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CITY OF DIAMOND BAR �^����D
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�'%�� BUILDING PERMIT APPLICATION FIRMLY
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� I HEREBV AFFIRM UNDER PENALTV OF PERIURV THAT I AA1 E%EMPT FROM hIE CONTRACTORS LI� G9l9gB/CefpOR
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w NRE,PRIOR TO RS ISSUANCE.AL50 REQUIRES THE APPLICANT FOR SUCH VERMIT TO FlLE A SIGNED w P8ii0/D6CI(
� STATEMENT THAT HE OR SHE IS LICENSED PURSUMlT TO THE PROVISIONS OF THE CONTRACTORS LI- �
CENSE LAW(CMAPTER o(COMMENCINQ WITH SECTqN 7000)OF DIVISION 3 OF THE BUSINESS AND PFO- PooVSpa
� FESSIONSCODE)ORTHATHEORSHEISEXEMPTTHEREFROMANOTMEBASISFORTHEALLEOEOEXEMP� (�
TION.M1V VIOUTqN pF SECTION 7031.5 8V ANV APPLICANT FOR A PERMIT SU&lECTS THE AVPLICANT T0 Z Re-Raof
� A CML PEN�LTV OF NOT MORE THAN FIVE HUNORED DOLURS(f5o0�.):
I O OI.ASOWNEROFhIEPROPERiY,ORMVEMPLOYEESWITHWAQESASTHEIRSOLECOMPENSATION, � Commercial
Z WILL DO THE WORK,AND THE S7RUCTURE IS NOT IN7ENDED OR OFFERED FOR SALE(SEC.7a4,BUSI� J �
N NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLV TO!W OWNER OF �
. PROPERTYWHOBUILDSORIMPROVESTHEREON,ANDWHODOESSUCHWORKHIMSELFORHERSELFOR
� THROUGH MIS OR HER ONRJ EMPLOVEES,PROVIDED THAT SUCH IMVROVEMENTS ARE NOT INTENDED OR m
� Q OFFEREDFORSALEIF,HOWEVERTI'1EBUILDINGORIMPROVEMENTISSOLDWITHINONEVFJ�ROFCOMRE�
Z TION,7HE OWNER�BUILDER WILL HAVE 7HE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
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[[ TO CONSTRUCT THE PR0.IECT(SEC.7Wa,BUSINE55 AND PROFESSIONS CADE:1HE CONTRACTORS LI- V01U8fi011 ADJ.AREA
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� WHOCONTRACTSFORSUCHPFUIECTSWITHACONTqACTOR(S)LICENSEDPURSUANTTOTHECONTMG QUANTITY DESCFIPTION FEE
70RS LICENSE LAW.). �
� ❑I AM E%EMPT UNDER SEC. B.6 P.C.FOR THIS REASON Q
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� I HEREBY AFFIRM UNDER PENALTV OF PERJURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
� 9(COMMENqNOWITHSECT10N70a0)OFDIVISION�OF7HEBUSINESSANDPROFESSIONSCADE,AND I
��� MY LICENSE IS IN FULL FOflCE AND EFFECT. m
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� I HEREBV AFFIRAI UNDER PENALTV OF PERJURV ONE OF 7HE FOLLOWINO DECLARATIONS: Z
� _IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' _
� COMPENSATION,AS PROVIDED BV SECTION 3700 OF THE LABOR CODE,FOR THE PERFORMANCE U
Q OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. �
Qw _I HAVE AND WILL MAIMAIN WORKERS'COMPENSATION INSURANCE,AS RE�UIqED BV SECTION ►
3�0o OF THE LABOR CODE,FOR TME PERFORMANCE OF THE WORK FOR WHICH 7HI5 PERMIT IS
ISSUED.MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICV NUMBER AAE: CONSTRUCTION -
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Z ICERTIFV7HATINhIEPERFORMANCEOFTHEWORKFORWHIp1TH15PERMITI515511ED,1 MECHANICAL 1 7 �'':�,��;`^�_ 5
(,'} SHALL NOT EMPLOV ANV PERSON IN ANV MANNER SO AS TO BECOME SU&IECT TO THE � � /1- � r'
N WORNERS'CAMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECAME INSPECTION FEE � � I I '� � )
SU&IECT TO THE WOflKERS'CAMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR '
S CODE,I SHALL FORTHWITH COMPIV WITH TFqSE PROVISIONS. ISSUANCE � ' /'
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p DATE: APPLICANT: � SMIP f I i
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J WARNINO:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
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� SU&IECTANEMPLOVERTOCRIMINALPENALTIESANDCNILFINESUPTOONEHUNDREDTF10U5AND ENERGYPERMIT �:��. '
DOLURS(f100,000).IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
� SECTION a]a8 0F THE LABOR CODE,INTEREST,AND ATTORNEV'S FEES. RETENTION FEE: � - - ' �
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEf7EBV AFFIRM UNDER PENALTV OF PERIURV THAT THERE IS ACANSTPUCTION LENDINO AQENCV
FOR THE PERF-0RMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.C.).
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� LENDERS NAME
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w I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CARRECT. TOTAL FE ES I Z I. � �� ",/��` /`O
� I AOREE TO COMPIV WITH ALL CfTV AND CAUNTV ORDINANCES M!D STATE UWS REIATIN(i TO BUILDINO ' ��
� CANSTRUCTION,AND HEREBY AUTFiORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE P �A,_]� '
Z ABOVE-MENTIONED PROPERTV FOR INSPECTION PURPOSES. e MMtrNTS'�ecS � 1
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WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy
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