HomeMy WebLinkAbout13-0613 _ _��__ CITY OF DIAMOND BAR
� DEPARTMEN�'OF COMMUNITY&DEVELOPMENT SERVICES �
21810 Copley Drive,Diamond Bar,CA 91765
(909)839-7020 Fax(909)861-3117 Building Inspection Hotiine(909)839-7027 PRESS
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� CENSE LAW(CHAPTER e(COMMENCING WITH SECTION looa)OF OIVISION 7 OF THE BUSINESS AND PR0. PooUSpa
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� A CML PEIULTV OF NOT MOFE THAN FIVE HUNDRED DOlURS(SSOD).�:
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Z WILL DO THE WORK�ND THE STRUCTURE IS NOT IMEIJDED OR OFFEHED FOR S�LE(SEC.70��,BU51- J
� NESS AND VROFESSIONS CO�E:hIE CONT{iACTORS LICENSE LAW DOES NOT AP7LY 70 AN OWNER OF �
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� 1 HEREBY AFFIqM UNDER PENALTY OF PERIURY THAT IAM LICENSED UNDER VROVISIONS Of CHAPTER � �n . � i r� 1 �
� Y(COMMFNCINO WITH SECfION 7000)OF DIVISION J OF THE BUSINESS ANO PROFESSIONS CODE,IN� Z �/lJ _
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� WORKERS'COMPENSATION DECLARATION Q
� I HEREBV AFFIRM UNOER PENAL7Y OF PERJUHV ONE OF THE FOLLOW WG OECtAAATIONS: Z
� _I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT 70 SELF-INSURE FOR KORKERS' a
'�d- CAMPENSATION,AS PROVIDED BY SECTION 37000F THE UBOR CODE,FOR THE PERFORMANCE �U'
Q OF THE WORK FOR NM1iICH THIS PERMIT IS ISSUED. � '
w �I HAVE AND WILL MAIMAIN WORKERS'COMPENSA710N INSURANCE.AS REOUIRED BY SECTION
Q 97000F THE LA90R CODE,FOR THE PERFORMMlCE OF THE WORK FOR WHldi THIS 7ERMI715
ISSUED.MY WORKEAS COMPENSATION INSURANCE CARfiIER AND POLICY NUMBER ARE: CONSTRUCTION
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Z I CERTIFY THAT IN TiE PERFORMANCE OF iHE WOHI(FOR WHICH THIS PERM�T IS ISSUED,I MECHANICAL
(.�J SHALL NOT EMPLOY ANV PERSON IN ANY MANNER SO AS TO BECAME SU&IECT TO 7HE
(,/) WORKERS'COMGENSATION UWS Of CALIFORN11 AND AGREE THAT IF I SHOULD BECOME INSPECTION FEE
= SUBJECT TO THE WORKERS'COMVENSATIDN PqOVIS10NS OF SECTION 37o00F THE LABOR I, ^ �]
CODE.1 SHALL FORTHWITH COMPLY WITH THOSE PROVISIO ISSUANCE �T� T 7
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p DATE: � Z� APPLICANT: �SMIP
J WARNINO:FARLRE TO SECURE WORKERS'CAMPENSATION fUGE IS UNUWFUL,AND SF1ALl BE ENERGY P/C
� SUBJECf AN EMPIOYER TO CHIMINAL PENALTIES AND GVIL FINES UP TOONE HUN�RED 7HOUSAND ENERGY PERMIT
DOILARS(S1ao,o0o),IN ADDITON T07HE COST OF COMPENSATpN,DNAAGES AS PROVIDED FbR IN
J SECTbN 37oe OF 7HE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. � ,OD
p� FETENTION FEE: Z
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBYAFFIRM UNDEH PENAL7Y OF PERJURV THA7 THERE IS ACONSTRUCTIOH LENDWO AGENCY � L,, ��
FOR THE PERFORMANCE OF THE WORK FOR WHIC�1 THIS PERMIT IS ISSUEU(SEC.70W,CIV.G).
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� LENDERS NMIE
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w 1 CEii71FY 7HA71 HAVE READ THIS MPLICATION AND STATE iHAT THE ABOVE INFORMA710N i5 CARRECT. TOTAL FEES 1 S,a t,
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