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_!F� CITY OF DIAMOND BAR � �
DEPARTMENT OF COMMiJNITY&DEVELOPMENT SERVICES `J��
W 21660 E.Copley Drive Suite 190
(909)860-3195 Faz(909)861-3117 PRE$$
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S iHAC1UGH HIS OR HER ONM EMPLOYEES,PROVtDED TIAT SUCH IMPROVEMENTS ARE NOT INTEHDED OR m
� OFFEREDFORSALEIF,FpWEVEf�7HEBU0.DINOORIMPROVEMENTISuOtDWfT}ANONEYEAROFCOMPLE-
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W ❑I.A90WNEROFTHEPROPEHTV,AMIXCLUSNELVCOHTRACTWOWRHLICENSEDCONTMCTORS
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� �`�� � WORKERS'COMPENSATION DECLARATION Q
� I HER V AFFlRM UNDER PENALTV OF PERIURY ONE OF 7HE FOILOWING DECLARATIONS: Z
� HAVE AND WILL MAMTIUN A CERTIFICATE OF CONSEM TO SELF-INSURE FOR M/ORKERS' a
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Q COMPRISATION,AS PROVtDED BV SECTION�7000F THE UBOR CODE,FOq THE PERFORMANCE U
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0 tSSUED.MV WO RS'COMPEN$A710N INSURANCE CARRIER AND POLICV NUMB ARE: CONSTRUCTION
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(,'J SF7ALL NOT EMPLOY ANV PERSON W ANV MPNNER 50 AS TO BECOME SU&IECT TO THE
(/� WORKER5 COMPENSATION UWS OF CALIFORNIA,AND AGREE 7HAT IF I SFqULD BECOME INSPECTION FEE
S SU&IECT TO THE WORNERS'COMPENSATION PROVISIONS OF SECz ION 37oa OF TME LABOR
cooe,i sw�.�coRn�rnnN coMv�r win� E PROVISIONs, / ISSUANCE
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DOLLMS(f100.000).IN ADDITION 707HE CAST OF COMPENSATpN,DAMAOES AS PROVIDED FOR IN
� SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEVS FEES. ' RETENTION FEE:
OCONSTRUCTION LENDING AGENCY PAE-ALT FEE:
� I HEREBY AFFIRM UNDER PENPLTV OF PERJURV THAT ERE IS A CONSTRUCTION LENDING A(iENCV
� FOR TIE PERFOFMMICE OF THE WORN/FOR WHICH T PERMfT IS ISSUED($1 EC.3oG7,GV.C.).
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� ABOVE�MENTIONEO PROPERTV f-0R IN PECTION PURPOSES. COMMENTS �-
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