HomeMy WebLinkAbout12-1267 ----����-- DEPARTME T OF COMMUNITY&DEVELOPM/ENT�VICES V �`��` I " �
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21810 Copley Drive,Diamond Bar,CA 91765
' (909)839-7020 Fax(909)861-3117 Building Inspection Hotline(909)839-7027 PRESS
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Z N7LL DO THE WORK M1D THE STRUCTURE IS NOT IMENDED OR OFFERED FOR SALE(SEC.7a�,BU51- J �
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� I HEREOY AFFIRM UNDER PENAL7Y OF PE0.IURY THA7 I AM IICENSED UNDER PROVISIONS Of CHAPTER �
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� 1 HEREBY AFFIRM UNDER PENALTY OF 7ERIURY ONE OF THE FOLLOWING DECLARATIONS: Z
�Z _I HAVE AND WILL MAINTAIN A CEFTIGICATE OF CONSENf TO SELF-INSURE POfi YARKERS ¢ I
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COMPENSATION,AS PROVIDED BY SECTION 37a0 Of THE UBOR CODE,FOR THE PERFORMANCE U
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� ��HAVE M1D WIIL AWNTAIN YJbRKERS'COMPENSATON INSURANCE,AS REOUIRED BY SECTION
Q 770o OF THE UBOR CODE,FOR THE PERFORMANCE OF THE WORN FOR WHIp1 THIS PERMIT IS ��� 'v�
ISSUEO.MY WORK S'CAMPENSATI INSURANCE CARRIERAND POLICY NUMBERARE: CONSTRUCTION
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C.�3 SHN.L NOT EMPLOY ANY VERSON IN ANY MANNER SOAS TO BECAME SU&IECT TO THE
� WORKERS'COMPENSATIONLAWSOFCn11FORN10.NdDAGREETHATIFISHOULDBECAME INSPECTIONFEE
? SU9IECT TO THE WORKEHS'COMPENSATION PROVISqNS OP SECTION]700 OF THE I�BOR .^�
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� LENDER'S NMIE
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w I CERTIFY THAT 1 HAVE READ THIS MPIICATION AND S7A7E T1MT THE ABOVE INFORMATION IS CORRECT. TOTAL FEES I�� �
� I AGREE TO COMPLV VATH ALL CITY ANO COUNTY OROWANCES M!D STATE UWS REUTING TO BUILDIN6 � I !
� CONSTPUCTION,AND HEREBY AIRHORIZE REPRESEN7ATNE5 Oi T11S CWtfTY TO ENTER UPON iHE .
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