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� CTI'Y OF DIAMOND BAR
---�� -- DEPARTMENT OF COIvIIvIUNITY&�DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117 PRESS
��'%�^�� BUILDING PERMIT APPLICATION FIRMLY
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p I HEREBV AFFIRAI UNDER PENALTV OF�ERJURV THAT I AM E%EMPT FROM THE CONTRACTOqS LI- G8f0gB/C81pOff �
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W NRE.PRqR TO ITS ISSUANCE.ALSO REWIRES THE APPLICANT FOR SUpi PERMIT TO FILE A SIGNE� w P8t10/DBCI( ',
� STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- . '
� CENSE LAW(CHAPTER i(COMMENCING WITH SECTION�000)OF DIVISION 7(1F THE BUSINE55 AND PRO� � POOUSPB
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Z WILL DO THE WORK�ND THE STRUCTURE IS NOT INTENOED OR OFFEREO FOR SALE(SEC.70u,BU51� J
N NESS AND VROFESSIONS CODE:THE CONTRACTORS�ICENSE LAW DOES NO�APPLV TO AN OWNER OF �
PR07ERTV NM1IO BUILAS OR IMPROVES THEREON,AND NMO OOES SUCH WORK HIMSELF OR HERSELF OR
� THROUOM HIS OR HER OWN EMPLOVEES,PROVIDEO THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR CO
� OFFEREDFORSALEIF,HOWEVERTMEBUILDINOORIMPROVEMENTISSOLDWITHINONEVEAROFCOMPIE-
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I HEREBV AFFIRM UNDER PENALTY OF PERIURV THAT I AM LICENSED UNDER PROVi510N5 OF CHAPTER �
� D(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PP.OFESSIONS CODE,AND Z
LLI ���CENSE IS IN FULL FORCE AND EFFECT. m
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� � WORKERS'COMPENSATION DECLARATION Q
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� �HEREBV AFFIRM UNDER VENN.7Y OF PERIURV ONE OF THE f-0LLOWING DECLARATIONS: Z
� _I MAVE AND WILL MAINTAIN A CERTIFICATE OF CqNSENT TO SELF-INSURE FOR WORNERS' a
� COMPENSATION,AS�ROVIDEDBVSECTION37000FTHELABORCODE,FORTHEPERFORMANCE U
wOF THE WORK FOR WHICH THIS PERMIT IS ISSUED. �
� _I HAVE AND WILL MAINTPJN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTION .
Q 3700 OF THE LABOR CODE.FOR THE PERFORMANCE OF THE WORN FOR WHICH THIS PERMIT IS
ISSUED.MV WORICERS'COMPENSATION INSURANCE CARRIER AND POLICV NUMBERARE: CONSTRUCTION
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Z POIICY NUMBER ELECTRIC
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Z I CERTIFV TH�T IN THE PERFORA/ANCE OF THE WORN FOq WHICH THIS PERMIT IS ISSUED.I MECHANICAL
C} SHALL NOT EMPLOV ANV PERSON IN ANY MANNER 50 AS TO BECOME SU&IE�T TO THE
(ry WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME INSPECTION FEE
SU&IECT TO THE WORNERS'COMPENSATKKJ PROVISIONS OF SECTION 3700 OF THE LABOR
�j CODE,I SHALL FORTNWITH COMPLV WITH THOSE PROVISIONS. ISSUANCE ' �
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p DATE: APPLICANT: SMIP
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J WAHNINO:FAILURE TO SECURE WORKERS'COMPENSATKKJ COVERAGE IS UNUWFUL,AND SHALL BE ENERGY P/C
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� SU&IECTANEMPLOVERTOCRIMWALPEN/�1.TIESMIDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT
DOLLAFiS(f100.o00).IN ADDI710N TO THE COST OF COMPENSATION,OAMAOES AS PROVIDED FOR IN
� SECTION 37oe OF THE LABOR CODE.INTEREST,M1D ATTOFNEV'S FEES. RETENTION FEE: y
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O CONSTRUCTION LENDING AGENCY PRE-ALT FEE: �
� I HEREBV AFFIFM UNDER PENALTV OF PERJURV THAT THERE IS A CONSTRUCTION IENDING AGENCV
� FOF THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEO(SEC.70Y'!,CIV.C.).
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� LENOER'S NAME
F- LENDER'SADDRESS
� TOTALFEES � �
� I CERTIFV THAT I HAVE READ TMI$APPUCATION AND STATE THAT THE ABOVE MFORMATION IS CORRECT.
w I AGREE TO CAMPLY WITN ALl CITV AND COUNTY ORDINANCES AND STATE UWS PEIATING TO BUILDING
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� CONSTRUCTION,AND HEREBV AUTFqqIZE REPRESENTATNES OF THIS COUNTV TO ENTER UPUN THE
Z ABOVE�MENTIONED PROFERTV FOR INSPECTION PURPOSES. COMMENTS
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TEMP POWER � FIREPLACE BONa BEAM
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SHOWER�TUB TEST P(JOL ELEGTRIC
EXT. LATH/SIDING POOL FENCING
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CEILING INSULATION CF�SIT� IMPS. �
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