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�� � CITY OF DIAMOND BAR -
DEPARTMENT OF COMMUNITY 8c DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
' (909)860-3195 Fax(909)861-3117 PRES$
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� I HEREBY AFFIRM UNDER PENALTV OF PERNRY ONE OF 7HE FOLLOWING DECLARATIONS: �
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� I HAVE AND WILL MAINTAIN A CEHTIFICATE OF CONSENT TO SELF-INSURE FOR WORNERS' 2 � ' ' � � ,
� CONPENSATION,AS PROVIDED BY SECTION 3700 OF 7ME LABOR CODE,FOH THE PERFORMANCE W
OF THE WORK FOR WHICH TNIS PERMIT IS ISSUED. �
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w I HAVE AND NALL MAIMAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTION
Q 370o OF THE LABOR CODE,FOH THE PEHPDRMANCE OF THE WORK WR WHICH 7HIS PERMIT IS O
ISSUED.MY WOp��5�COM1P`NSATION I URANCE CARRIE@1 AND POLICV NUMBER ARE: CONSTRUCTION �
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Z I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMI715 ISSUED,I MECHANICAL �
('} SHALL NOT EMPLOY ANY PERSON IN ANY MANNEH SO AS TO BECAME SU&IECT TO THE ^ q
� WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME INSPECTION FEE A Y R 1 . /�
S SU&IECTTO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 370o OF THE LABOR ISSUANCE �v
CADE,I HALL FORfHWITH COMPLV WI7 OSE PROVISION .{� ,
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� SU&IECTANEMPLOVERTOCHIMINALPENAL7IESANDCIVILFINESUP700NEHUNDREDTHOUSAND ENERGYPERMIT
OOLIJ�RS(f100,000),IN ADDITION TO THE COST OF CAMPENSATION,DAMAGEu'AS PROVIDED FOR IN
� SECTqN 370e OF 7HE LABOFi CODE.IN7EREST,AND ATTORNEY'S FEES. � RETENTION FEE:
a CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
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� I MEREBV AFFIRM UNDER PENALTY OF PERIURV 7HAT THERE IS ACONSTRUCTION LENDING AGENCV
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� LENDER'S NAME ' �
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W I CERTIFY T1AT 1 NAVE READ iHIS APPLICATION AND STATE 71iAT THE ABOVE INFORMATION IS CORRECT. TOTAL FEES /J�(n�/ t
� I AGREE TO COMPLV N7TH ALL CRY AND COUNTY ORDINANCES AND STATE LAWS RELA7ING 70 BUILDING (� `r��
CONSTRUCTION,AND HEREBV AUTFIORIZE REPRESENTA71VE5 OF TNIS COUN7Y 70 ENTER UPON THE
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