HomeMy WebLinkAbout13-797 CTTY OF DIAMOND BAR • y'
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21810 Copley Drive,Diamond Bar,CA 91765 J
(909)839-7020 Fax(909)861-3117 Building Inspection Hotline(909)839-7027 PRESS
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STA7EMEHT hiAT HE OR SHE IS 110ENSED PURSUANT 70 hIE PROVISIDNS OF THE CONTMCTOR9 LL
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Z WILL 00 THE WORK ANU THE STRUCTURE IS NOT INTFNDED OR OFFEAED FOR Sr1E(SEC.7ou,BUS�- J
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2 I HEREBY AiFlRM UNDER PENALTY Of VERAIRY TFIAT IAM LICENSED UNDER VROVISlONS OF CHADTER � '
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X MY LICENSE IS IN FULL FORCE AND EFFECT.
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� WORKERS'COMPENSATION DECLARATION � ¢ �
� I HEREBY AFFIiW UNDEA PENAITV OF PEiWflY ONE OF THE f-0ILOWWG OECLARATqNS: Z ,
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� _I HAVE AND NRLL MAINTAW ACERTIFlCATE OF CONSENT TO SELF�INSURE FOR WORKERS =
Q CAMPENSATION.A4 PROVIDFD BY SECTION]7ao OF THE UBOR COOE,FOR THE PERWiiMANCE W
Q OF THE WORK FOR WHICH THIS PEFMIT IS ISSUED. � i
_I HAYE AND WILL MANlTAW WORKERS'COM7ENSATION INSUqANCE,A4 REOUIFED BV SECTIOH
QQ �7000F THE IABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WMp1 THIS PERMIT IS
ISSUED.MY WOPo(ER5 COAIPENSATION INSURlWCE CARRIER Allll POLIGY NUMBER ME CONSTRUCTION
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. Z 1 CERTIFY THAT W THE PERFOfU1ANCE OF THE WOPo(FOH WHILN THIS PER/A1T IS 455UED,I MECHANICAI �
(•} SHALL NOT EMYLOY M!Y PERSON Po AHY IJANNER 50 AS TO BECOME SU&IECT TO 7NE
� WORKERS'COAIPENSATqN UWS OF CAIIFORNI�AND ACiREE THAT IF I SFiOULD BECAME INSPECTION FEE
S SUBJECT TO THE WOFKERS'COMPEN9A710N PROVISqNS OF SECTION 770o OF THE LA90R
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WARNWl3:FAILURE TO SECURE WOPo(ERS'COMPENSATION COVERACE IS UNUN/FUI.AND SHALL BE
� SU&IECf AN EMPLOVER TO CHIMINAL FENALTIES ANO C1VIL FVJES UP TOONE HUNDRED 7}fOUSAND '
DOlUR4(f100.000j,W A6DI710N TO THE C0.ST OF COMPENuATMJN,�MIh�ES ti5 P/10VIDED PoH IN ENERGY PERMIT �j
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� 1 HEREBY AFFlRM UNDER PEN/�L7Y OF PE0.)Ufi'I7HA7 THERE IS ACONSTRUC710N LENDWO A(3fNCY
FOR THE PERFOiUTANCE OF THE WORK FOR WHICN THIS PERIAR IS ISSUED(5EG 3097.CIV.C.). .
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� LENDER'S NAME ' .
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� I CERTIFY THAT I HAVE READ iHIS MPLICATION AND STATE TUT THE ABOVE PlFORMATION I,4 CORHECT. TOTAL FEES � � �.,S_Z�
W 1 A6REE TO COMPLY N7TH ALL CRV M!D COUNTY OROWANCES M1D STATE UWS RELATINO TD BUILAINO
� CONSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATNES OF THfS COUNTY TO EMER UPON THE �
� ABOVE-A1ENT10NED 7ROPERTY FOR WSPEC710N FURP0.5ES. �
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