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---��'"4--- CITY OF DIAMOND BAR
� COMMUNITY DEVELOPIvIENT DEPARTMENT
_ 21660 E.Copley Drive Suite 190 PRESS
� (909)860-3195 Fax(909)861-3117 '
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. �- - OWNEA-BL'ILDER DECLARATION - SFR/ADD/REM
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[].. I HEREBY AFFIRM UNDER PENAITY OF PERJURY THAT 1 AM E%EMPT FROM THE CONTRACTORS LL .,� � Gara e/Ca 0!I--�-�-�� � -
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� �� - TUflE,PFlIOR TO ITE ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNE� .
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��� , CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 700D)OF DIVISION 3 OF THE BUSINESSAND PRO� -' � PooU5p8
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z WILL 130 THE WORK,AND THE STPUCTURE IS NOT INTENDED OR OFFERED FOfl SALE(SEC.7U44,BUSI- J
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� I HEREBY AFFIRM UNOER PENM1LTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER �
� � 9(COMMENCING WITH SECTION 70W)OF DIVISION 30F THE BUSINESSANO PROFESSIONS CODE,AND Z
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-- t�1- - - WORKERS'COMPENSATION DECLARATION - � - - - -
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Z 1 CERTIFYTHAT IN THE PERFORMANCE OF THE WOPK FOR WHICH THIS PEFMIT IS ISSl1ED,1
(,� SHALLNOTEMPLOYANYPERSONINANYMANNERSOASTOOECOM[SUBJECTTOTHE . .
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� SUBJ[CTTOTHEWORNERS'COMPENSATIONPROVISIONSOFSFCTION37000FTHELABOFi ISSUANCE I���` dl1- �
, � CAOE,I SHALL FORTMWITH COMPLY WITH THOSE PRDVISIONS.
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p DATE: APPLICANT: �
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- � SUBJECT.AN EMPLOYER TO CflIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDREO T410USAND ENERGY PERMIT ������ 5� � ���; ____.. _
DOLLARS(S1ao,0a0J,INAD01T10NTOTHECOSTOFCOMPENSATION.DAMAGE5A5PHOVIUEDfOHIN �x�� , •
� SECT��N 37oe OFTHE 1A80R CODE,INTEREST,AND ATTORNEV'S FEES. ' RETENTION FEE:
�-W CONSTRUCTION LENDING AGENCY PRE-ALT FEE: �
� IHERE6YAFFlRMUNDEftPENALTYOFPERIUPYTHATTHEREISACON5TRl1CTIONLEN�INGACaENCY � __
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2 LENDER'SNAME -.-.. __—_.._ ' ' � '
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� 1 AGREE TO COMPLY WlTil ALL qTY AND COUNTY OR�INANCES AND STATE L4WS RELATWG TO BUIIDMG � f J ��, . � �"�
CONSTRUCTION,ANOHEflEBYPUTHORI F'ePRESENT lVESOFTHISCOUNTYTOENTERUPONTHE ��1. ����L � � � -
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