HomeMy WebLinkAbout18501 (28) CITY OF DIAMOND BAR �X � �
- ��� ---� DEPARTIvIE?`'T OF COMMUNTfY&�DEVELOPMENT SERVIC�c
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117 PRE$$
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I HEREBV AFFlRM UNDER VENALTV OF PERIURY THAT I NA E%EAIPT FqOM THE CONTqACTORS l.l� GdfO 0/C9 O!I
W CENSE LAW FOR THE FOLLOWING REASON(SEC.'l031.6 BUSINE55 AND PFOFESSIONS�'ADE:M'Y CITV OR (n 9 �
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w NRE,PRIOR TO ITS ISSUANCE,ALSO REWIiiES THE APGLICANT FOR SUCH PERMIT TO FILE A SIGNED w
i � STATEMENT THAT HE OH SHE IS LICENSED WRSUMlT TO THE PROVISIONS OF THE CONTRACTORS LI� . �
CENSE UW(CHAPTER Y(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO� POOUSPB I
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Z WILL DO TME WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.70u,BUSI� J
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PROPERTV NT/0 BUILDS OR IMPROVES THEREON,AND NMO DOES SUCM WORN HIMSELF OR HERSELF OR
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Z TqN,THE OWNER-BUILAER WILL HAVE THE BURDEN OF PROVING'HAT HE OR SHE DID NOT BUIID OR
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� LICENSED CONTRACTORS DECLARATION W
� I NEREBYAFFIRM UNDER PENALTV OF PERIURV THAT IAM LICENSED UNDER PROVi510N5OF CHAPTER �
� o(COMMENCING WITH SECTION 7000)OF DIVI510N 30F THE BUSINE55 AND PP.OFESSiONS CODE,AND Z
`X MV LICENSE IS IN FULL FORCE AND EFFECT. m
� LICENSE CLASS LIC.NO. �
V DATE CONTRACTOR a
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� WORKERS'COMPENSATION DECLARATION Q
� 1 HEREBYAFFIRM UNDER PENALTY OF GERIURV ONE OF7HE FOLLOWING DECIAqATIONS: V
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� _I HAVE AND WILI MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSUPE FOR NqRKERS' a
� COMPENSATION,AS PROVIDED BV SECTION 3100 OF THE LABOR CODE,FOR TME PERF-0RMANCE U
OF TME WORK FOH WHICH THIS PERMIT 19 ISSUED. �
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Qw _I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE.AS REOUIRED 9Y SECTION
370o OF THE LABOR CODE,FOR TME PERFOFMANCE OF THE WORK FOR WHICH THIS PERMIT IS � c
ISSUED.MV WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CONSTRUCTION �
� CAqRIER PLAN REVIEW �
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Z I CERTIFV THAT IN THE PERFORMANCE OF THE WORN FOR WHICH THIS PERMIT IS ISSUED,1 MECHANICAL
C.�} SHALL NOT EMPLOV ANV 7ERSON IN ANY MANNER 50 AS TO BECOME SU&IECT TO THE
Uj WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECAME INS?ECTION FEE
'= SU&IECT TO THE WORNERS'COMPENSATION PROVIS10N5 OF SECTION 370o OF THE LABOR
CA�E,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. ISSUANCE
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p DATE: APPLICANT: SMIP
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J WARNING:FAILURE TO SECURE M/ORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE ENERGY P/C
� SU&IECTANEMPIOVERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHl1NDREDTHWSAND ENERGYPERMIT
DOLLAfiS(f 100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAOES AS PROVIDED FOR IN
J SECTION 3708 OF THE LABOR CODE.INTEREST,AND ATTORNE�"5 FEES. ��.
OC RETENTION FEE:
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: �
� I HEREBV AFFIRM UNDER PENALTV OF PERJURV THAT THERE IS ACANSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUE�(SEC.3087,CIV.C.).
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� LENDER'S NAME
H LENDER'SADDRE55
w I LERTIFY THAT I HAVE READ THIS APPUCATION ANO STATE THAT THE ABOVE INFORMATION IS CARRECT. TOTAL F E ES I �V�
� I AGREE TO COMPLV WITM ALL CITY AND COUNTY ORDINANCES AND STATE LAWS PELATING TO BUILOINO .
� CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATNES OF THIS COUNTV TO ENTER U WN THE
Z ABOVE�ME IONED PFOPERTV FOR INSPECTION PURPOSES. tl COMMENTS
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= RECPT.NO. PAID BY VALIDATION
~ WHITE—Department Copy,YELI.OW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant Copy
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DRYWALL NAIUNG � DEDICl�T10NS
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SEPTIC TANK LANDSGAPEtiRRIG.
SEEP PIT/L.L. � ON SiTE IMPS. �
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