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CITY OF DIAMOND BAA �����CD
---��� DEPARTMENT OF COMMUNITY dt DEVELOPMENT S�RVICES
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(909)86Q3195 Fax(909)861-3117 PRESS
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COYPENSATION,AS PROVDED BV SEC710N 370o OF 7HE LABOR CODE,FOR THE PERFORMANCE �U
Q OF THE WORK FOR YA11CF1 THIS PERMIT IS ISSUED. �
Qw _t HAVE MID WILL WUNTAIN WORlCERS'COMPENSA710N INSURANCE.AS REWIRED BV SEC710N � t
3700 OF THE UBOR CODE,FOR hIE PERFORMANCE OF THE WORK FOR NM1iICH 7HI5 PEFUIR IS � I�j T �
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(n WORKERS'COMPENSATION LAWS OF CALIFORNI/�AND AOREE TMAT IF I SMOIAD BECOME INSPECTION FEE
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� DATE: �G� O � SMIP •
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� SUBJECTANEMPLOVERTOCRWPIM.PENALTIESANDCIVILFWESUP700NEHUNDREDTFqUSAND ENERGYPERMIT �
OqURS(f700.000),IN ADDITION TO7HE C0.ST OF COMPENSATION,DAMAOES AS PROVIDED FOR IN
J SECTIDN 3708 OF THE LABOR CODE,WTEREST,AND ATTORNEY'S FEES. � i
� RETENTION FEE:
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: �
� I HEREBV AFFIRAI UNDER PENALTY OF PERIURY THAT THERE IS A CONSTRUCTION IENDWG AOENCY �
FOR THE PERFORMANCE OF h1E WORK WR WHlpi THIS PERMIT IS ISSUED(SEC.30Y7,CIV.C.�.
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� LENDERS NAME "
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� I CERTIFV hiAT I HAVE READ THIS MPLICATqN M1D STATE TNAT hiE ABOVE WFORMATION IS CORRECL TOTAL FE ES �y�,��
w I A(iREE TO COMPLV WITH ALL CT'M1D COUNTY ORUINANCES AND STATE UWS REU7INO TO BUILDINO I h 1
QONSTRUCTION,AND HEREBY AUT1iORIZE REPRESEMATIVES OF THIS COUNTY TO ENTER UPON THE V
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