HomeMy WebLinkAbout18078 ^ �� _ CTTY OF DIAMOND BAR
DEPARTMENT OF COrRvfUNITY&DEVELOPMENT SERVICES
21825 E.Copley Drive '
'� (909)8603195 Fax(909)861-3117 PRESS
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w NRE,PRIOR TO ITS ISSUANCE,ALSO REOUIFiES 7HE APPUCANT FOR SUCH.PERMIT TO FILE A SIGNED w
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� CENSE LAW(CHAPTER Y(COMMENCINO WITH SECTION 7000)OF DIVISION 7 OF THE BUSINE55 AND PRO� � POOUSPB 1��
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Z WILL DO THE WORI(AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.704a,BUSI- J �
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PROPEHTY NT10 BUILDS OR IMPROVES TMEFEON,M1D NM1IO DOES SUCH WORK HIMSELF OR HERSELF OR
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w ❑I,ASOWNEROFTHEPROPERTV,AME%CLUSIVELYCONTRACTINOWfTHLICENSEDCONTRACTORS
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� I HEREBV AFFIRM UNDER PENALTY OF PERIURV THAT I AM LICENSED UNDER PROVISIONS OF CHAFTER � / ��� ��
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� I HEREBY AFFIqM UNDER PENPLTY OF PERIURV ONE OF TiE FOLLOWING DECLAqAT10NS: V
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� �PENSATION,AS PROVIDED BV SECiION J700 OF THE LABOR CODE,FOR THE PERFORMANCE U
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w _IHAVEANDWILLMAWTAINWORKERS'COMPENSATIONINSURANCE,ASRE�UIREDBVSECTION
Q 3700 OF THE IABOR CODE.FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS GERMR IS ��
� ISSUED.MY WORNE P1ENSATION INSURANCE CARRIER AND ICV NUMBER e: CONSTRUCTION
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Z I CERTIFV THAT IN THE PERFOflMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL LJ 2 7�
('} SHALL NOT EMPLOV ANV PERSON IN ANV MANNER 50 AS TO BECOME SUBJECT TO THE •
(/7 WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECAME INSPECTION FEE
� SU&IECT TO THE WORKERS'COMPENSATION PROVISIONS OF GT�ON 77000F THE LABOR '^�,e�
� CODE.ISNALLFORTHWITHCOMPLVWITHTFqSEP VIS S. . ISSUANCE c.v
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� SVBJECTANEMPIOVERTOCRIMWALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT
DOLLARS(f1oo,00o),INADDITIONTOTHECOSTOFCOMPENSATION,DAMAGESASPROVIDEDFORIN f �O
� SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEV'S FEES. RETENTION FEE: /.�
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: ) _
� I HERE6V AFFIRM UNDER PENALTV OF PERIURV TIATTHERE IS ACONSTRUCTION LENDING AGENCV
FOR THE PERFORMANCE OF THE WORN FOR WHICH TMIS PERMIT IS ISSUED(SEC.30D7,CIV.C.).
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� LENDER'S NAME
� LENDER'SADDRESS ' •'
W I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. TOTA L FE ES • �� � �`
� 1 AGREE TO COMPLV WITH ALL CITV AND COUNTV 0{iDINMlCES AND STATE LAWS REIATINO TO BUILDING �j�� . Q,
� CONSTRUCTION,AND HEREBV AUTHORRE REPRESENTATIVES OF THIS COUNTV TO ENTER UPON THE /
Z ABOVE�MENTIONED PROPERTV FOR INSPECTION PURPOSES. . � �_
� �--' �j� - COMMENTS _
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� SIGNATUREOFP ITTE DATE
� RECPT.NO. PAID BY � VALIDATION
WHITE-0epartment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy
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ROOF SHEATHING 8 F1'. �UND BEAM
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FINAL ELECTRIC DEV. FEES PAID
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