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CITY OF DIAMOND BAR /-az-4-"
DEpARTMENT OF COMMUNITY & DEVELOPMENT SERVICES PRESS
216M E. Copley Drive Suite 190 FIRMLY
(909) 860-3195 Fax (909) 86 �r rr drrnlu
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OWNER -BUILDER DECLARATION
LICENSED CONTRACTORS DECLARATION
1 HEREBYAFARM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROWStONS OF CHAPTER
P (COMMENCING WITH SECTION 7DWI OF DLVISION 3 OF THE BUSINESSANO PROFESSIONS COOE. WD
MY LICENSE I31N FULL FORCEAND EFFEECT.
LICENSE CLASS �� LTC. NO.��___
DATE,T CONTRACTOR
1
WORKER 'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PETUURY ONE OF THE FOLLOWINO DECLARATIONS:
,INANEA._ AIM0 ACERTIFICAtEOFCONSETHTOSELF INSURE FOR WORKERS'
COMPEN ,ASPRDVIDFO 9YSECTICN Si00 pf THELABOR CODE, FOR THE PERFORMANCE
OF RK FOR WHICH THIS PERMIT IS ISSUED.
I HAYS AND WlLL MAINTAIN WORKERG' COMPENSATION IN501AN0E, AS REQUIRED BY SECTION
3—OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
15 .,MYWORKFP5'COMPENSA INSU NLE RFtlER WD POLICY NUMBERARE
CAP.RIEq (��r�
POLICYNUMBER
(THIS SECTION NEED NOT BE Cc,MM.ETED OF THE PERMIT IS FOR ME HUADPEOX(RS(V N)OR LESS),
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS IS5UEO. I
SHALT. NOT EMPLOYANY PERSON IN ANY MANNER SO AS TO BECOME SUWFCT TO THE
GOQ 1/S(H�A:A. /O�)WfHWiTH COMPLY WI Tl1 OVISIONS,
DATE, ` APPLICANT.
WARNING: FAkURF TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL8E
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL PINES UP TO ONE HUNDRED THOUSAND
DOLLARS (6+oo.BW ). IN ADDITION TO THE COSTOP COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION WOS OF THE LABOR CODE, INTERFST AND ATTORNEY' FEES.
CONSTRUCTION LENDING AGENCY
I HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FDA THE PERFORMANCE OF THE WORK FOR WHICH THI5 PERMIT* FS5VEO (SEC. 30W. CW. C.).,
LENDERS NAME �-
LENDER'S ApORESS
I CERTIFY THAT I RAVE READ THIS APPLICATION AND STATE THATTHE ABOVE INFORMATION IS CORRECT.
IAGREE TO COMPLY WHN ALL CITY AND COUNTY OR D INANC AND STATE LAWS RELATING TO SUROM'G
CONSTRUCTION, AND NFFIC. 11HOHUE REPRESENTATIY OF iNf3 COUNTY iO ENTEfl UPON THE
A80YE`MENTIONEDPROPERTYFORINSPEC PURPOS
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61GNATU FPEgMTTTEE �'DATC
-
APPLICATION 3 / 16 (U 1
PERMIT
NUMBER
PIC
16270 # —
DATE
TYPE
OCC
ISSUE
CONST
GROUP
DATE
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SETBACKS
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FRONT
REAR
SIDElSIDESTAEET
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PROPOSED USE
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MECHANICAL
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ENERGY PERMIT
RETENTION FEE:
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FEE
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