HomeMy WebLinkAbout12861CITY OF DIAMOND BAR `
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
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I HEREBY AFFIRM UNDER PENALTY OF PERJURY Li-
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CENSE LAW FOR THE FOLLOWING REASON (SEC. 703I.SBUSINESSAND PROFESSIONS CODE: ANY CITY OR
C.i COUNTY WHICH REOUIRESA PERMITTO CONSTRUCT. ALTER ,IMPROVE, DEMOLISH, OR REPAIR ANY STRUC•
WTURE, PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE LAW (CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE OASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7031.E BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($50011.): THEIR COMPENSATION,
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I, AS OWNER OFTHE PROPERTY, OR MY EMPLOYEES WITH WAGES AS
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PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HEfl OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
W OFFERED FORSALE IF HOWEVEfl,THEBUILDING ORIMPROVEMENTIS SOLD WITHIN ONEYEAROF COMPLE•
TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
W O1, AS OWNEROF WEPROPELTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT 7HE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U-
CENSE LAW DOES NOTAPPLY TO AN OWNER OF APROPERTY WHO BUILDS Ofl IMPROVES THERE
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTflACTOR(S) LICENSED PURSUANTTO THE COFITRAC•
TORS LICENSE LAW.).
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u- DATE OWNER
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I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT i AM LICENSED UNDER PROVISIONS OF CHAPTER
� 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND
X MY LICENSE IS IN FULL FORCE AND EFFECT.
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� WORKERS' COMPENSATION DECLARATION
C0 I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
WORKERS'
_ I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR
COMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
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� _INANE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE, AS REQUIRED BY SECTION
ISSUED. MY WORKEOF THE LABORRS' COMPEN ATION IDE. FOR THE NSURANCE CARRIER AND POLICRMANCE OF THE WORK FOR Y NUMBER ARE:CH THIS
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W I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME
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SHALL FORTHWITH CO PLY WITH THOSE PROVISIONS.PROVISIONS OF SECT ON 3700 0� THE LABOR
Q DATE:
APPLICANT:
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J WARNING: FAILURE TO SECURE YlORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALLBE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
J SELA SCTION 3708 THE LABORION To TH E CODE, NTEROST OF COMP EN EST, AND ATTORNSEYS FEERAGES AS PROVIDED FOR IN
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CONSTRUCTION LENDING AGENCY
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CL FORT HE PERFORMANCE OF THE ORK FOR WHICH THIS EPERMIT IRE IS S ISSUED (SEC.3097, CIV C;ENCY
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LENDER'S NAME
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W I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
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TCTIOFLPAND HE BY AUTHORIZEPRESENTATIVLY WITH ALL CITY AND COUNTY ES OF THIS S AND ACOUNTY TO ENTER UPON THE
TE LAWS RELATING TO NG
ABOVE• NTIONED PRQPIERTY FOR INSPECTION PURPOSES -
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RECPT. NO. I ') PAID BY
-Assessor Coat, GOLDENROD —File COPY, (