HomeMy WebLinkAbout12-1631 _���_ CITY OF DIAMt'iNn BAR
� DEPARTMENT OF COMMUNITY&DE�TELOPMENT SERVICES � � �
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(909)839-7020 Fax"(909)861-3117 Building Inspection Hotline(909)839-7027 PRESS
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o ADDRESS' 2 �• � ZONING SETBACKS
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W TURE,VRIOR TO RS ISSUANCE,ALSO REOUIRES THE APPUCANT FOR SUCH PERMIT TO FILE A SIGNED w
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� CENSE UW(CHAPTER B(COMMENCiNO WI7H SECTION 7000)OF DIVISION 9 OF T1E BUSINESS AND PRO� POOUSpO
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� NESS AND PRDFESSIONS CODE:THE CONiRACTORS LICENSEUW DOES NO7 AP�LY TO AN ONMEH OF �
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� UCENSED CONTAACTORS DECLARATION �
� 1 HEREBY AFFIRM UNOER PENALTY OF PERIURV THAT IAMIICENSED UNDER PhOVIS10NS OF CHAPTER � � - � .
� D(COMMENCINO WITH SECTION 7000)OF DIVISION 30F THE BUSINESS AND PROFESSIONS CODE,AND Z .
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� WORKERS'COMPENSATION DECLARATION Q .
� I HEREBV AFFIRM UNDER PENALTV OF.PERIURY ONE OF THE FOLLOWING DEClARA710NS: Z � � �
� _I HAVE AND WILL MAINTNN A CERTIGICA7E OF CONSENf TO SELF-INSURE FOR WORICERS' _
COMGENSATION,AS PROVIDm BY SECTION 370o OF 7HE LABOR CODE,FOR THE PERFORMANCE �U
Q OF THE WORK FOR WHICH THIS VERMIT IS ISSUED. � � � '
Qw 1 HAVEAND WILL MAIMAIN�WORKERS'COMPENSA710N INSUHANCE,AS REOUIRED BV SECTION
�370o OF THE LABOR CODE,FOR THE PERFORMANCE DF THE WORK FOR WHIp1 THIS PERM1715
ISSUFD.MY WORIjERS'COA/PENSATION INSURANCE CAARIER AND.POLICY NUMBER ARE: CONSTRUCTION�
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Z 1 CERTIFV THAT W THE PERFORMANCE Of THE WOHK FOR WHICH THIS PERMIT IS ISSUED.1 MECHANICAL
(} SHALL NOT EMPLOY ANY PERSON IN ANV MANNER SO AS 70 BECAME SU&IECT TO TiE -
� WORKERS'COMPENSATION LAWS OF CK�FORNIA,AND AGREE iHAT IF I SHOULD BECAME �NSPECTION FEE
SUBJECT TO THE WOHKERS'COMPENSATION PROVISIONS OF SECTION�70o OF THE UBOR � �- -
Ocooe.�sHn Forrrrmnni coiaP�r owsioNs. ISSUANCE �7`�.�
p DATE: �APPLICANT:
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J WARNINO:FAIWRE70SECUREWORI(ERS'COMPEN IONCOVEMGEISUNUWFUL,ANDSHALLBE ENERGY�P/C .
�—y SUBJECTAN EMPLOVEH TO CRIMINAL VENALTIES AtJD CIVIL FINES UP TO ONE HUNDRED THOUSANU ENERGY�PERMIT
DOLURS(5100,000),IN ADDI710N TOTHE C0.5T OF CAMPENSATION,DAMAGES AS PROVIDED FOR IN
J SECTION 370E OF THE LABOR CODE,IN7EREST,ANDATTORNEYS FEES. �
p� RETENTION FEE: �__ S.?
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBYAFFIRM UNDER PENALTY OF PERIURY THAT THERE IS A CONSTRUCTION LENDIN6 A6ENCY
FOH THE PERFORMANCE OF iHE WORK FOR NMICH THIS PERMIT IS ISSUED(SEC.3097,CW.C.).
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�--�� LENDER'S NAME
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� ICERTIFYTHATIHAVEREADTHISMPLICATIONANDSTATETHATTHEABOVEINFORlAATIONISCORRECT. TOTAL FEES ' �� �
w I AGREE TO CAMPLY N7iH ALL CITV AND COUNTY ORDINANCES AND STATE UWS REUTING TO BUILDING
� CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTV TO EHiER UPON iHE '
� ABOVE-M EO PROPERTY FOR INSPECTION 7URPOSES.
Z COMMENTS '
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� �SIGNATURE R DATE �
= RECPT.NO. PAID BY VALIDATION
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