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^---��` _ CIT'Y OF DIAMOND BAR �
DEPARTMENT OF COMMUNTTY 8c DEVELOPMENT SERVICES �
21825 E.Copley Drive
(909)860-31'95 Fax(909)861-3117 PRESS
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� STATEMEM THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTMCTORS U- �
� CENSE LAW(CHMTER Y(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF TNE BUSINESS AND PRO� POOUSPB
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� 1 HEREBV AFFIRM UNDER PENALTY OF PERIURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER � /1 ' .
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COMPENSATION,AS PqOVIDED BV SECTION J700 OF TME IABOR CODE,FOR THE PERFORMANCE U
Q OF 7HE WORK FOfi WHICH THIS PERMIT IS ISSUED. �
Qw �I HAVE AND WILL MAINTAIN WORKERS'COMPEN9ATION INSURANCE,AS REW IRED BV SECTqN /'� `
370o OF iHE LABOR CADE.FOR THE FERFORMANCE OF THE WORK WR WHICN THIS PERMIT IS , 1 4 1 U
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Z I CEflTIFV THAT INTHE PERFORMAIJCE GF THE WORK FOR WHICN THIS PERMIT IS ISSUED.I MECHANICAL
C,'} SHALL NOT EMPLOV ANV PERSON IN ANV NANNER SO AS TO BECAME SU&lECT TO THE �
(/� WORKERS'COMPENSATION LAWS OF CALIFpRNI�AND AOREE THAT IF I SHOULD BECOME INSPECTION FEE /
� SUBJECT TO THE WORKERS'COMPENSATpN�ROVISk1NS YF SECTION 3700 0F THE LABOR /
,� CODE,I SHALLFORTHWITHCOMPLV WITHTFI�SE� ISIONS. ISSUANCE � O/\
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p DATE: bL APPLICANT: N SMIP � JQ� /
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J WAqNING:FAILUflE TO SECURE WORNERS'CAMPENSATIdN CqVERA IS UNLAWFUL.AND SHALL BE ENERGY P/C
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J SECTION37oeOFTHELABORCODE,INTEREST,ANDATTpRNEV5FEE5. ���� �\
OC � RETENTION FEE: �
OCONSTRUCTION LENDING AGENCV PR6ALT FEE �
� I HEREBV AFFlRM UNDER PENALTV OF PERJURV 7HAT THERE IS A CONSTRUCTION LENDING AOENCY
� FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERAIIT IS ISSUED(SEC.3087,CIV.C.). �
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� LENDERS NAME ��
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F'- LENOEF'SADDRESS
w ICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETHAT7HEABOVEINFORMATIONISCOqRECT. TOTAL FEES F � �a, �� � ��� I�
� 1 AGREE TO COMPLV N7TN ALL CITV AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDINO ,
� CONSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATNES OFTHIS COUNTV TO ENTER UPON 7HE ��
Z ABOVE-MENTpNED PROPERTY FOR INSPECTION PUflPO5E5. COMMENTS � '
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