HomeMy WebLinkAbout17695 ^---��-- CIT'Y OF DIAMOND BAR ' �
DEPARTIv1ENT OF COIvIIvIUNITY&DEVELOPMENT SERVICES
21825 E.Copley.Drive �ZZ/(f3
(909)860.3195 Fa�c(909)861-3117 PRESS
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� NESS AND FROFESSIONS CADE:THE CANTRACTORS LICENSE UW DOES NOT APPLV TO AN OWNER OF �
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� I HEREBV AFFIRM UNDER PENALTV OF PERJURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER �
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� I HEREBV AFFIRM UNDER PENAL7V OF PERIURY ONE OF THE FOLLOWING DECLARATIONS: Z
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Q COMPENSATION,AS PROVIDED BV SECTION 370o OF THE LABOR CODE,FOR THE PERFORMANCE U
Q OF THE WORK FOR NM171CH 7HI5 PERMIT IS ISSUED. �
Qw _I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS RE�UIRED BV SECTION
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N WORKERS'CAMPENSATION LAWS OF CALIFORN10.�ND AGREE THAT IF I SHWLD BECOME INSPECTION FEE
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� SUBJECTTO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 370o OF THE LABOR
� COOE,I SHALL FORTFIWIiH COMPLV WITH THOSE PROVISIONS. ISSUANCE 1 ^
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p DATE: APPLICANT.
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� SU&IECTANEMPLOVERTOCRIMPIALPENALTIESANDCNILFINESUPTOONEHUNDREDTHWSAND ENERGYPERMIT � �
DOlURS(f 700.000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
J SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEV'S FEES. �
¢ RETENTION FEE:
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBV AFFIRM UNDER PENALTY OF PERJURV THAT THERE IS A CONSTRUCTION LENDINO AOENCY '
FOR iHE PERf-0RMANCE OF 7HE WORK FOR WHICH 7HI5 PERMIT IS ISSUED(SEC.7DB�,CIV.C.).
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� LENDER'S NAME
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w I CEflTIFY THAT I HAVE REPD THIS APPLICATqN AND STATE THAT iHE ABOVE INFORMATION IS CORRECT. TOTAL FE ES • � �' � 1 �.j J�
� I AGREE TO COMPLV WITH ALL AND COUNTV OR INMlCES AND STATE LAWS RELATINO TO BUILDINO ' V�V�1
� CONSTRUCTION,ANDHERE THORIZEREPR TATIVESOFTHISC NTYTOENTERUPONTHE j� �D�Z' I
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� SIGNATUREOF I A E
� RECPT.NO. PAID BY VALIDATION
WHIT —Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy
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