HomeMy WebLinkAbout12-2261 _.��_ CITY OF DIAMOND BAR
� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �
21825 Copley Drive,Diamond Bar,CA 91765
i (909)839-7020 Fax(909)861-3117 Buildiog Inspection Hotline(909)839-7027 PRESS
'�^'� BUILDING PERMIT APPLICATION FIRMLY
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w TURE,PRIOR TO ITS ISSUANCE,ALSO RE�UIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w
� STATEMENT THAT HE OR SHE IS LICENSED PUHSUAN7 TO THE PROVISIONS OF 7HE CANTRACTOPS LI- �
CENSE UW(CHAPTER e(CAMMENCING WITH SECTION 70oa)OF DIVISION 3 OF THE BUSINE55 AND PRO- POOVSPe
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� NE55 AND PROFESSIONS CADE:THE CANTRACTORS IICENSE UW DOES NOT APPLV TO AN OWNEfi OF j
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Q THROUGH HIS Oq HER OWN EMPLOVEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR m
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� WORKERS'COMPENSATION DECLA ATION Q
� I HEREBV AFFIRM UNDER PENALTV OF PERJURY ONE OF THE FOLLOWING DECURA710N5: Z
� _I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS' a
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O OF THE WOPK FOR WHICH THIS PERMIT IS ISSUED. �
Qw ,�IAVE AND WILL MAINTAIN WOHKERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTION
3700 OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED.MV WOR S'f�MPE�N�y`j�TION INSU CE CARRIER D 70LICV NUMBER ARE: CONSTRUCTION
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Z I CEfiTIFY THAT M THE PERFORMANCE OF THE WORK FOq WHICH THIS PERMI715 ISSUED,I MECHANICAL
C}' SHALL NOT EMPLOY ANY PERSON IN ANV MANNER SO AS TO BECAME SUBJECT TO THE
�/j WORKEFS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULO BECOME INSPECTION FEE
� SUBJECT TO THE WORI(ERS'COMPENSATION PROVISIONS OF SECTION 37000F TNE LABOP
� CODE.1 SHALL FORTHWITH COMPIV WITH THOSE PROVI ONSy. ' ISSUANCE � �
p DATE: U T APPLICANT: G� �(/C (/ ! v '� ���� SMIP
J WARNING:FAILURE TO SECURE WORKERS'CQMPENSATION COVERAGE IS UNLAWFUL,AND SHALLBE ENERGY P/C
� SU&IECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND ENERGY PERMIT
DOLLARS(St W,000).IN ADDITION TO THE COST OF CAMPENSATION,DAMAGES AS PROVIDED FOR IN �
� SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNE�"S FEES. RETENTION FEE:
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH TMIS PEHMIT IS ISSUE�(SEC.3097,CIV.CJ.
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� CANSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF THIS COUNTV TO ENTER UPON THE
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ROUGH ELECTRIC ROUGH GRADING
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SHOWER/TUB TEST POOL ELECTRIC
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CEILING INSULATION OFF SITE IMPS.
DRYWALL NAILING DEDICATIONS
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SEEP PIT/L.L. ON SITE IMPS.
GAS AIR TEST FINAL ZONING
FINAL CONST. FIRE DEPT. FINAL
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FINAL ELECTRIC DEV. FEES PAID
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