HomeMy WebLinkAbout11947 - CTTY OF DIAMOND BAR �
COMMUNTfY DEVELOPMENT DEPARTMENT �� � �
21660 E.Copley Drive Suite 190 PRES•S+
� (909)86P3195 Fax(90�9)861-3117
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� I HEREBV AFFIRM UNOER PENALTV OF PERJUPY THAT 1.461 LICENSED UNDER PROVISbNS OF CHAPTER �
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� _I HAVE AND WILL MAINTAIN A CERTIFlCAtE OF CONSENT TO SELF-INSURE FOR WOFKERS' _
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¢ OF THE WORK FOR WHICM TMIS PEflM1T IS ISSUED. �
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� CARRIER PLAN REVIEW
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(f SHALL NOT EMPLOY ANV GERSON IN ANV MANNEq SOAS TO BECAAIE SU&IECT TO THE
� WORKERS'COMPENSATION LAWS OF CALIFORN�A.ANDAGREE THAT IF I SHOULO BECOME INSPECTION FEE ___���—F�—
SUBJECTTO THE WOPKERS'COAAPENSATION PROVISIONS OF SECTION 770D OF THE LABOR
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J WARNING:FAILURE TO SECURE VJORKERS'COMPENSATION CAVERAGE IS UNIAWNL,AND SHALL BE ENERGY P/C
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OOlLAR6�3700.oa07,IN ADDIT�ON TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
� SECTION370BOFTHEUIBORCOOE.INTEREST,ANDATTORNEY'SFEES. RETENTIONFEE: V
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� I HEREBV AFFIRM UNOER PENALTY OF PERJURY THAT TNEAE IS A CONSTRUCTION IENDING AGENCY
FOR THE PERFOflMANCE OF THE WORK FOH WHICH THIS PEPMIT IS ISSUEO(SEC.3097,CIV.C.�. ,,,,,+
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� CANSTRUCTION.IW�HERE6Y AUTHORRE REPRESEN7ATIVES OF THIS COUNTY i0 ENTER UPON THE
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SLAB GRADE "- FIREPLACE FDUNDATION `
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