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^ __��_ CTI'Y OF DIAMOND BAR
DEPARTNIENT OF CONIIvfUNTI'I'&DEVELOPMENT SERVICES
21825 E.Copley Drive
- (909)860.3195 Fax(909)861-3117 PRESS
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Z WILL DO THE WORK�D THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7044,BUSI� J
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0 I HAVE AND WILL MAINTAIN A CERTIFlCATE OF CONSENT TO SELF�INSURE FOR WOfiKERS' _
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Q OF 7HE WORK FOH WHICH 7HIS PEfUAIT IS ISSUED. �
Qw �I HAVE AND WILL MAIMAW WORKERS'CAMPENSATION INSURANCE,AS REOUIRED BV SECTION � �•
3700 OF THE LABOR CADE,FOR THE PERFORAIANCE OF THE WORK FOR WHICH THIS PERMIT IS ��`C., ��
ISSUED.MV WORKERS'COMPENSATKKJ INSURANCE CARRI R AND POLICY NUMBERARE: CONSTRUCTION � J
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C.'} SHALL NOT EMPIOY ANY PERSON IN ANV MANNER 50 AS TO BECOME SUBJECT TO THE �-�- -i�` '- ' '
(/� WOFKERS'COMPENSATION LAWS OF CALIFORN10.AND AGREE THAT IF I SHOULD BECAME INSPECTION FEE I -
= SU&IECTTO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 37000F THE LABOR
CODE,I SHALL FORTHWITH COMPLV WITH T �SE PROVISIONS, ISSUANCE I �/� s•
p DATE: II—I'3�D/ APPLICANT: SMIP I /J ••�
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WARNIN6:FAILUHE TO SECURE WORKERS' ENSATION CqVERA(iE IS FUL,AND SHALL BE ,„� �•
� SU&IECTANEMPLOVERTOCFIMWALPENPI ESANDCNILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT L �
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� I HEREBV AFFIqM UNDER PENALTV OF PERIURV THAT THERE IS A CONSTRUCTION LENDING AGENCV
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. � LENDER'S NAME
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