HomeMy WebLinkAbout14408CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Cwlcy Drive Suite 190
(909) MO-3195 Fax (909) 861-3117
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OWNER-BUILDER DECLARATM,
HERESY AFrdW LEADER pENA&Ty OF PEMIRY THAT I AM EXEMPT FROM THE CONTRACTORS U
086SELAW FORTHE FOLUX140101 REASON (SEC. 7=.5 BUINNESSAIND PROFESSIONS COMANYCIINOR
PAQUIRESAPERMIRTOCONSTRUCT MYER IMPROVE DOXXISKORREPMANYSTmr-
..TINE, PRIOR .0 ITS WBUAHCE, ALSO REQUIRES THE APPLACANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LIGE NSW PURSUANT W THE PROVISIONS OF THE CONTRACTORS LS
CEMrE LAW {CHAPTER 9 (DOMMEMOING WITH SECTION ?Wo) OF DIVISION 3 OF THE BUSINESS AND PRO-
IFESSIONS CODE) OR THATHE OR SHE IS EXEMPT THEREFROM AND THE BASS FOR THE ALLEGED 00AP-
JKK ANY VIOLATION OF SECTIONTONA BY ANY APPUICANT FORAPERWIT SULIECTS THEAPPLIGANTTO
ACNL PENALTY OF NOT MOM THW FIVE HUNDRED MUM (45" k
13LAS&AKMOFTMPROPWM,ORWY&04=MVATHWAMASTHMMEODMPEN"TOOK
_AWL DO THE WORK AND1HE STRUCTURE 19 NOT INTENDED OR OFFERED FOR SALA ISM 7044 91,0-
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PROPERTY V*DWUWORWF^"IN"EOAMOMMDMUMMOM HUWLPCRHERS&FOR
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LICENSED CONTRACTORS DECLARATION
I HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER..
OF US BLISIMMAND PF40FESSKM CODE
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WORKERS' COMPENSATION DECLAR4059'
INEHFBrAFRiM LEADER pENALTy OF pEriLm ONE oFTHE FOLLOWIM DECL4RATIOHS:,
_I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SEUl`4NSURE FOR VXWKEW
COMP11MATION. AS PROVIDED BY SECTION 3700 OF THE LABOR OWL FOR THE PERFORMANCE
OF THE WCM MR WHICHURB REPENT O'SM ED
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ERILIM My WORCEW COMPENSATION INSURANCE CARR" AM POLM NUMBER AFF-
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I C9RM THAT IN THE PERFORMANCE OF THE WOK FOR WHICH THIS PERMIT IS ISSUED, I
SHALL NOT SM." AM PERSON MANY MANNER BOAS TO BECOME SLALIELT TO THE
WOFNMRV COMPENSATION LAWS OF CALSOFINA, 00 AaKE THAT IF [SHOULD BECOME
SURACTTOTHEWORKERSI` WAWENSATUNPRONSIONS OF SECTION 37W OF THE LABOR
ANITHWITH COMPLY VM THOSE PROVISIONS.
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FAURE To SECURE INORI COMPENSATION COVERAGE 13 UNLAWFUL. AND SHALL BE
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SUBX-CT AN EMPLOYER To cpjmn4L PENALTIES AND CW FIMES UP TO ONE HUNDRED THOUSAND
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�(SJK THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN
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CONSTRUCTION LENDING AGENCY
OONSTRUCTIONLENDMAC ENCY
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FORTE PERFORMANCE VMFRW=;rPEZS ISSUED (SEC 30F7. CRA,
LENDen I....
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UNDEMBADDAM
- CERTIFY THAT I WARE READ THIS APPLICATION AM STATE THAT THE ABOVE INFORMATION IS OCORRECT.O.
, AaFEE TO oomKy WITH Am CITY Am COUNTY ORDINANCES AM STATE LAWS RELATING 70 BUlUDlNG
CONS. —., AND mEmsvAun4DRaEftB4*ZEM-MESOFTMODUKffTOBUERUPMTHE
Agova.MENTIOHED PROPERTY FOR MIS PRUlAJPXM)$m
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TOTAL FEES 2.:�F
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