HomeMy WebLinkAbout15128CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
(909)860-3195Fax (909) &61-3117 PR SS
BUILDING PERMIT/�APPLICA
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OWNER -BUILDER DECLARATION
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YL9W_ PRIOR TO ITS ISSUANCE, ALSO REOUIES THE APPLICANT FOR SUCH PERMIT TO FSE A SONED -
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STATEMENT TWQ HE OR SME IS LICENSED PURSANT:O THE PAOVWONS OF US bomrRACTORS LL
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CBIBE LAW (CFWTERP tCOMG�HCMq WIM 8ECfON 7000) OF DIVISION 3 O THE BUSINESS AND PRD
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0 LASOMEROFTHE PROPERTY. OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION. _
UNITS STORIES
WILL DO THE WORT( AND THE STRUCTURE IS NOT MENDED OR OFFERED FOR SALE (SEG 7OI4, SJSi-
NESS AND PRCKSSIOWS CODE. THE CONTRACTORS LKYTISE LALY DOES HOTAPPLY TO AN OWNER OF
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PROPERTY WHO BIRDS OR IMPROVESTHEReON.ANO WHO DOES SUCH MORKHMSELFORHERSE.FOi
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I HERESY AFFIRM DOER PENALTY OF PERAIRY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER -
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WORKERS' COMPENSATION DECLARATION
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WIJ. MANTAN WORKERS' COMPENSATION NSlRANCE, AS REQUIRED BY SECTION
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I CERTIFYTHAT LATHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I
SHALL NOT EMPLOY ANY PERSON NAVY MANLIER BOAS W BECOME SUBJECT TO THE :
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LODE, I SHALL FORIFNATH COMPLY WITH PPROVIISS�K]P/S.
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WAIiNN(t FAILURE TO SECURE WORKERS' OOMPENUTON COVERAGE IS UNLAWFUL. MO SNAIL BE
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SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES LIP TO ONE HUNDRED THOUSAND
OCLLARS(SI00.000} N ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FORK
SECTION 3700 OF THE LABOR CODE. INTERIM AND ATTORNEYS FEES..
CONSTRUCTION LENDING AGENCY
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M UNDER PENALTY OF PERAIRY THAT THERE 6 A CONSTRUCTION LENDING AGENCY
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I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
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I AGREE TD COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION. AND HEREBY AUTHORIZE REPRESEMA OFTHIS TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR NSP
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