HomeMy WebLinkAbout17616 (25) CITY OF DIAMOND BAR � '
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� I HEREBY AFFIRM UNOER PENALTV OF PEFiJURV THA7 I AM LICENSED UNDER PROVISIONS OF CHAPTER Z J \'�
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� I HEREBY AFFIRM UNDER PENALTV OF PERJURV ONE OF THE FOLLOWING DECLARATIONS: Z �
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Q CAMPENSATION,AS PROVIDED BV SEC7ION 370o OF THE LABOR CODE,FOR THE PERFORMANCE W
Q OF7HE WORK FOR WHICH THIS PERMIT IS ISSUED. � .
W _I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIflED BY SECTION
Q 37000F THE LABOF CODE,FOR THE PEHFOHMANCE OF THE WORK FOR WHICH THIS PEFMIT IS �
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Z I CERTIFY THAT M THE PERFORMANCE OF THE WORN FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL � �aJ V
L} SHAIL NOT EMPLOV ANY PERSON IN ANY MANNER 50 AS TO BECOME SUBJECT TO THE
� WORKERS'COMFENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECAME INSPECTION FEE
= SU&IECTTO THE WORKERS'CAMPENSA N PROVISIONS OF SE ION 37000F HE LA R (�(S 'j�
CO I S A L FOHTHWITH COMPLV WI 5 PHOVI51 5. ISSUANCE \J�) �
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J WARNING FAIWRE TO SECUHE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE ENERGY P/C
� SU&IECT AN EMPLOYER TO C{iIMINAL PENALTIES AND CIVIL FINES UP 70 ONE HUNDRED THOUSAND ENERGY PERMIT
DOLLARS(f700.000�,IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
� SECTION 3708 OF THE LABOR CADE,INTEREST,AND ATTORNEY'S FEES. RETENTION FEE:
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� I HEfiEBYAFFIRM UNDER PENALTY OF PERJURV THATTHERE IS ACONSTRUCTION LEN�ING AGENCY
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� LENDER'S NAME � �
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� I CERTIFV THAT I HAVE F1EAD THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
w I AGREE TO COMPLV WITH ALL CITV AND COUNTY ORDINANCES AND STATE LAWS REUTING TO BUILDING
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ZCANSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF THIS COUN7V TO ENTER UPON THE '^ e7��f ,`r pO y��{� p_{` _ cD
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