HomeMy WebLinkAbout17900 ' � � ___��_— CTTY OF DIAMOND BAR
DEPARTMENT OF CONIIvIUNTI'Y&DEVELOPMENT SERVICES
21825 E.Copley Drive '
(909)860-3195 Faac(909)861-3117 PRE$$
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� CENSE UW(CHAPTER D(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- PooUSpa
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Z WILI DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.704a,BU51- J
� NE55 M1D PROFESSIONS CODE THE CANTRACTORS UCENSE LAW DOES NOT APPLV TO AN OWNER OF �
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I HEREBY AFFIRM UNDER PENALTV OF PERIURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER � (�
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Qw �I MAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BV SECTION
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J ISSUED.MY WORI�ji�COMP NSATION I��CE C�IER AND POLICY NUMBER AAE: CONSTRUCTION
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C'} SHALL NOT EMPLOY ANV PERSON IN ANY MANNER SO AS TO BECOME SU&IECT TO THE
� WORKERS'COMPENSATION UWS OF CALIFOqNIA,AND AdREE THAT IF I SHOULD BECAME INSPECTION FEE
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR `
rj CODE,I SHAf,L FORTHWITH COMPLY WITH E PRO S. ISSUANCE �V C
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DOLLARS(5100,000),IN ADDIiION T0 THE C0.ST OF COMPENSATION,DMIAGES AS PROVIDED FOR IN
J SECTqN 3708 OF THE LABOR CODE,WTEREST,AND ATfORNEY'S FEES.
[C ' FETENTION FEE:
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBV AFFIRAI UNDER PENALTV OF PERJURV THAT THERE IS A CONSTqUCTION LENDIN�AGENCY
FOR THE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.308'!,CIV.CJ.
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� LENDER'S NAA/E
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w I CERTIFY THAT I HAVE flEAD THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CARRECT. TOTAL F E ES � ��' .y�
� I AGREE TO COMFLV WITH ALL CITV AND COUNTV ORDINANCES AND STATE LAWS RELATINO TO BUILDING
� CONSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
Z ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. COMMENTS
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~ WHITE—Depariment Copy,YELLOW�inance Copy,PINK—Assessor Copy,GOLDENRO�File Copy,GREEN—Applicant's Copy
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