HomeMy WebLinkAbout11003 (5)r
• CITY OF DIAMOND BAR
COMMUNITY DEVELOPMENT DEPARTMENT
.0 21660 E Copley Drive Suite 190
PRESS__-_
*^ BUILDING PERMff APPLICATION FIRMLY
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,DESIGNER
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OWNE 141ULDERDECLARATION
I HERESY AFFIRM UNDER PBIALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LF
CESE WNFORTHEFGLLOWiP4AEASON(SEC.70Si.SBL"CSSANDPROFMIOP64OOMMVCNOR-
000DYWHS(S(REd1NESAPMWT000NSTRUO ALTMILWROVE.DBAOUSKOFIREPAItANYSTRUC-
TURE„ PRIOR TO RS SAMNCE, ALSO REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A Ste'
STATEMENT THAT WE OR SHE S LICENSED PIISUANT TO THE __THE comnuCTORS v--
-CESE LAW ""TER I (COMMENCOG WITH SECTION 7000) OF DIVISION ] OF THE BUSINESS AND PRO.
FESSIONS COW OR THAT HE OR SME S EXEMPT THEREFF1361 NO THE BASIS FOR THE ALLEGED ExEmr,
TION.MIYVIOLATIWOFSECnONT0514BYANYAPPLCCAHTFORAPBWTSUB.ECTBTHEA"L4h TTO
ACIVLEN
PENALTY OF NOT MORE THAW FRE HNDREDDOlLARS(55mkk
O LASOWNER OFTNE PROPERTY, OR MY EMPLOYEES WITHWAOESASTHEIR SOLE COMPENSATION,:
MILL DO THE WORK AND THE STRUCTURE M NOT 00040 D OR OFFERED MR SALE (SEC. 7044, SUSF -
OESB AND PROFESSIONS CODE THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF-
PROPEMYWHO RULDS OR IMPROVES THEREON. AND WHO DOES SUCH WORK HIMSELF ORIERSRFOR'
THROUON HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH YWROVEAENTSARE NOT INTENDED OR
OFFEREDPoRSALEF.HDWEVERTHESLWAWBORMIWDVEMEHTISSOLDWOT MC"YEMOFCOLM6
TION, THE OVMERa1{DE11 WALL FIVE THE BURDEN OF PROYNN THAT HE OR SHE 00 NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SAM OR
IMPROVE
O L AS OW NEROFTHE PROPERTY. AM EXCLUSAMLYCONTRACTNG WITH UC940 CONTRACTORS
TO CONSTRUCT THE PROJECT (SEG 7004, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS u.
CENSE LAB (TOES NDTAPPLY TOM OWNER OF APROPERT' WHO BtR0.S OR IMPROVES THEREON, AD
TORRkl0FJ/6E LAW1, K04PRO WMVNTNA�LKeGWPUNLSIAINTTOTHECONTRA4
..DIAL ETEM►T UNDER 8E4 -•-. _.- B.SP.C.NDRTFMB fEA80N,
DATE WINNER _
UCENSED CONTRACTORS DECLARATION
I HEEBYAFRMI UNDER PENALTY OF PERJURY THAT IAM LK%TS® UNDER POVISDNBOFCMAPTSA -
- / (COMMENCING WITH SECTION TOM) OF DIVISION SOF THE BUSINESS APD PROFESSIONS CODE, AND
MY LICENSE S N FULL FORCE ARID EFFECT.
LIC. MD.W-77?
0017ECOMI'RACTPR 0.
WOWERS' CCMAPENSATIOM OECL/LAATIOIi a
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FIX I OWNS DECLARATIONS:
-1 HANE AND WILLMANRAN ACERTIFICATEOF CONSENT TO SEFWBURE FOR WOIWMW
OOYPENSATICKAS PROVIDED BY SECTION SM OFTFE LABOR CODE. FOR THE PERFORMANCE
,ry! OF THE WIOiY(FOR WHICH THIS POW S"Na
}�1 HAVE MID WILLMANTAIN WORKERS' COMPENSATION INSURANCE. AS REOUIfED BY SECTION
57000E THE LABOR CODE, FORTHE PERFORMANCE OF THE WORK FOR WLORI THIS PEFMBTS
- .. SBUED. MYMID�E16' T �ESj�B IE ID- LICYIAILIBFAARE: -
G1RaFR
POLICYIUMBER 4=XZ=-
RMBSW NAE®NOTBEGRAPL MCFIKMD76EFBFMGWHIOR®OCMAFISOI0EORLEB%.
1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I
SHALL NOT EMPLOY ANY PERSON N ANY MAM ER SOASTO BECOME SUBJECT TO THE
WORKEFW COMPENSATION LAWS OF CALIFORNUI.AND AMES THAT IF I SHW,D0600ME
SUBJECT 70 THE WORKERS' COMPENSATION PROVISIONS OF SECTION LI
37000E THE BOR
DQE:, ' f�7/ '�A.FK.IGH,: NC�^-"+�
V44RNWM FAAJU E TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND INALLBE
SUBIECTM EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP MNDRED THOUSAND
DOLLARS (5100.0001,NADIXLION TO THE COST -COMPENSATION. DAMAOESASPNOVDED FORM
SECTION 5700OFTHEIABOR CODE. NTEHEST,NIDATTORNEWS FEFB
CONSTRUCTION LENDING AGENCY
H HERESY AFFIRM UNDER PENALTY OF PERJURY THATTIERE S AOONSTRICTION LiNDNAt ACEDY
FOR TNS PERFORMANCE OF THE WORK FOR WHIM THIS PEWIT IS ISSUED (SED. 5007, CIN CJ
LEDERSNAME _
LEDERSADDRESS
1 CERTIFY THAT t HAVE READ THISAPPUCAT07NAND STATE THATTHE ABOVE NWRMATDN S COAECT:
1 AGREE TOOOMPLY WITH ALL OWA D COUNTY ORDINANCES AND STATE LAWS REATND TO IKN DBO
OONSTR =oK AND NEFEBYANHORRE REPRESENTATIVES OF TNS COURYTO ERERUPON THE
ABOVE,ME FIONED PROPERTY FOR INSPECTION PURPOSE&
PER _
ISKINANIURVOPPERMIYTIRE
.. _ _ .. DATE
APF`UCATION ' '! ate,
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PERMIT
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Pci>ATE
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NUMBER
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QUANTITY DESCRIPTION —.
FEE
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ISSUANCE I
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ENERGYMC
ENERGY PERMIT
RETENTION FEE:
PRE ALT FEE:
TOTAL FEES
COMMENTS
V/LLIDA
RECPT. NO. 1-T 110 7 PND BY
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