HomeMy WebLinkAbout18125 (25) CITY OF DIAMOND BAR �
� ------��'--- DEPARTMENT OF COIvIIvIiJNITY&DEVELOPMENT SERVICES i'
. 21825 E.Copley Drive PRESS
(909)8603195 Fax(909)861-3117 ,
"`:9;��W BUILDIIVG PERMIT APPLICATION FIRMLY
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I HEREBYAFFIRM UNDER PENALT'OF PERJUFY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER V.
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� WORKERS'COMPENSATION DECLAFATION J
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� IMAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF�INSUREFORWORKERS' _
Q COM7ENSATION,AS PFOVIDED BV SECTION��W OF THE LABOR CODE,FOR THE PERFORMANCE w
OF WORN FOR WHVCHTMIS PERMIT IS�SSUED. �
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w VE AND WILL MAWTNN WORKERS'COMPENSATION INSURANCE.AS FEOUIRED BV SECTION
O 3700 OF THE OR CODE,FOR 7HE PERFOHMANCE OF THE WORN FOR WMICH THIS PERMIT IS
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(r} SHALL NOT EMPLOV ANV PERSON IN ANY MANNER 50 AS TO BECAME$V&IECT TO THE
� WOqNERS'COMPENSATIONLAWSOFCALIFORNIA.ANDAGREETHATIFISFIOULDBECAME INSPECTIONFEE
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p DAT� PPLICpNT:
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� J WARNINO:FAILURE TO SECURE WOHKERS'COMPENSATION CAVEHAGE i5 LINLAWFUL,AND SHALL BE
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� CONSTRUCTION LENDING AGENCY ' PRE-ALT FEE:
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� I AQREE TO COMPL�WfTH P1l CITV AND COUNTY OROINANCES AND STATE UWS REUYINO TO BUILDING
CONSTRUCTION,AND HEFEBV AUTHORIZE REPRESENTATIVES OF 7H15 CWN7Y TO ENTER UPON THE
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FINAL ELECTRIC J � DEV� FEES PAID
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