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' ` ��_ CITY OF DIAMOND BAR �
�, � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES ��( �J
21810 Copley Drive,Diamond Bar,CA 91765 `�
(909)839-7020 Fax(909)861-3117 Building Inspection Notline(909)839-7027 PRESS
�"�^'. BULL.DING PERMIT APPLICATION FIRMLY
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o ADDRESS ZONING SETBACKS
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p 1 HEREBY AFFIRM UN�FA PENAL7Y OF PERIUPY THAT 1 MI EJ(EMPT FROM THE CANTqACTORS LI- (jafflQBlCe(POA
W CENSEUWFORTIEFOILOWINGREASON(SEC.7031.SBUSINESSPNDPROFESSIONSCOOE:ANYCRYOR (�
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w NRE.PRIOR TD RS ISSUANCE,ALSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w Patio/Deck
� STATEMENT 7HAT HE OR SHE IS UCENSED PUpSUAtJT TO THE PHOYISIONS OF iHE CONTMCiORS LI- �
� CENSE UW(CHAPTER�(COMMENCING WITH SECTION 7000)OF DIVISION]OF THE BUSINESS AND PR6 POOUSpO .
� FESSIONSCOO�OR7HATHEORSMEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEDE%EMP• �
V TION.ANYVIOLATIONOFSECTION70.11.5BYANYAPPLICANTFORAPERMITSU&IEC7S7HEAPPLICANTTO Z R9-R001
A CIVILPENALIY OF NOT MORE THAN FIVE HUNDRED DOLLMS(S5a0).):
Z ❑I,ASOVINEROFTHEPROVER7Y,ORMYEMPLOYEESWITHIVAGESASTHEIRSOIECOMPENSATION, � COrtIfI1BfCIaI -
WILL DO THE WORK,ANO TFIE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC,7oa�,BU51- J
� NESS AND GROFESSIONS CODE:THE CONTRACTORS UCENSE LAW DOES NOT APPLY TO AN OWNER OF �
VROPEHTY NM1iO BUILDS OH IMPROVES THEREON,AND WHO DOES SUCH WORK HIIASELF OR HEHSELF OR
Q THROUGH HIS OR HER OWN EMPLOYEES,VROVIDED THAT SUqi IMPROVEMEMS ARE NO7INTENDED OR m
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Z 710N,THE ONRJER-BUIIDER VALL HAVE hiE BURDEN OF PROVING THAT HE OR SHE DIO NO7 BUILD OR
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[[ TO CANSTRUCT THE PROJECT(SEC.70�1,BUSINE55 ANO VROFESSIONS CODE:THE CONTMCTORS Ll- V81U8110f1 AQJ.AREA
W CENSEUWDOESNOTAPPLYTOANOH?IEROFAPROPERTYWHOBUILDSORIMPROVE57HEREON,AND
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� LICENSED CONTRACTORS DECLARA7lON � w
� 1 HEREBY AFFIRM UNDER PENALTV Of PE0.1UqY 7HAT I AA/LICENSED UNDER PROVISIONS Of CHAVTER �
. � Y(COMMENCINf3 WITM SECTION 7000)OF DIVISION 9 OF THE BUSINE55 AND PROFESSIONS CODE,AND Z
� X MY LICENSE IS IN fULL FORC AND EFFECT.
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� WORKERS'COMPENSATION DECLA N Q ' � ' .
NI HEREBV AFFIRM UNDER PENALTY OF PERIUflY ONE OF THE FOLIOWING OEQARATqNS: Z 1 1�� ��•
� _I HAVE ANO WILL MAINTAIN ACERTIFICATE OF CANSENT TO SELF-INSURE FOR WORNERS' 2
COMPENSATION,/S PROVIDED BY SECTION 37000F THE LABOR CODE,FOR THE PERFORMANCE �U 4'
QOF THE WORK FOR WHICH hIIS PERMIT IS ISSUED. ' �
W HAVE AND WILL MAINTAIN WOR)(ERS'COMPENSATION INSURANCE;0.5 REOUIRED BV SECTION
Q J7000F THE LABOR CODE.FOR THE PERf-0RMANCE OF THE WORK FOR WHIOi THIS PERMI715
I;SUED.MV KER COMPENSAT.�INSUFANCE CMRIER AND POLICY NUMBER ARE: CONSTRUCTION
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Z I CERTIFY hIAT IN h1E PERFORMANCE OF 7HE WOHK fOR WFiICH 7HI5 PERA117 IS ISSUED,I MECHANICAL O� '�
(� SHNl NOT EMPLOY ANY 7ERSON IN ANY MANNER SO AS TO BECAME SUBJECT TO THE
� WORKERS'COMPENSATION UWS OF CALIFORNI/�AND AGREE TMAT IF 1 SHOULD BECOME INSPECTION FEE
SUBJECT TO TNE WORICERS'COMPENSA710N 7ROVISIONS Of SECTION 770a OF THE LABOR '��
� CADE,1 SHALL FOIi�HWITi COAIPLY TI TH45E PROVt510NS. ISSUANCE �
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p DATE: \\)'`IC/'r ` APPLICANP.
J WARNINO:FAILURETO SECURE WOFKERS'COMPENSA7< VERAGE IS UNtAWFUL,AND SH/�LLBE ENERGY P/C
� SU&IECT AN EMPLOYER TO CRIMINAL PENAL71E5 ANO CIVIL ES UP TOONE HUNDRED TFIOUSANO ENERGY PEFMIT
DOLURS(5100.00o�.W ADDITON TO THE COST OF COMPENSATION,DAMAGES AS PiiOVIDED FbR iN
� SECTION 370!OF 7HE LABOR CODE,WTEREST,AND ATfORNEYS FEES. ' RETENTION FEE: ' O I
a CONSTRUCTION LENDING AGENCY PRE-ALT FEE: - �
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� t HEREBY AFFIRM UNDER VEN/�LTY OF PERIURV THA7 TMERE IS ACANSTRUCTION LEN�INO AGENCY
FOR TNE PERF-0RMANCE OF THE WORK FOR WHICH THIS GERMIT IS ISSUED(SEC.3077,CIV.C.).
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� LENDER'S WVAE
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� ICERTIFYTHATIHAVEREADTHISMPLICATIONANDSTATETHATTHEABOVEINFOM/ATIONISCARAECT. TOTAL FEES � a---/ ( �llJ
w I AGREE TO CqMPLY VATH ALL CITY AND COUNTV ORDINANCES AHD STATE UWS REUTNG TO BUILDINO - � T
� CONSTRUCTION.AND HEPEBY AUTHORIZE REPRESENTA7NE5 OF 7HI5 CWMY 70 ENTER UPON iHE
� A80VE�ME1lTIONED 7ROPERTY FOR INSPEGTION PUHPOSES.
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