HomeMy WebLinkAbout16295 (22) � _�� CITY OF DIAMOND BAR
' � - DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suitc 190
.(909)860-3195 Faz(909)861-3117 PRESS
� ����'� BUILDING PERMIT APPLICATION • FIRMLY �
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� I HEREBY AFFIRM UNDER PENALTV OF PERIURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER �
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� I HEREBY AFFIRM UNDER PENALTV OF PERIURY ONE OF THE FOLIOWING DECLARATIONS: Z
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� _I HAVE AND Wlll MAINTAIN A CERTIFICATE OF CONSENT TO SELF�INSURE FOR M10RKERS' _
COAIPENSATION,AS PqOVIDED 8Y SECTION 370o OF 7HE LABOR CODE,FOR THE PERFORMANCE U
Q OF THE WORK FOR Vh/1CH THIS PERMIT IS ISSUED. �
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_I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BV SEC710N
Q 3700 OF 7HE LABOR CODE,FOR THE PERFOfiMANCE OF THE WORN FOR WHICH iHIS PERMIT IS
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Z 1 CEHTIFV THAT IN hiE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I MECHANICAL
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� WORNERS'COMPENS�TION LAWS OF CALIFORNI D FEE TH IF I LD BECOME INSPECTION F _
� SU&IECT TO TH WORNERS'COMPENSATION OVI S OF I 7 OF THE UBOR _
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J WARNINO:FAILURE 70 SECURE WORKERS'CAMPENSA71 N COVERAGE IS UNLAWFUL,AND SH�LL BE ENERGY P/C
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.� SECTION 370E OF THE LABOR CODE.INTEREST,AND ATTORNEY'S FEES. RETENTION FE
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� I HEREBV AFFIRM UNDER PENALTV OF PERJURV 7HA77HERE IS A CANS7RUC710N LENDING AGENCV
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� LENDER'S NAME � �
F- LENDER'SADDRESS
� I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CQRRECL TOTAL FEES � 1 U � � ��
� I AGREE TO COMPLV WITM ALL CfTY AND CAUNTV ORDINANCES AND STATE LAWS RELATING TO BUILDING ���
� CONS7RUCTI D HEREBV AUTHORIZE REPRESENTATIVES OF 7HI5 COUNTV TO EN7ER UPON 7HE _
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