HomeMy WebLinkAbout17045 (25) ^ ��` _ CTI'Y OF DIAMOND BAR
DEPARTIvIENT OF COMMUNITY&DEVELOPMENT SERVICES �
21825 E.Copley Drive
(909)860.3195 Fax(909)861-3117 PRESS
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w TURE.PHIOR TO ITS ISSUANCE,AL50 REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w P8U0/DBCK
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CENSE lAW(CHAPTER V(COMMENCIN�WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- � POOUSPB
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� I HEREBYAFFIRM UNDER PENALTV OF PERIURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER �
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� I HEREBV AFFlRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: V
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� _IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' _
� CAMPENSATION,AS PROVIDED BV SECTION 370o OF THE LABOR CODE,FOFi THE PERFORMANCE U
OFTHE WORK FOR WHICN THIS PERMIT IS ISSUED. w
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w I HAVE AND WILL MAMTAW WORKERS'COMPENSATqN INSURANCE,AS REOUIRED BV SECTION
Q 700 OF THE LABOR CADE,FOR iNE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS �
ISSUED.MV 5' PENS NSURANCE RRIER AND POLICV NUMBER ARE: CONSTRUCTION ���� C�
� CARRIER { PLAN REVIEW
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Z �CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
C.'} SHALL NOT EMPLOV ANV PERSON IN ANV MANNER 50 AS TO BECAME SU&IECT TO THE
(/� WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHWLD BECAME INSPECTION FEE
j SU&IECT TO THE WORNERS'COMPENSATION PROVISIONS OF SECTION 3�OOOF THE UBOR �^�
CADE.1 SHALL FORTHWI7H COMPLV WITH THOSE PROVISIONS. ISSUANCE . OV
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p DATE: � APPLiCANT: SMIP
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J WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAOE IS UNLAWFUL,AND SHALL BE ENERGY P/C
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� SU&IECTAN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TOONE HUNDRED THOUSPND ENERGY PERMIT
DOLURS(i100,000�,W ApDITION TO THE COST OF CAMPENSATION,DAMAGES AS PROVIDED FOR IN
J SECTqN 3708OFTHE LABOR CODE,MTEREST,ANDATTORNEV'S FEES. QO
OC � FETENTION FEE: -
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBV AFFIRM UNDER PENALTV OF PER1UqV THAT THERE IS ACONSTRUCTION IENDING A4ENCY '
FOR THE PERFORMANCE OF THE WOFK FOR WHICH TI115 PERMIT IS ISSUED(SEC.3087,CIV.CJ.
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w I CERTIFY THAT I HAVE READ THIS APPUCATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. TOTAL FE ES 1��� O � ����
� I AGREE TO COMPLV WITH ALl CRV AND COUNTV ORDINANCES M!D STATE IAWS RELATING TO BUILDING V
� CONSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF THIS COUNTV TO ENTEF UPON THE � ���^ �^1
Z ABOVE�MENTIONED PROPERTV FOR IN PE TION PURPOSES. 1/ ✓
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