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CITY OF DIAMOND BAR \
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21825 E.Copley Drive
- (909)860.3195 Fa�c(909)861-3117 PRESS
��'%���� BUILDING PERMIT APPLICATION FI RM LY
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w NRE,PRIOH TO ITS ISSUANCE,AL50 REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIONED w Patlo/Deck
� STATEMENT THAT HE OR SHE IS LICENSEb PURSUANT TO THE PROVISIONS OF T1E CONTMCTORS LI�
g CENSE UW(qUPTER e(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PR0. � POOUSPB '
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A CNIL PENALTV OF NOT MORE THAN FNE HUNDRED DOLIAqS(f600�.):
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Z WILL DO THE WORK,AND THE STRUCNRE IS NOT INTENDED OR OFFERED FOR SALE(SEC.704s,BU51- J
� NESS AND PROFESSIONS CODE:7HE CONTRACTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF �
PROPERTV N?10 BUILDS OR IMFFOVES THEREON.AND VAiO DOES SUCH WORK HIMSELF OR HERSELF OR
2 THROUGH HIS OR HER OWN EMPLOVEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR m
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Z TION.THE OWNER�BUILDER WILL HAVE THE BURDEN OF PROVINO THAT HE OR SHE DID NOT BUILD OR
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w ❑I,ASOWNEROFTHEPROPEHTV,AMEXCLUSNELYCONTRACTINGWfTHLICENSEDCONTMCTORS
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� ❑I AM E%EMPT UNDEH SEC. B.6 P.C.FOR THIS REASON Q I L{./�N�rT
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CL I HEflEBV AFFIRM UNDER PENALTV OF PEH.IURV 7HAT I AM LICENSED UNDER PROVISIONS OF CHAPTEfl � �
� o(COMMENCINO WITH SECTION 7000)OF DMSION 3 OF THE BUSINE55 AND PROFESSIONS CODE,AND Z
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� I HEREBV AFFlRM UNDER PENALTV OF PERJURV ONE OF THE FOLLOWING DECIARATIONS: Z
�Z _I HAVE AND WILL MNINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORNERS' a
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Qw �IHAVEANDWILLMAINTAINWORKERS'COMPENSATIONINSURANCE,ASREOUIqEDBYSECTION
37000F THE LABOR CADE,FOR THE PERFORMANCE OF THE WORI(FOR WHICH THIS PERMIT IS �K•��
ISSUED.MV W�OR�KER•S/'C�qM�PENSATION INSURANCE Cq,�`RIER AND POLICY NUMBER ARE: CONSTRUCTION ✓
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Z I CERTIFV THAT IN THE PERFORMANCE OF THE WORN FOR WHICN THIS PEHMIT IS ISSUED,I MECHANICAL '
CJ SHN.L NOT EMPIOY ANY PERSON IN ANY MANNER SO AS TO BECOME SU&IECT TO THE
N WORNERS'COMPENSATION LAWS OF CALIFORNIqAND AOREE THAT IF I SFIOULD BECOME � INSPECTION FEE
= SUBJECT TO THE M/ORKERS'COM7ENSATION PROVISIONS OF SECTION 7]00 OF THE LABOR �
DE.ISHALLF R 7HCAMPLVWI SE ROVISIONS. ISSUANCE
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J WARNINO:FAILURE TO SECURE WORKERS'COMPENSATqN CAVERAGE IS UNLAWFUL,AND SHALL BE ENERGY P/C
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� SU&IECTANEMPLOVEflTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTMOUSAND ENERGYPERMIT
DOLL.4RS(f700.0ao).IN ADDITION TO THE COST OF COMPENSATION,DAMAGES A$PROVIDE�FOR IN
J SECTION3�OBOFTHEUBORCODE,INTEREST,ANDATTORNEV'SFEES.
OC RETENTION FEE:
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBV AFFIRM UNDER PENALTY OF PERIURV THAT THERE IS ACANSTRUCTION LENDINa AGENCV
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3oe7,CIV.C.).
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� I CERTIFV THAT I HAVE HEAD THIS APPUCATION AND STATE THAT THE ABOVE INFORMATqN IS CARRECT. �J�V
w I AGREE TO COMPLV WITH ALL CITV AND COUNTY ORDINANCES AND STATE UWS RELATING TO BUILDIN6
� CONSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF THIS COUNTV TO EMER UPON THE
� ABOVE-MENTqNED PR07ERTV FOR INSPECTION PURPOSES.
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= RECPT.NO. PAID BY ALIDATION
~ WHITE—Deparimen[Copy,YELLOW—Finence Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy
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DRYWA�L NAIUNG DEDICATIONS
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