HomeMy WebLinkAbout17843 (25) I CTTY OF DIAMOND BAR �
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21825 E.Copley Drive "J
(909)860-3195 Fax(909)861-3117 PRESS
'"����� BUILDING PERMIT APPLICATION FIRMLY
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I HEREBV AFFIRM UNDER PENALTV OF PERJURY THA7 I AM EXEMPT FROM THE CONTRAC70R5 LI� G0f8 J8/C8fp0A
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W TURE,PRIOR TO ITS ISSUANCE.ALSO REOUIRES 7HE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w Patio/Deck
S7A7EMENT 7HAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF 7HE CANTMCTORS LI-
� CENSE LAW(CHAPTER B(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINE55 AND PRO� � POOVSpO
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U TION.ANYVIOLA710NOFSECTION7031.SBVANVAPPLICANTFORAPERMITSU&IECTS7HEAPPLICANTTO Z Re-Roof
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❑I,ASOWNEROFTHEPROPERTV,ORMVEMPLOYEESWITHWAGESASTHEIRSOLECAMPENSATION, �
Z WILL DO THE WORK,AND 7HE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7o4I,BU51- J COrt1rtIBfCi91 �
� NESS�flD PROFESSIONS CODE:THE CANTRACTORS LICENSE lAW DOES NOT APPLY TO AN OWNER OF � �( •,`�
PROPERTVWHOBUILDSORIMPROVESTHEREON,ANDWHODOESSUCHWORKHIMSELFORHERSELFOR I V
� 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 PROVING 71�AT HE OR SHE DID NOT BUILD OR
� IMPROVE FOR THE PURPOSE OF SALE).
w OI,ASOWNEROFTHEPROPER7Y,AME%CLUSNELVCONTRACTINGWITHUCENSEDCONTRACTORS
� TO CONS7RUC7 THE PR0.IECT(SEC.70a�,BUSINE55 AND PROFESSIONS CODE:THE CON7RAC70R5 LI- VelUellOfl ADJ.AREA
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�� ❑I AM E%EMP7 UNDER SEC. B.8 P.C.FOR THIS REASON Q
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� LICENSED CONTRACTORS DECLARATION w
� I HEREBY AFFIRM UNDER PENALTV OF PERJURV THA7 I AM LICENSED UNDER PROVISIONS OF CHAP7ER �
� Y(COMMENCING WITH SECTION 7000)OF OIVISION 3 OF THE BUSINESS AND PROFESSIONS CADE,AND Z
`X MY LICENSE IS IN FULL FORCE AND EFFECT. m
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V DATE y��Z� CONTRACTOR �4�o�st�r d
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� WORKERS'COMPENSATION DECIARATION Q
� I HEREBV AFFIRM UNDER PENALTY OF PERJURV ONE OF THE FOLLOWING DECLARATIONS: Z
Z _I HAVE AND WILLMAINTAIN A CERTIFICATE OF CONSENTTO SELF�INSURE FOR WORKERS' _
Q COMPENSATION,AS PROVIDED BY SECTION 370o OF 7HE LABOR CODE,FOR 7HE PERFORMANCE �U
Q OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. �
w I HAVE AND WILL MAINTAIN WOflKERS'COMPENSATION INSURANCE,AS REOUIRED BV SECTION o
Q 3700 OF THE UBOR CODE,FOR THE PEHWRMANCE OF THE WORK FOR WHICH THIS PERMIT IS ' j� I •�O
ISSUED.MV WORKERSL'C_OM'PENSAJTIp�,N�INSURANCE CARRIER AND POLICY NUMBER ARE: CONSTRUCTION _ . Q U
� CARRIER ��rTC1'� r��� �9 PLAN REVIEW J_
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� (IHISSECIqNNE�NOTBE00MPLFfEDOFTI-IEPERMITISFORONEHUPDREDDOLLARS(5100)ORLESS). PLUMBING
Z I CEf1TIFV THAT IN THE PERfORMANCE OF THE WORN FOR WHICH 7HI5 PERMIT IS ISSUED,I MECHANICAL
C3 SHALL NOT EMPLOY ANY PEHSON IN ANV MANNER SO AS TO BECOME SUBJECT TO THE �
� WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME INSPECTION FEE
� SUBJECTTOTHEWORKERS'COMPENSATIONPROVISIONSOFSECTION37000FTHELABOR
� CADE.ISHALLFORTHWITHCOMPLVWITHTHO EPROVISIONS. ISSUANCE �
O DATE: � ��Z APPLICANT: �B.tY/t�.A�� SMIP �
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J WARNING:FAILURE TO SECUflE WORKERS'COMPENSATION COVERAGE IS UNUWFUL,AND SHALL BE ENERGY P/C ��
LL SUBJECTANEMPLOVERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT 1
DOLLARS(f100.000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
� SECTION 7708 OF THE LABOR CODE.INTEREST,AND ATTORNEV'S FEES. RETENTION FEE: �
d CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
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� I HEREBV AFFIRM UNDER PENA�TV OF PERJURV THAT THERE IS A CONSTFUCTION LENDINC,AGENCY
FOR THE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.7097,CIV.C.).
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. � LENDER'S NAME
� LENDEH'SADDRE55
� I CER7IFV THAT I HAVE FEAD THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. TOTAL FE ✓
w I AGREE TO COMPLV WITH ALL CITY AND COUNTY ORDINANCES AND STATE UWS RELATING TO BUILDING � �
� CONSTRUCTION,AND HEREBV AUTHORRE REPRESENTATIVES OFTHIS COUNTV TO ENTER UPON THE
� ABOVE�MENTIONED PROPERTV FOR INSPECTION PURPOSES.
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~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENRO�-File Copy,GREEN—ApplicanYs Copy
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