HomeMy WebLinkAbout16130 (23) CITY OF DIAMOND BAR EXp�RED
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21660 E.Copley Drive Suite 190� ��;J 17 2002 PRESS
(909)860-3195 Fax(909)861-3117
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N I HEREBY AFFIRM UNDER PENALTV OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
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� I HAVE AND WILL MAINTAIN A GERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS' S
� COMPENSATION,AS PROVIDED BV SECTION 370o OF THE LABOR CADE,FOR THE PERFORMANCE �U
9FiHE WORK FOR WHICH THIS PERMIT IS ISSUED.' �
W �� I HAVE AND NALL MAINTAIN WORNERS'COMVENSATION INSUMNCE,AS RE�UIHED BY SECTION , ` \
O 37000F THE LABOR CODE.FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PEiiM1T IS � ��
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Z I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
(,�J SHALL NOT EMPLOY ANY PERSON IN ANV MANNER SO AS TO BECOME SU&IECT TO THE ,�
� WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGHEE THAT IF I SHOULD BECOME INSPECTION FE
� SU&IEC770 THE WORKERS'COMPENSA710N PROVISIONS C710N 37000FTHE LABOR
� LODE,I SHALL FORTMWITH COMPLY WI OSE VIS s. SSUANCE �
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� SU&IECT AN EMPLOVER TO CRIMINAL PENALTIES AND C IL FINES UP 700NE HUNDRED THOUSAND ENERGY PERMIT
DOLLARS(f100.000).INl�OITION TO THE COST OF COMPENSATION,DAMAGES AS PPOVIDED FOR IN
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� I HEREBV AFFIRM UNDER PENALTV OF PERIURV THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF 7HE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3097,qV.C.).
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� LENDERS NM1E
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� I CERT�FV THAT I HAVE REPD THIS APPLICATION M'D STATE THAT THE ABOVE INFORMATpN IS CORRECT. TOTAL FE ES I � •
w I AGHEE TO CAMPLV WITH ALL CITY AND COUNTY ORDINANCES AND STATE UWS REUTING TO BUILDING
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Z �VE��ENTIONED PROPERTY FOF INSPEC710N PURPOSES. COMMENTS
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