HomeMy WebLinkAbout17644 (50) CITY OF DIAMOND BAR �
- �'� --- DEPARTMENT OF COMMUNITY&DEVELOPIv�NT SERVICES
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w TURE,PRIOR TO ITS ISSUANCE,AL50 REOUIRES THE APPLICAN7 FOR SUCH PERMIT TO FILE A SIGNED w �
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FESSIONS CA�E)OR THAT HE OR SHE IS E%EMPT THEREFROM AN�THE BASIS FOR THE ALLEGED E%EMP� (�
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� _I HAVE AND WILL MAMTAIN A CERTIFICATE OF CANSENT TO SE�F�INSURE FOR WOFKERS' _
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w _I HAVE AND WILL MAINTAIN WOFNEPS'COMPENSATION INSURANCE,AS REOUIRED BV SECTION
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CJ SHALL NOT EMPLOV ANV PERSON IN ANY MANNER 50 AS TO BECOME SU&IECTTO THE j � - �.�� .„, . , ' "'
(/) WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF 1 SHOUID BECOME INSPECTION FEE
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CODE.I SHAIL FORTHWITH COMPLY WITH THOSE PROVISIONS. ISSUANCE [' /�
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OOLLARS(S10o 000),IN ADOITION i0 THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN �� �
� SECTION 3]OB OF THE LABOR CODE,INTEREST,ANDATTORNEY'S FEES. � �
RETENTION FEE: ����� --�-�-"" `�
a CONSTRUCTION LENDING AGENCY PRE•ALT FEE:
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� I NEREBV AFFIRM UNDER PENALTV OF PERJURV THAT THERE IS A CONSTRUCTION LENDING AGENCV .
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¢ I CERTIFV iHAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMA�ION IS CORRECT. TOTAL FEES '
w I AGREE TO COMPLY WITH ALL CITV AN�COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
� CONSTRUCTION.AND HEFEBY AUTHORIZE REPRESENTATIVES OF 7HI5 COUN7Y 70 EN7ER UPON THE
7 ABOVE�MENTIONE�7ROPERTY FOq INSPECTION GUFPOSES. r(IMMENTS _—
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