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r��� CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERV ES
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(909)8G0-3195 Fax(909)861-3117 , PRE$$
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� (�775E UW(CHAVTER Y(COMMENCWO N7TH SEC710N 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- � P��SPB I
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� UCENSED CONTRACTORS DECLARATION W � ,
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I HEREBYAFFIRM UNDER PENALTY OF PEFLIUfiY T}IAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER �
� Y(CO�IMEHCVJO Wlhl SECTION 7000)OF DNISIDN 3 OF THE BUSINE55 AND PROFESSIONS CODE,AND Z ' -
X. MY LICENSE IS W FULL FORCE AND EFFECT. �
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N1 HEREBY AFFlRAI UNOER PENALTV OF PERri1RV ONE OF TME FOLLOWINa DECLARATIDNS: Z
� _I HAVE M!D WILL MAIN7NN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS' ¢
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COMPENSATION,AS PROVIDED BV SECTION 37000F THE UBOR CODE,FOR THE PERFORMANCE �U
OF THE WORK FOR NMICH TMIS PERMIT IS ISSUED. �
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N WORKERS'COMPENSATION LAM/5 OF CALIFORNIA,AND A(iREE THAT IF I SHOULD BECOIAE INSPECTION FEE . ��.�
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DOLLARS(f100,000).IN ADDITON TO THE C0.ST OF COMPENSATION,DAMAOES AS PROVIDED FOR IN
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� I HEREBV AFFIRM UNDER PENALTY OF PER1UfiV THAT THERE IS ACANSTRUCTION LENDWG AOENCV �
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.7087,CIV.C.). , .
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� LENDERS NMIE � �
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w I CERTIFY TMAT I HAVE RE/iD THIS APPLICATION ANO STATE THAT THE ABOVE INFORA/ATqN IS CORRECT. TOTAL FE ES ' _
� I ACiPEE TO COMPLY WITH ALL C�TY AND CWNTV ORDWMICES AND STATE IAWS RELATING TO BUILDING / �3 �
� CONSTRUCTION,AND HEREBY AUTHOHIZE REPRESENTATIVES OF THIS COUNTV TO ENTEF UPON THE
Z ABOVE�M NTIOFlED PROPENTV FOR INSPECTION PURPOSES. COMMENTS �
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