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Home My WebLink About1 (35) WORKETZ'S COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure,or a certificate of �� j Workers'Compensation Insurance,or a cectified copy thereof(Sec.3800,Lab.C.) f Cit of Diamond Bar Policy No. Company y 21660 E. Copiey Drive, Suite 100, Diamond Bar, CA 91765 ❑ CeRified copy is hereby furnished. �9�9� 396�567f ❑ Certified copy is fileA wiUt the City Engineering DepaRment, .� � nace Applicant The undersigned hereby makes application to grade on private property at the location described below with the understanding all work is subject to the provisions of Chapter 70 oF the Building Code,the plans and General and Special Provisions approved by the CERTIFICATE OF EXEMF'ITON FROM WORKERS� City Engineer. I am aware that in the interest of public safety,special regulations apply in hillside areas and that geological or engineering cotvmErrsn'r[orr uvsuxa�rrcE reports,or both,may be required before a permit is issued. (1'his section need not be completed if ihe work involved by the permit is for one If excavated materials are ko be obtained from or are tn be disposed of on a separate,non-contiguous site,located within the hunarea aoltars(Stoo)or 1ess.) City of Diamond Bar,a grading permit shall be required for that site also. I certify fhat in the perFormance of the work for which this permit is issued,I shall not In consideration of the granting of the permit,it is further agreed by the applicant that the City of Diamond B az and any of its employ any person in any manncr so as to become subject to the Worke�s'com�o- officers or employees shall be saved harmless by the applicant from any liability or responsibility for any accident,loss or damage to sation�.aws. persons or property,happening or occurring as the proximate result of any work undertaken under the terms of this appiication and the Dac� Applicant permit or permits which may be granted in response thereto,and that all liabilities are hereby assumed by the applicant. N01TCE TO APPLICANT:If,after making this Cadificate of ExempHon,you should becomesubjecttotheworkers'CompensauonprovisionsoftheI.aborCoae,youmust FOR APPLICANT TO FILL IN SITE /� forfhwith comply with such provisions or lhis permit shall be deemed revoked. ADDRESS ;� �'C �� SITE ,-� J ,�� i a 1 LICENSED CONTRACTORS DECLARATION ADDfiESS � ��r� �>� � �-� l�,�, CROSS S7REET . ��"�f"'� �1�+a I hereby aft5rm that I am licensed under provisions of Chapter 9(commencing with LOT ,o, MAP NO. �TA7E HWY PFOCE ED BY Section 7000)of Division 3 of the Business and Rofessions Code,and my license is NUMBERS .�� BLOCK YES❑ NO �a in full force and effect TRACT � CUBIC YDS. PERMIT NO, License Number Lic.Class NUMBER �(.�� HANOLED: OWNER �t�i u��,-�. 4�c.t�a Ve s�uror � �� ' ��' �� Contractor 4 -��°``�° Date MAIL ❑ I am exempt from the licensing requirements as I am a licensed architect or a '� � n �1 (', USE ZONE SPECIAL registeredprofessionatengineeractinginmyprofessionalcapacity(Section705I, ADDRESS -�� ,p��:.r� ►��v�v, ; CONDITIONS Business and Professions Code). TEL.�,�^� CI'FY �G t�.u�.�a.. NO. �7��°ra e�_��L�a;y Lic.orReg.No. Da� STATE ENGINEER �-�.� ��'�- REG.NO. <b�4%G�I�� HOMEOWNER-B[JILDERDECLARATION MAIL �, I hereby affim�that I am exempt from the Contractor's License Law for the Following MADDRESS ��G"" �~ ��^^�-�s��'� i�,�(�� reason(Section 7031.5,Business and Professions Code): TEI.. SUR6TY$ �d-•--cr�:>" ❑ I,asowneroftha ro ert ,orm em lo eeswithwa esastheirsolecom nsa- C�T� �� -� Np, �l� � �.`j1 •��3 �..�'�� _ �p�ND P P Y Y p Y g Pe BOND tion,will do the work and the stmcture is not intended or offered for sale(Section GRAOING TEI.. SURETY 7044,Business and Professions Code). CONTRACTOR NO. COMPANY DATE REC'D ❑ I,as owner of the propecty,am exclusively contracting with licensed contractors ADDRESS FILED BY to construct the project(Section 7044,Business and Pmfessions Code). CASH PROPOSEDUSEOFGRADEDSITE S DEPOSIT$ �,�evc� � �C?f,a.� FILED �"�`�`� CONSTRUCTION LENDING AGINCY I hereby aifirm that there is a conswction lending agency for the perfomiance of the - THIS IS A LIMITED TIME PERMIT work for wMch this permit is issued(Sec.3097,Civ.C,). Lender'sNazne ALl WORK AUTHORIZED MUST BE COMPLETED BY Lender'sAadress TIME LIM►T: IceRifythatIhavereadthisapplicationandstatethattheaboveinformationiscocrect. CHECKIFSUPERVISEDGRADING ❑ 6XTENDEDTO: gy. I agree to comply with all City ordinances and State laws retating to building SIGNATUpE constmction,andherebyauthorizerepresentativesofthisCitytoenterupontheabove- OFAPPLICANT EXTENDEDTO: gy; mentioned propeRy for inspection purposes. TEL. ADDRESS NO. P.C.FEE$ `"� Permit Fee � � '� � �e"`�" Signacure of Pernrittee Date PERMIT IS REQUIRED BEFORE COMMENCING WORK. ��- � ��>� INSPECTION IS REQUIRED. Issuance Fee � CA�L(909)39fi-5671 AT LEAST 24 HOURS BEFORE STARTING WORK. ` �_r � ] �"7 r`� -� �`�'� Total Fee � / �� t�