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CITY OF DIAMOND BAR �� �� �w t� /�
� � DEPARTME?�iT OF COMMUNI7'Y&DEVELOPMENT SERVICES G—��,,f lL�C���" C
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(909)860-3 L95 Fas(909)861-3117 PRESS
�'%�� BUILDING PERMIT APPLICATION FIRMLY
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1 HEREBV AFFIflM UNDER PENALTV OF PERJURY THAT 1 AM EXEMPT FFOM THE CONTRnCTORS LI� G8f2g8/C8R70f1
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TURE,PRIOH TO ITS ISSUANCE,RLSO REQUIFES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
w STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PflOVI510NS OF THE CIXJTRACTORS LI- w
� CENSE LAW(CHAPTER B(COMM1AENCING WITN SECTION 7a00)OF DIVISION 7 OF THE BUSINE55 AND PRO� LL' POOUSPB
FESSIONSCADE)ORTHATHEORSHEISEXEMPTTHEREFPOMANDTHE6ASISFORTHERLLEGEDE7(EMP- �
� TION.ANVVIOLATIONOFSECTIDN7031.SBYANVAPPLICPN�GORAPERMITSU9JECf5'fHFAPPLICANTTO z Re-Roof
A CIVIL PENALTV OF NOT MORE THAN FNE HUNDRED DOLLARS(S5o0).): '
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Z WILL DO THE WORK,AND THE:iTRUGiURE IS NOT IN i END[D OR OFFEiiED fOH SALE(SEC.]0<6,BU51� J
I � NESS AN�PROFESSIONS CO�F::THE GONTRAGTOFS UGENSE LAW UOES NO�AVPLY TO AN OWNEF OF �
PFOPERTV WHO BUILDS OR IMi'ROVES TMEREON,AND WHO DOES SL1CH WORN HIMSELF OR HEHSEIF OR
� THROUGH HIS OR HER OWN EMPLOVEES,PROVIDED THAT SUCH IMPROVEMENTSARE NOT INTENDEDOR m
I � OFFEREDFORSALE.IF,HOWEVE:R.THEBUIIDINGORIMPROVEMENTISSOIDWITHINONEVEAROFCOMPIE-
Z TION,THE OWNER-BUILOER WILL HAVE THE 9UR�EN OF PROVING'.HAT HE OR SHE 01�NOT BUILD OH
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�'�, � LICENSED CONTFACTORS DEC . ATION W
I � I HEREBY PFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROViSIONS OF CHAPTEF �
d 9(GOMMENGING WITH SEGTION 1oWj OF ONISIOfJ 3 OF THE BUSINESSAN�PPOFESSIONS GODE,AND Z
�X MY LICENSE IS IN FUIL FORCE�4N0 EFFECT. m
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� WORiKEFS'COMPENSATION DECLARATION Q
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j N I HEREBY AFFIRM UNDEfl PENALTV OF PERIURY ONE OFTME fOLLOWMG OECURATIONS: Z
II � I HAVEAND WILLMAINTAINACERTIFICATE OF CONSENT�O SELF�INSl1RE FOR WOPKERS' $
Z COMPENSATION,ASPPOVIDE�BYSECTION�]OOOFTHELABORCO�E,FORTHEPERFORMANCE U
'. a OFTHE WORK FOR WHICH TMIS PERMIT IS ISSUE�. �
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w I HAVEAND WILL MAINTAIN WORNERS'COMPENSATION INSURANCE.AS REOUIRED BY SECTION � ', O
Q �� 3]0o OF THE LABOR COOE.FOR THE PERFORMANCE OF THC WORK FOR WHICH THIS PERMIT IS
0 ISSVED.MV WORKERS'COMPENSATION INSURANCE CARRIER AND POUCV NUMBER ARE: CONSTRUCTION /
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� (iHISSECTIONNEmN01�BECOMPIE�EDOFTHEPEMM�SFOFONEHUPDREDDOLLARS(5100�OR.E55). PLUMBING _,_
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Z I CERTFV iHAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEO.1
(.'} SHALLNOTEMPLOVAMYFERSONINANVMANNLRSOASTOBECOMESUBJECTTOTHE — �
� WOFK�RS'GOMPENSATION�AWSOfCALIFOqNIA,ANDNGREE7HATIF15HOULDBECOME INS?ECTIONFEE
? SUBJEGTiOTMEWOFICERS'CDMPENSATIONPfYOVISION50F5EGTION3�000FTHELA80R -' — �
CODE.I SHALL FORTHVVITH COMPLY WITH THOSE GqOVI510NS. ISSUANCE
p DATE�. APPLICANT SMIP �• \��� H � ��� _ �
w WFRNING'FAILURE TO SECUR[WORKERS'COMPENSATION COVEi1PGE IS UNLAWFUL,AND SHALI BE ENERGY P/C �� _._
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� SUBJE�TAN EMPLOYEFTO CRIMINAI�ENALTIES AND CIVIL fINES UV IOONE HUNDRED THWSAND ENERGY PERMIT
DOLLARS(f100,000),IN ADDITION TOTHE GOST OF COMPENSATION.�AMAGESAS PROVIDED FOR IN —
J SECTION 3]OB OF THE LABOR CODE.INTEREST.AND ATTORNEV'S FEES. RETENTION FEE:
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� CONSTRUCTION LENDING AGENCV PRE-ALT FEE: �
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Q I HEftEBV AFFIqM UNDER PEN/�LTV OF PERJURV THAT THERE IS ACONSTftUCTiON LENDING AGENCY
� FURTHE PERFOfiMANCE OFTHE WOFN FOR WNICH THIS PERMIT IS ISSUED ISEC.]091,CIV.C.�. � —
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� I GERTIFV TI1AT I HAVE REA�THIS AGPLICATION AND STATC THATTHE ABOVE INFORMATION IS CO{7RECT
� I AGREE TO GOMPLY WITHALL C�TV AN�COUNTV OPDINANCES AND STATE LAWS RELATING TO AUIL�ING �
CONSTRUGiION,AND HEREBY AUTMORI2E flEPRESENTATIVES OF THIS COUNTY TO ENTER UPUN THE
ZABOVE�MENiIONtDPflOPEHTIFORINSPEGTIONPURPO5E5. COMMENTS '
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CITY OF DIAMOND BAR
DEPARTME?�iT OF COMMUNTIY&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
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