HomeMy WebLinkAbout16938, '
_ . ' ^---_��— CTI'Y OF DIAMOND BAR �\
DEPARTIv�NT OF COMMUNTTY&DEVELOPMENT SERVICES
21825 E.Copley Drive '
� (909)860-3195 Fax(909)861-3117 PRESS
"� ��'%�^�+� BUILDING PERMIT APPLICATION �/ FIRMLY
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W NRE,PRIOR TO ITS ISSUANCE,ALSO REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w Patio/Deck
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� CENSE UW(CHAPTER Y(CAMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO� � POOI/SP0
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Z WILL DO TFiE WORK�D THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.70N,BU51- J J
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wTHROUGH HIS OR MER OWN EMPLOVEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR m
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� I HEREBV AFFIRM UNDER PEN�LTV OF PERIURV THAT I AM LI SED UN R PROVISIONS OF CFIAPTER �
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� WORKERS'COMPENSATION DECLARATION a
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� I HEREBV AFFIRM UNDER PENALTV OF PERIURV ONE OF THE FOLLOWING DECUfUTIONS: Z
�Z I HAVE AND WILL MAINTAIN A CERTIFlCATE OF CONSEN7 TO SELF-INSURE FOfl WORKERS' a
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OF hIE WORK FOR WHICH THIS PER7AIT IS ISSUED. �
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Qw _I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTION
3700 OF THE LABOR CqDE,FOR THE PERFORMMICE OF THE WORK FOR WHICH THIS PEFiMfT IS /� �'
ISSUED.MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICV NUMBER AAE: CONSTRUCTION / �V.
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Z I CERTIFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
C'S SHALL NOT EMPLOY M!Y PEHSON W ANV M/�NNEH SO AS TO BECOME SU&IECT TO THE �
(n WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAOREETHATIFISHWLDBECAME INSPECTIONFEE I
� SU&IECT TO THE WORNERS'COMPENSATION PROVISIONS OF SECTION 3'!00 OF THE LABOR , .. I p a
CODE,I SHALL FORTHWI7H COMPLV WITH TFqSE PROVISIONS. ISSUANCE
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p DATE: APPLICANT: SMIP
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� SUBJECTANEMPLOVERTOCRIMWALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT '
DOLURS(5100,000),IN ADDITION TO THE COST OF COMPENSATKKJ,DAMAOES AS PROVIDED FOR IN
J SECTION 3708 OF THE LABOR COOE.INTEREST,AND ATTORNEV'S FEES.
OC RETENTION FEE:
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBV AFFIRM UNDER PENALTV OF PERIURV THAT THERE IS A CANSTRUCTION LENOINO AGENCV
FOR iHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEO(SEC.3087,CIV.C.).
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� LENDER'S NAME
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w I CERTIFY THAT I HAVE READ THIS APPUCATION AND STATE THAT THE ABOVE WFORMATqN IS CORqECT. TOTAL F E ES ��, O v
� I AOREE TO COMPLV N7TH ALL CITV AND CAUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDIN(3
� CANSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF THIS CWNTV TO ENTER UPON iHE
Z ABOVE-MENTIONED PROPERTV FOR INSPECTION PURPOSES. COMMENTS
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= RECPT.NO. PAID BY
~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanYs Copy
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ROOF SHEATHIh1G 8 Ff. BOND BEAM
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ROOF COVER � PRE-GRADING
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SHO�VERrfUB TFST POOL ELECTRIG
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WALL INSULATION POOL FINAL
CEILING INSULATION OFF SITE IMPS.
DRYWALL NAIUNG DEDICATIONS
SEWER FINAL ENG.
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