HomeMy WebLinkAbout17597 (25) CITY OF DIAMOND BAR
COMMUNTTY DEVELOPMENT DEPARTMENT
.„.,,� 21660 E.Coplcy Drive Suite t90 PRESS
(909)860-3195 Fax(909)861-3117
� `""" BUILDINGPERMITAPPLICATION � FIRMLY
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DATE NUMBER #
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- ui DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
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. CENSE LAW(CHAPTEFi 9(CAMMENCING WITH SECTION 7000)OP DIVISION 9 OF THE BUSWESS AND PRP � � PooVSpa
- FESSIONSCAD�ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEOEXEMP- �
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Z WILL�O THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOfl SAIE(SEC.7044,8US6 J
- � NESS AND PROFESSIONS CA�E:THE CANTRACTORS LICENSE LAW�OES NOT APPLY TO AN OWNEfl OF ♦p�
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- W OI,ASOWNEROFTHEPROPERTY,AMEXCLUSIVEIYCANTRACTINGWITML�CENSEOGONTRqCTOflS
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W CENSELAWOOESNOTAPPLVTOANOKTJEROFAPROPERTYWHDBl11LDSORIMPROVESTHEPEON,AND
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- V"' �ATE � 'i OWNER^,(, � �
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� i HEREBV AFFIRM UNDEF PENALTY OF PERJUHV THA7 I AM LICENSED UNDER PROVISIONS OG CHAPTER �
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� WORKERS'COMPENSATION DECLARATIDN Q
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� I HEREBYAFFIRM UNDER PENFLTY OF PERJUFY ONE OF THE FOLLOWING DECLARATIONS:
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� _IHAVEANDWILLMAINTAINACERTIFICATEOFC�NSENTTOSE�F-INSUREFORWORKERS' $
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O 37000FTHELABORCO�E,FORTHEPERFORMANCEOFTHEWOFKFORWHICHTHISPEFlMITIS
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kti (7 SHAILNOTEMPLOVANYP[(�SONINANYMANNERSOASTOBECOMESUBJECTTOTHE —
(n WORKERS'COMPENSATIONLAWSOFCpLIFOFNIA,ANDAGHEETMATIF�SHOULDBECOME INSPECTIONFEE , �._
t SUBJECTTOTHEWORKERS'COMPENSATIONPROVISIONSOFSECTION37000FTHELABOR ci �'�: ��
� O COOE,I SHAL(.FORTHWITH COMPLY WITH hIOSE PFOVISIONS. ISSUANCE 6.��3"t S I �-
��. p DATE: APPLICANT. SMIP � .-_ _�_________�_ ,._
S� � - ENERGY P!C �� E"@ 9- E`s3 f`'.I��i�:� �-'.�;'�
J WARNING:FAILURE TO SECURE WORKERS'CAMPENSATION COVERAPE I5 UNLAWFUL,ANO SHALL BE �„,,.,,,,,,9•,�
;- LL SU&IECTANEMPLOYERTOCFIMINALPENALTIESANDCIVILFlNESUP700NEHUNDREDTHOUSAND ENERGYPERMIT ��p �q rYI� �AS°Fi':.� aJi'�C��d �
DOUARS(5700.000j.IN ADDRION TO THE COS f OF GOMPENSRTION,DAMPGES AS PROVIDED FOR IN ��y{�k'�
J SECTION37oeOFTHELA60RCODE,WTEREST,ANDATTORNEV'SFEES. RETENTIONFEE:
� —
� � CONSTFUCTION LENDING AGENCY pRE-ALT FEE:
��-� � I HEREBV AFFIRM UNOEH PFNALTY OF PERJURY THAT THERE IS ACANSTRUCTION�ENDINO AOENCY
FOR THE PER WRMANCE OF THE WORK FOH WHICH THIS PERMIT IS ISSUED(SEC.3097,CN.C.).
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' � LENDER'S NAME
1— LENDEP'SRDORE5S
� ICERTIFYTHATIHAVEREADTHISAPPLICATIONANOSTATETHATTHEA80VEMFORMATIONISCORRECT. TOTAL FEES
� w IAGREETOCOMPLYWITHALLCITYAN�COl1NTVORDINANCESANOSTATELAWSPEL4TINGTOBUILDING
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N 0 AT E OF PERMI EE DATE A
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~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENR06—File Copy,GREEN—AppllcanYs Copy
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