOME SU&IECT TO THE
(q WOAKERS'COMPENSATION LAWS OF CALIFORNIA,AND AOREE THAT IF I SFiOULD BECOME INSPECTION FEE
SU6IECT T0 THE WORKERS'COMGENSATqN PROVISIONS OF SECTION 370o OF THE L.�BOR
OCWE,I SHALL PoRTHWITI COMPLY WITH 7HOSE PHON510N5. ISSUANCE ���� ,��y n n .T_
p DATE: � APPLICANT: SMIP
J WARNINO:FAILURE TO SECURE WORI(ERS'COMPENSATION COVERA(3E IS UNLAWFUL,M!D SH�LL BE ENERGY P/C �CIT�Y(��rti1 �1����I���{��
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J SECTION J70E OF THE LABOR CODE,INTEREST,/�ND ATTORNE'/'S FEES. � -
Q RETENTION FEE:
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I MER�V AFFlHM UNDER PEN/�LTV OF VERIURV THAT TMERE IS ACONSTRUCT/0N LENDMO AGENCV � �
FOR THE PERFORMANCE OF THE WORK FOR WHICH TMIS PEfiMIT IS ISSUED(SEC.30Y7,CIV.C.).
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� LEHDER'S NAME
� LENDER'S ADDRESS
� I CERTIFV THAT I HAVE READ THIS APPLICATION AND STATE TMAT THE ABOVE INFORMATqN IS CORRECT. TOTAL FE ES `�'�� � � `�
� I AOREE 70 COMPLV WITH ALL CfTV AND CWNTY ORDINANCES AND STATE UWS RELATIN(3 70 BUILDINO �
� CONSTRUC710N,AND HEREBV AUTFIORIZE REPRESENTATIVES OF THIS COUNTV TO ENTER UPON 7HE �
Z MBOVE-MENTIONED PROPERTY FOR INSPECTION PURP0.5E5.
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