HomeMy WebLinkAbout18221 (28) _��� _ CITY OF DIAMOND BAR
DEPARTIv�NT OF COMMUNTI'1'&DEVELOPIv1ENT SERVICES
21825 E.Copley Drive
'� (909)860-3195 Fax(909)861-3117 PRESS
�'-���w BUILDING PERMIT APPLICATION � 2 I FIRMLY
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p I HEREBV AFFIRM UNDER PENALTV OF PERNRV THAT I AA1 E%EMPT FROM THE CONTRACTORS LI� G8fe9B/Ca1POfS
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w NRE,PRIOR TO ITS ISSUANCE./�LSO REOUIRES THE APPUCANT FOR SUCH PERMIT TO FILE A SIGNED w Patlo/Deck
� STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI�
� CENSE LAW(piMTER e(COMMENCINO WITH SECTION 7000)OF DIVISION 3 0F THE BUSINESS AND PRO� � POOVSPB
� FESSIONSCODE)ORh1ATHEORSHEISEXEMPTTHEREFROMANDTHEBA515FOHTHEALLE4EDE%EMP- (�
V TION.ANYVqLATIONOFSECTION7031.6BYANYAPPLICANTFORAPEPMITSU&IECTSTHEAPPLICPNTTO Z Re-Root
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(f500)J:
� OI,ASOWNEROFTHEPROPERTV,ORMVEMPLOVEESWITHWAGESASTHEIRSOLECAMPENSATION, � COrtIrtI0fCi81
Z WILL DO THE WORK�ND THE STRUCTURE IS NOT INTENDED OR OFFEREO FOR SALE(SEC.7014,BUSI� J �
N NESS AN�PROFESSIONS CODE:THE CONTfiACTORS LICENSE UW DOES NOT APPLV TO AN OWNER OF �
PROPERlY W/10 BUILDS OR IMPROVES THEflEON,M1D NM110 DOES SUCH WORK HIMSELF OR HERSELF OR
� THROUGH MIS OR HER ONM EMPLOVEES,PROVIDED 7HAT SUCH IMPROVEMENTS ARE NOT INTEN�ED OR m
� OFFEREDFORS/�LEIF,HOWEVERTMEBUILDIN60RIMPROVEMENTISSOLDWITHINONEVEAROFCOMPLE�
Z TION,THE OWNER-BUILDER WILL MAVE THE BURDEN OF PROVING 7HAT HE Ofl SHE DID NOT BUILD OR
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� I HEHEBV AFFIRM UNDER PENALTV OF PERIURY THAT I AM LICENSEO UNDER PROVISIONS OF CHAPTER V.
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V DATE CONTRACTOR a
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� WORKERS'COMPENSATION DECLARATION Q
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� I HEFEBV AFFIRM UNDER PENALTY OF PERJURV ONE OF THE FOLLOWING DECLARATIONS: Z
� 1 HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOq WORKERS' _
� COMPENSATION,AS PROVIDED BV SECTION 370o OF THE LABOR CODE,FOR THE PERFORMMlCE U �
OF TME WOR1C FOR WHICN THIS PERMIT IS ISSUED. w
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Qw _I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BV SECTION
37000FTHE LABOR CODE,FOR THE PERFORMpNCE OFTHE WORN FOR WHICHiH15 PERMIT IS
ISSUED.MV MIOHICERS'COMPENSATION INSURANCE CARRIER AND POLICV NUMBERARE: CONSTRUCTION
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0 POLICV NUMBER
Z ELECTRIC
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Z I CERTIFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSIIED,I MECHANICAL �
�}' SHAIL NOT EMPLOY ANV PEFSON IN ANV MANNEF 50 AS TO BECAME SU&IECT TO THE
(n WORKERS'CAMPENSATION LAWS OF CALIFORNIA,AND AOREE THAT IF I SHOULD BECOME INSPECTION FEE
= SU&IECT TO THE WORI(ERS'COMPENSATKKJ PROVISKKJS OF SECTION 3700 0F THE LABOR
CODE,I SHALL FOHTHWITH COMPLV WITH THOSE PROVISIONS. ISSUANCE �
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p DATE: APPLICANT.
w NERGY P/�
J WARNING FAILURE TO SECURE WOAKERS'CAMPENSATION CAVERAOE IS UNLAWFUL,AND SHALL BE
� SU&IECTAN EMPLOVEF TO CRIMINAL PENALTIES AND CIVIL FINES 11P TOONE HUNDRED THOUSAND ENERGY PERMIT
DOLURS(5100,000).IN ADDITION TO THE COST OF COMPENSATqN,DAMAGES AS PqOVIDED FOR IN �
J SECTION 37oB OF THE LA80H CODE,INTEREST,AND ATTORNEV'S FEES.
OC RETENTION FEE:
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBV AFFIRM UNDEH PENN.TV OF PERIURY THAT THERE IS A CANSTRUCTION LENDING AOENCY
FOR THE PERFOHA/ANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.70G7,CIV.G�.
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� LENDER'S NAME
H LENDER'SADORESS
w I CERTIFY THAT I HAVE READ THIS APPLICATIONAIJD STATE 7HATTHE ABOVE INFOfiMATION IS CARRECT. TOTAL FEES 5�S � OS � �7'\ �
� I AGREE TO CAMPLV WITH ALL CITY AND COUNTV ORDINANCES AND STATE UWS RELATING TO BUILOINQ � V�
� CONSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATNES OF 7HI5 COUNTY TO ENTER UPON THE /� /� A
Z ABOVE-M NED PROPEHTV FOR���yssee���TION PURPOSES. /� C%(J�C 2
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