HomeMy WebLinkAbout1764, _ _�� _ CITY OF DIAMOND BAR
DEPARTMENT OF COrRv1UNITY&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117 PRESS
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� I HEREBV AFFIRM UNDER PENALTV OF PERJUPV THAT 1 AM UCENSED UNDER PROVISIONS OF CHAPTER �
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_I HAVE AND WILL MAINTAIN WORKERS'CAMPENSATqN INSURANCE.AS REOUIRED BV SECTION ��' �
Q 3700 OF THE LABOR CODE,FOR 7HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED.MV�WORK�ER�S'CO.,M�P,ENSALTg�INSU�R�ANC�E CARRIEfl AND POLICV NUMBER ARE: CONSTRUCTION
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Z I CERTIFV THAT IN THE PERF-0RMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
�'} SHALL NOT EMPLOV ANY PERSON IN ANY MANNER 50 AS TO BECAME Sll&IECT TO THE
(/7 WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHWL�BECAME INSPECTION FEE
= SU&IECT TO THE WORKERS'CAMPENSATKKJ PROVISIONS OF SECTqN 7�00 OF THE LABOR �
CODE,I SHALL FORTHWITH COMPLV WITH 7}q5E PROVISIONS. ISSUANCE
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J SECTION 37ae OF THE LABOR CADE,INTEREST,AND ATTORNEV'S FEES.
OC RETENTION FEE:
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O CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBV AFFIqM UNDER PENALTY OF PERJURV THATTHERE IS ACANSTRUCTION LENOWO AOENCY
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� LENDER'S NAME
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� I AGREE TO COMPLV WITH ALL CITV AND CAUNTY ORDINANCES AND STATE UWS RELATINO TO BUILDING
� CONSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATNES OF THIS COUNTV TO ENTER UPON THE ' ���
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