HomeMy WebLinkAbout10-777 (10) �� CITY OF DIAMOND BAR
DEPARTMENT OF COMMUIVITY&DEVELOPMENT SERVICES �
21825 Copley Drive,Diamond Bar,CA 91765 i
(909)839-7020 Fax(909)861-3117 Building Inspection Hotline(909)839-7027 PFiESS �
��'TM". BUILDING PERMIT APPLICATION FORIUILY
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Z WILL THE WORKµ�THE STRUCTURE IS NOT IMENDED OR OFFERED FOR SALE(SEC.7WA,BU51- J '
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� I HEREBY AFFIRM UNOER PENAL7Y OF 7ERlURV ONE OF TME FOLLOYANG DECLARATIDNS: �
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� _I HAVE AND WILL MAMTPJN A CERTIFICATE OF CONSENT TO SELF�INSURE FOR WORNERS' a
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w _I HAVE ANO WILL MAWiAOJ WOR1(ERS'COMPENSATION INSUiUNCE,A5 REIX11flE0 8Y SECTqN
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J ISSUED.A/V NqRKERS'COA/PENSATION INSURANCE CARRIER AND POLICV NUMBER ARE: GON TION /� [J� �.�
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C'} SHALL NO7 EMPLOV ANV PERSON IN ANY AIANNER SO AS TO BECAME SU&IECT TO TME � �
(/J WORKERS'COMPENSATION l.AWS OF CALIFORNIA,ANO AGREE THAT IF I SHOULD BECAME INSPECTION FEE
SU6IECT TO THE WORKERS'CAMPENSATION VROVISIONS OF SECTqN 7]OO OF THE UBOR ��. ``���
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� SUBJECT AN EMPLOVER TO CRIMINAL PENAITIES M!D CIVIL FINES UP TO ONE HUNDRED THOUSAND �NERGY PEAMIT • � �_� ,
DOLU�FiS(it0u.000�.W IDDITION TO THE COST OF COMPENSATION,DAMAGES AS PPOVIDED FOR IN
� SECTqN a7oe OF TME LABOR CODE.INTEREST,M1D ATTORNEV'S FEES. ETENTION F � . ��CJ
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.. � I HEREBV AFFIRM UNDER 7ENALTY OF PERJURV THAT THERE IS A CONSTRUCTION LENDING AGENG7 � �///7+++ �D '
FOR THE PERFORMANCE OF THE WORK FOR N7i1CH TNIS PERYIT IS ISSUED(SEC.3oYl,pV.C.). �' �
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� LENDER'S NAME
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w 1 CEfiTIFV THAT I HAVE REAO TH15 MPLICATION M1D STATE THAT THE ABOVE INFOfU/ATKKJ IS COflRECT. TOTAL FE ES ��T� '�� �%�� � �7tp �,(/ .
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� CONSTRUC710N,AND HEREBV AUTHORIZE REPRESENTATNES OF THIS COUNTV TO EHTER UPON T}1E i / ���;�
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