HomeMy WebLinkAbout13389 (14) -'�
CITY OF DIAMOND BAR ` �
-�� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �/�
� _ _� 21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117 PRESS
� ��'��"� BUILDING PERMIT APPLICATION FIRMLY
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y DE5CRIPTION 54.FT. FACTOR PSF ADJ.AREA/VALUAT�ON
� OWNER•BWLDER DECLARATION SFR/ADD/REM ,,
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� I HEREBV AFFIRM UNOER OENALTY OF PERILIRY THAT I AM E%EM7T FROM THE CONTRACTORS l I� Gdf7)B/CafpOfl �
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U COUNTYWHICHREWIFiESAPEAMiTTOCONSTflUCT,ALTER,IMPROI�E,DEMOiISH,ORRE�AIRSNYGiRUC� � patio/�eck
W TURE,PRqR TO ITS ISSUANCE.PLSO REUUIRES THE APPLICANT fOH SUCH PERMIT TO FILE A SIGNED _
STATEMEM 7HAT HE OR SHE IS LICENSED PURSUANT TO THE PFWISIDNS OF THE CONTMCTORS LI�
� GENSE UW(CHAPTEfl e(COMMFNCIN�WITH SECTION�oao)OF pIYI510N 3 OF THE BUSINESS AND PRO� � POOUSPB
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V TKKJ.ANVVIOlAT10NOi3ECTION7o3t.5BYAtJVAPPIICANTFOFAPFHMITSU6JECTSTHEAPPLICANTTO Z Re-Rnot
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� ❑I,ASONMEROFTNEPROPERTY.ORAIYEMPLOYEESWITHWAGESAS7HEIRSOLECOMPFNSATION, � CommBrC�ai
WILL DO THE WORK,AND THE STpUCTURF.IS NOT INTF.N�ED OR OFFERED�OR SALE(SEC 7044,BUSI. J I"
y NE33 AND PROFESSIONS CODE THE CONTRACTORS LICEN9E LAW DOES NO?APPIY TO AN OWNER O'r � f
PROPERIY WF10 BUILD$OR IMPROVES THEREON,AND WMO DOES SUCH WORK HIMSELF OR HEFSELF OR I'
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OOFFEflEDFORSAlEIF,FiON�EYERTME9UILDINOORIMPROVEMEMI550LDWITHINONEYEAROFCOMPLE _
Z TION.THE OWNER-B111L�ER WILL MAVE THF BUR�EN Of PROVI4G 7HAT HE OR SHE DID NOT 9lJiLD Ofl 1{� ' k
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W f.II,ASOWNEflOFTHEPROPEfiiY,AA/E%ClUSNELVCONTqpCTINGWIhIIiCENSEUCANTRACTORS —
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� LICEN3E�CDNTRACTORS DFCIARATIGN W
� I HEREBV AFFIflM UNDER PENALTY OF PERJURY THAT IAM LICENSED UN�[Ft PROVISiONS OF GHAP�ER � ' �9
p. 9(COMMENCINOWITHSECTIaN�oao)�FUIVISION30FTHE6USINESSANDPF!OFESSIOY;CCCe'.AND Z _ _ �;
X MY LICENSE IS IN FULL FORCE AND EhFEC( '
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c'� WORKERS'CAAdPENSATION DECLARA710N � G.
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� 1 HEREBV APFIRM UNDER PENN.ri OF PENUR'/ONF OFTHE FOLLOWING DECLA�ATIONS .
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(� I HA'dE MA WILL MAINTRIN A CERTIi'ICATL OF CONSENi TO SELFINSUHE FOR WOAKFqS' Y
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� OF THE WORK FOR WHICN THIS PERMIT IS ISSUED. W
W IHAVEANDWILLMAINTFINWORKENS'COMPENSATION!NSURANCE,ASHEQL'IHEUI3�SECTION � � � � �•�` /��-�� ^
Q 370o Oi 7HF LABOR COUE.FOR THE PFflFORAfANCF OF THE WORK FOR W'HICH THI5 VERMIT IS �� ;(F /[ )l./ / )_ �
ISSUED MY WORKERS'CCA9PENSATION INSURANCECFRRIERAN�PC•_ICY NUMdENhRE CONSTRUCI ION {� __ �;,�___ 4i/ .�.i s,
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CAUE,I SHALL FOfifHWITH COM.PLY WI7H THOSE PROYISION^u
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p DATE.____— APPLIGANT __'..._ _ SMIP ' _' + ^ ___L_� �
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� ENERGY P/C �'.�.��_
J WARNINGFAILURETOSECUREWORKERS'COMPEN9ATIO4COVERAGLISUNLAWFl1L,ANDSIIALLBE /�
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�y SU0.IECTANEMPLOYERTOCRIMINAI.PENALTIEShNDCIVILFME5l1PTOONENUNDREDTHOUSANO ENERGYPEfiM1T I(/.�
ODLLAFS(i100.000),W/�DITIONTOTHECOSTOFCAMPENSATION.UAMAGESASPPOVI�EDFORIN ------------ ----
¢ SECTION3708 OF THE LABOR CODE,INTEREST,ANU A7TORNEY'S FEES RETENTION FEE: __���
� CONSTRUCTION LENDINGAGENCY P�R/—�{/ALT���FEj ____ _ __.___—
� I HEREBV AFFIflM UNDCR PLNALN OF AERJURYTNAT iHERE IS A CONS7 RUCTION LEN�ING AGENCY v _ [.✓�� __________________
n- FORTHEPERFORAIANGEOFfHEWORKFOFWHICHTHISPERMITISI55UEU(SEC3o97,CIVC)
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~ ITE—Deparlment Copy,YELLOW—Finance Copy,PINK—Assessw Copy,GOLDENROD--Fite Copy,GREEN—ApplicanYs Copy
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