HomeMy WebLinkAbout11950 CTTY OF DIAMOND BAR �' � � �
CaMMUNITY DEVELOPIv1ENT DEPARTMENT �
-;,.� . 2166�E.Copley Dnve Suite 190 PRES•S
(909)860-3195 Fax(909)861-3117
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� CENSE LAW{CHAPTER 9(COMMENCING WITH SECTION l000�OF DIVISION 3 OF TNE BUS�NESS AND PRO• � PoOUSpe
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A CIVII PENALTY OF NOT MORE THAN FNE Hl1NDRE0 DOLUHS(S6o0�.):
❑I,AS OWNER OF THE PROPERTV,OR MV EMPLOVEES WITH WAGFS AS THEIR SOI,E COM7ENSATION,
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PROPERTV WHO 9U0.DS OR IMPROVES THEREON.AND WHO DOES SUCH WORK NIMSELF OR HERSELF OR
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� WORKERS'COMPENSATION DECLARATION a
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� _I HAVE AND WILI MAINTqIN A CERT�FICATE OF CqNSEMTO SELFINSURE FOR WORKER5 =
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d ��o00F THE IABOR COOE.FOF TNE PERFORMANCE OF THE WORK FOR WHICH THIS PEPMff IS ��
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Z I CEHTIFY 7HA7 M THE PEpFORMqNCE OF THE WpRK FOP WHldl THIS PEAN�T IS ISSUE�,I MECHANICAL
L'7 SHALL NOT EMPLOY ANV PERSON IN ANV MANNEF 50 AS TO BECOME Sl1BJECT 70 iME
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p OATE: APPLICANT: SMIP �
� WRRNINO:FAILURE TO SECURE WORNERS'COMPENSATION CAVERAGE IS UNLAWFIIL,AND SHAL4 BE ENERGY P/C
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� 1 MERE9Y AFFIRM UNDER PENAITY OF PERJURV TNAT THERE IS r1CAN5TFUCTION LENOING AGENCV
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� LENDER'SNAME
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� I CERTIFY TW1T I HAVE READ iN15 APPLICATION AND STATE n-IAT THE ABOVE INFORMATION IS CORFECT.
� IAGREETOCOMPIYWITHALLCITYANOCOUNTYORDINANCE5AND5TATElAMSRELATINGTOBUILDING -'
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SLAB GRADE FIREPLACE FOUNDATION
TEMP POWER FIREPLACE BOND BEAM
WA7ER SERVICE ' - -' `' ' 'r M!D HT. BOND BEAM
ROOF SHEATHING " � 8 FT. BOND BEAM
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