HomeMy WebLinkAbout17080 ^ ��_ CTTY OF DIAMOND BAR �
DEPARTMENT OF COMMUNITY&DEVELOPMENT SE RYI�FS �
21825 E.Copley Drive �/��
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"'"%.9��� BUILDING PERMIT APPLICATION ~�� _ . FIRMLY
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p I HEREBV AFFlWA UNDER PENALTV OF PERNRV THAT I AM E%EMPT FqOM THE CONTRACTORS LI� Gdf9 B/C8 OfI
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w NRE,PRIOR TO ITS ISSUPNCE,AL50 REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w P8110/DBCk
� STATEMENT hiAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI� LL
g CENSE LAW(CHAPTER B(COMMENCINO WITH SECTpN 7000)OF OIVISION 3 OF THE BUSINESS AND PR0. PooUSpa � ��.
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A CIVIL PENALTV OF NOT MORE THAN FNE HUNDRED DOLURS(f500).):
� ❑I,ASOWNEROFTHEPROPERTV,ORMVEMPLOVEESWITHWAOESASTHEIRSOLECOMPENSATION, � COffIRIBfCIaI
Z WILI DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.70�a,BU51� J J
� NE55 M1D PROFESSIONS CODE:THE CONTRACTORS LICENSE UW DOES NOT APPLV TO AN OWNER OF �
PROPEF7rV WFIO BUIIDS OR IMPROVES THEREON,MJD WHO DOES SUp1 WORK HIMSELF OR HERSELF OR
� THROUGH HIS OR HER OWN EMPLOVEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OP m
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Z TqN,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVINO THAT HE OR SHE DID NOT BUIID OR
� IMPROVE FOR THE PURPOSE OF SALE).
w OI,ASOWNEROFTHEPROPEHTY,AME%CIUSNELYCOMRACTINOWITHLICENSEDCONiRACTOqS
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� ❑I AA1 EXEMPT UNDER SEC. B.6 P.C.FOR THIS REASON � �
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� LICENSED CONTRACTORS DECLARATION w _
� I HEREBV AFFIRM UNDER PENALTV OF PERIURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER � `
� Y(COMMENCINO WfTH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS COOE,AND Z
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� WORKERS'COMPENSATION DECLARATION ¢ e0.
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N I HEREBV AFFIRM UNDER PENALTV OF PERIURV ONE OF THE FOLLOWINQ DECLAMTIONS: Z
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w _I MAVE M1D WILLMAMTAW WORKERS'COMPENSATION INSURANCE.AS REOUIHED BY SECTION
Q 3700 OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS � ,
ISSUED.MV WORKERS'COMPENSATION INSURANCE CARRIER AND POLICV NUMBERARE: CONSTRUCTION
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Z I CERTIFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS�SSUED.1 MECHANICAL
C.�} SHALL NOT EMPLOV ANV PERSON IN ANV MANNER 50 AS TO BECAME SU&IECT TO THE
(/� WORKERS'COMPENSATION LAWS OF CALIFORNIq AND AGREE THAT IF I SMOULD BECAME INSPECTION FEE
S SUBJECTTO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 37000F THE LABOR a
COOE.I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. ISSUANCE
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1p DATE: APPLICANT: SMIP � �
J WARNINO:FAILURE TO SECURE WORKERS'COMPENSATION COVER�GE IS UNLAWFUL,AND SHALL BE ENERGY P/C
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� SUaIECTANEMPLOVERTOCRIMINALPENALTIESANDCMLFINESUPTOONEHUNDREDTFIOUSAND ENERGYPERMIT
DOILARS(f 100.000),IN hDDITION TO THE COST OF COMPENSATqN,DAMAGES AS PROVIDED FOR IN
J SECTqN 3708 OF THE LABOR CODE,MTEREST,AND ATTORNEI"S FEES.
w RETENTION FEE: �
O CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � _
� I HEREBV AFFIRM UNDER PENALTV OF PERJURV THAT THERE IS A CANSTRUCTION I.ENDINO AGENCY
FOR THE PERFORMANCE OF THE WORN FOR WHICH THIS PERMIT IS ISSUED(SEC.30D7,CIV.CJ.
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� LENDER'S NAA/E
� LENDER'SADDRESS
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w I CERTIFV 7HAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATIOfJ IS CAFRECT. TOTAL FE ES L� � � /��
� I AGREE TO CAMPLV WITH ALL CfTY AND COUNTV ORDINANCES AND STATE LAWS RELATING TO BUILDINO (� /� ,oO
� CANSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF THIS COUNTV TO ENTER UPON THE COMMENTS` �GU 1 V �Q O `� � + V`" L/ \�v �
z ABOVE�MENTIONED PROPERTV FOR INSPECTION PURPOSES.
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