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CITY OF DIAhl0ND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
(909) $60-3195 Fax (909) 861-3117
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OW%WJV8UILDFR DECLARATION
I HEREBY AFFIRM UNDER PENALTY Or PERIAIRT THAT I AM EXEMPT FROM THE CONTPACIIORS U -
CERISE LAW FORTHIE FOLLOWING WMON (Srr. 7WI.5 BUMNESSAND PROFESSIONS CODE-' MY CITY OR
COUNTY WHICH 0141ARIESAPGAMIT TO CONSTAUCtAXER IMPROVE. DEMOLISH. OR REPARANY STAVC-
TUF`*- PRIOR TO ITS IBMJmNC-- ALSO F"RRES THE APPLICANT FOR SUCH KFIMIT TO MEA SIGNED
STATEMENT MW HE OR SHE 18 UCL46W PURSUANT To THE PROVISIONS OF THE CONTRACTORS LL
CERISE LAW (2UPTER 9 MOMMENCM WITH SECTION 7000) OF DIVISION 3 OF THE BLSWM AND PRO.
SESSIONS DOM ORTW HE OR ME 19 EXUIPT THEEREFROM AND THE SAMB FOR THE ALLEGED EXEMP-
TKK ANY V*XKFIDN OF sEcnow 701.6 BY ANY APPUCANT FOR A PERMIT SUBJECTSINE APPLICANT To
ALTA. PENALTY OF NUT MORE THAN FIVE KINDRED DOLLARS WWO k
0 LABOWNEROFTHE PROPERFY.OR MYEUPLOYEESWITHWAGOAS THEIR11OLE COMPENSATION,
WILL DO THE WIDM AND THE WALCTURE 16 NOT NTE MSD Olt OFFIERED MR SALE (B6C, M% SUM -
NESS 00 PROFESSIONS CODE THE CONTRACTORS LICENSE LAN DOES NOTAPPLY TO ANOWNER OF
PROPERTY VA406UUM OR IMPROVES THGAGDKAW WHOWN SUCH WORK HMINELFOR-HERSELFOR,
TWROU01 HISOR HEROWN EMPLOYEES, PROVOEDTHAT SUCH IMPROVEMENTSARE NOT INTENDED 00
OFFS "FOR&41LLF.HUWWMTHEBULDMORWROVUWKISSOLDWMWONEYFMOFCOMFLE-
TIOK THE OMAIf3t81ALl R VAL HAVE INS WROW OF PROWA THAT HE OR SK DO NOT STAID OR
IMPROVE FOR TK PURPOSE OF SALE).
13 LAS OWNER OF THE PROPEW. AM EXCLUSIVELYCONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 7064 BUSINESS AND PROFESSIONS CODE- THE CONTRACTORS L4
.CENSE LAW DOES NOTAPPLY TOAN OWNSR OFAPROPERTY VA40 BUILDS OR 994MO THERIECK AND
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TOASUCEMSELAK
01AMSDIEMPTUNDERSEC. &a M FOR THIS REASON
DATE OWNER
UCENSED CONTRACTORS DECLARATION
I HERESY AFFIRM TINDER PENALTY OF PEMW IMAT IAM LICENSED UNDER PROVISIONS OF CHAFTE
0 MOMMEMOM NTH &Ecnom TOW) OF DAIMON 3 OF THE SUI NESS AM PROFESSIONS awDL�
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VVORKEF49 COMPENSATION DEC TION � ?
I HERESY AFFIRM UNDER FIENAM OF PERAIRY UK OF THE FOLLOWING
I HAVE AND WILLMANTAIN ACERTORCATE OF CONSENT TO FOR
COMPENSATION. AS PROVIDED BY SWIM 3M OF THE LABOR "THE
OF YNE WOftt FOR WHIG" THIS POW 4 "WA
I HM AND WILL MAWAM WORKERS' COMPENSArION MSU A. AS I BY
3700 OF THE LABOR CODE FOR THE PERFORMANCE Or, THE THIS THIS IS
Isawamy COMPfikSAlXH INSURANCE CAFW" NUMBER
CARRIER A
POLICY A
MISSEMIDNNEEONorssawmmom INE MMORUffik
FORMANCE OF T. -B:
I CERTIFY THAT IN THE PM = IHIMCH :IRMT ISS issum I
SIVALNOT EMPLOYAW PERSON MANY NJ TO BECOME E(YrTOTHE
WOFKERsrCOmPEwSATION LAWS OF CAUS -AND w6THATwI BECOME
DF SECTION
Coor, I waiLLFORTHwir"cowwww
ImANIMIM FALUFI910 SECURE WORKERS' CLINSATION COVERAGE IS UNLAWFUL AND WILL BE
SUQLQCT AN EMPLOYIER TO CRIMINAL PENALTIES AND CPA FINES UP TO ONE HUNDRED THOUSAND
DOLLARS ($io%ogu), IN ADDITION TOTE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION SM OF THE LABOR CODE INTEREST. AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALtY OF PERJURY TMT 114M IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEQ 3007. CIV. CJ.
LENDERS NAMIE
LENDER'S ADDRESS
ICERTIFY TURI KWE READ THIS APPLICATION AND STATE THATTHEASOVE INFORMATION IS CORRECT
I AGREE TO COMPLY WITH ALL CITY AM COUNTY ORDINAXCESAND STATE LAWS RELATING 70 SUIUDMKI
CONSTRUCTION, AND HEAEBYALITHORIZE REPRESENTATNES OF THIS COLKTY TO ENTERUPON THE
ABOVlEMEwnoNED PROPERTY FOR INSPECTION PURPOSES
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