HomeMy WebLinkAbout17933 (10) _�,! _ CTTY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21825 E.Copley Drive
- (909)860.3195 Fax(909)861-3117 - PRESS
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w NRE.PRqR TO ITS ISSUANCE,�150 REOUIRES THE APPUCANT FOR SUC}i PERMIT TO FILE A SIGNED w P8I10/DBCk
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PROPEHTV WHO BUILDS OR IMPqOVES THEREON.AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
wTHROU6M HIS OR HER ON?J EMPLOVEES,PROVIDED THAT SUCFI IMPROVEMENTS ARE NOT INTENDED OR m
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w I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTION
Q 700 0F THE LABOR CODE.FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMR IS
ISSUED.MV RKERS'COMPENSA ION INSURANCE CARqIER AND POLICV NUMBErp ARE: CONSTRUCTION
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Z I CERTIFY THAT IN THE PERFORMANCE OF WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
C.�} SHALL NOT EMPLOV ANV PERSON IN ANV NER 50 AS TO BECAME SUBJECT TO THE
N WORK S' PENSATION LAWS OF CALI RN10. AGREE THAT IF I S/10ULD BECOME INSPECTION FEE
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� �. S FORTHWITHCOMPLV OSE VISIONS. ISSUANCE
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J WARNING: ILUR TO SECURE WORK S'COM NSATION CqVERAGE IS UNLAW M!D SHALL BE ENERGY P/C
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�y SUBJECT EM VERTOCRIMINAL EN/�LTIES CNILFINESUPTOONEHUN DTHOUSAND ENERGYPERMIT
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J SECTION 37oB OF THE LABOR CODE.IN REST, D ATTORNEV'S FEES. ' �(1
w RETENTION FEE: v
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� 1 HEHEBV AFFIRM UNDER PENALTV OF PERIURV THAT THERE IS A CANSTRUCTION LENDINO AGENCY
� FOR THE PERFORMANCE OF TXE WORK FOR WHIGi THIS PERMIT IS ISSUED(SEC.3087,CIV.C.).
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� LENDER'S NAME
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� I AGREE TO COMPLV WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATINO TO BUILDING
� CANS CTION,M!D HEREBV AUTHORRE REPRESENTATNES OF THIS COUNTV TO ENTER UPON THE
Z -MENTIONED P PERTV FOR INSPECTION PURPOSES. COMMENTS
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SIG REOFPERMI E DATE
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