HomeMy WebLinkAbout18590 � CITY OF DIAMOND BAR
� DFPARTIv1ENT OF C01vIMLJNrfY&bEVELOPMENT SERVICES
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(909)&60-3195 Fax(909)861-3117 PRESS
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w TURE,PRIOR TD ITS ISSUANCE.AlSO REDUIFES THE APPLICANT FOR SUCH PEaMIT TO FlLE A SIGNFfI W PdtiO�DBCk
� STATEMENT THAT HE OR SHE IS LICENSED PURSl1ANT TO THF FPOVISIONS OF THE CONTRACTORS U-
CENSE LAW(CHAPTER 9(CONMENCING WITH SECTION]000)OF DIVISION 3 C�F TNE EUSINESS AND PRO- � POOUSPB
Q FESSIONSCODE)ORTHATHEORSHEISE%EMPTTNcqEFROMANDTHEBA515FORTF'EALIEGEDEk[MP- �
U TION.ANVVIOLATIONOFSECTION]O�t,SBVANYAPFLICAN'GOFlAPEHMiTSJ9JECf5iHfAPPLICANTTO Z Re-Roof
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Z~ JI,ASONTJEROFTMEPROPERiY,ORMVEMPLOVcESWITHWAGESAJIMEIF50LECOMPENSAT�ON
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� NESSAND VROFESSIONS CODF::THE CON7RACT�RSIICENSE LAW GO'e5 NO'APP�V TO AN OWNER OF �
PROPERTY WHO BU ILDS OR IMF ROYES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OF
� THflOUGH HIS OR HER OWN EMPLOVEES.PROVIOED THAT SUCH IMPROYEMENTS ARE NO7INTENDED oR C�
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Z TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVIhG?HAT HE OR SHE DIrJ NOT BUILD OH
� IMPROVE FOR THE PURPOSE OF SALE�.
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� I HEREBV AFFIRM UNDEft PENAI.TV DF PEqJURY THAT I AM IICENSED UNOER PROVISIONS OF CHAP'ER �
� 9(COMMENCWG WITH SECTION 7000)OF DIVISION 3 OFTHE BUSINESS AND PPAFESSIONS CO�JE,ANC Z
X MY LICENSE IS W FULL FORCE D EFFECT / /!
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� I HEREBVAFFIRM VNOEF PENAITY�F GERJl1RY ONEOf THF FOLLOWING DECLARATIONS� Z
� I VEANDWILLMAINTAINACERTIFICATEOFCDNSENTTOSELF-�NSUREFORWORKERS' ¢
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O OF THE wORK FOP WHI�H TNIS PERMIT IS ISSUED. �
w I HAVE AND WILL MAINTi1IN WORKERS'COMPENSATICIN iNSURANCE,AS REOUIRE�6V SECTION ry /�
QQ a]00 Of THC LADOR CODE,FOR THE PERFORMANCE OF THE WOPK FOP V/HICHTHIS PEHMIT IS 1..�j '( ��.
_ ISSUED.MV WOFKEFS GOMPE SATION I RANCyy/�q RPoER qND POUCY NUMBEHARE: CONSTRUCTION � �� 6J
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Z I GERTIFY TH�T IN THE I'ERFORMANGE OF THE WORK FOR WHICH THIS PERMIT'�.S ISSUEU.1 MECHANICAL
C,'3 SHALL NO(EMYLOY AN'/PEFSON IN ANV MANNER SO AS TO BECOME SUBJEfT TO THE
(/� WORKERS'COMPENSA710N LAWS OF CALIFORNIA,ANO AGREE THAi IF I SHOULD BECOME INS�ECTION FEE __
? SUBJECT TO THE WORNERS'COMCENSATION PROVISIONS OF SEC?ION 37000F THE IABOR - . ��
CODE.I SHALL fORTHWITH COMPIV W17H THnSE PROVISIONS. ISSUANCE
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p DATE: APPLICANT SMIP _ l+j C,
J WARNING:FAIIURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALLBE ENERGY P/C _
� SUBJECTANEMPLOVERTOCRIWIINALPENALTIESANDCIVILFINESUPIOONEHUN�RE�THOUSAND ENERGYPERMIT
DOLLARS�f1D0.000).IN ADOITION TO THE COSTOF COMPENSATION.DAMAGES AS PROVIDED FOR IN
J SECTION3)o80FTHELABORCJDE.IN'ERES7.ANDATTORNEv'SFEES. � �
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� CONSTRUCTION LENDWGAGENCY PRE-ALT FEE: - �
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� I NEREBVAFFlFlM U'VDFR P[NAITV DF PEFJURY'HAT THERE IS PCONJTFUCTION LENDING AGENCY
a- FOR THE PEHFOFMANCE OF THE WOFK FOR WHICH THIS PEPMIT IS ISSUE�(SEC.3091.CIV.C.�. --
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1 CERTIFY THA�I HAVE HEAD THIS APPLIGATIONAND STATE THAT THE ABOVE INFORMATION IS CORRcCT � � .�
� I AGREE TO COMPLY WITH ALL CRY AND COUNTVORDINANCES AND STATE IAWS RELATING TO AUILDING
� CONSTRUCTION,AND HEREBV hUTHORIZE REPRESENTATNES OFT.IIS COUNTV TO ENTER UP�N�'HE
Z A90VE�MENTIONEO 7ROPERTV F TION PURPOSES.
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CITY OF DIAMOND BAR
DEPARTME'�:T OF COIvINIUNrfY&bEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
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PRESS
FIRMLY
WHITE-Department Copy,YELLOW-Finance Copy, PIN