HomeMy WebLinkAbout17253 (25) 'b CITY OF DIAMOND BAR :���I��r.l�t��'�
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I HEREBY AFFIRM UNDER PENALTV OF PERJURY THA71 AM E%EMPT FROM THE CONTRACTORS LI- G0f39B/CefpOh
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w TURE,PRIOR TO ITS ISSUANCE,ALSO REOUIRES THE APPIICANT FOR SUCH PERMIT TO FILE A SIGNED W PaSiO/DBCk
STA7EMEN7 THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRAC70RS LI�
� CENSE LAW(CHAPTER B(CAMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AN�PRO- � POOVSPO
FESSIONSCODE)ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALIEGEDEXEMP� (�
� TION.ANVVIOLATIONOFSECTION7031.SBVANVAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO Z Re-Roof
A CIVIL FENALTV OF NOT MORE THAN FIVE HUNDRED DOLLARS(S50o).):
❑I,AS ON?JER OF THE PROPERTY,OR MV EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
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Z WILL 00 THE WORK,AND THE STRUCTURE IS NO7 IN7ENDED OR OFFERED FOR SALE(SEC.7oI4,BUSI- J
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PROPERTV NhiO BUILDS OR IMPROVES THEREON,AND NhiO DOES SUCH WORK HIMSELF OR HERSELF OR
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� TION,THE OWNER-BUILDER WILL HAVE THE BUHDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
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Q_ ❑I,AS OWNER OF THE PROPERTV,AM EXCLUSNELV CONTFACTING WITH LICENSED CANTRACTOFS �7
TO CANSTRUCT THE PRQIECT(SEC.701�,BUSINE55 AND PROFESSIONS CODE THE CONTRACTOqS LI- V8IU0N0I1 �V ADJ.AREA
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� 1 HEHEBY AFFIRM UNDER PENALTY OF PERJURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER � �
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X MV LICENSE IS IN FULL FOHCE AND EFFECT.
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� I HEREBV AFFIRM UNDER PENALTV OF PERJURV ONE OF 7HE FOLLOWING DECLARATIONS: Z
Z _IHAVEANDWILLMAINTAINACER7IFICA7EOFCONSENTTOSELF-INSUREFORWORKEFS' _
¢ CAMPENSATION,AS PROVIDED BY SECTION 370o OF THE LABOR CODE,FOR THE PERFORMANCE W
Q OFTHE WORK FOR WHICH 7HIS PERMI7IS ISSUED. �
w �I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTION ��,JJJA
Q 3700 0F THE LABOR CADE,FOR THE PERFORMANCE OF THE WOFN fOR WHICH TNIS PERMIT IS /(�%^��
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Z I CERTIFY THAT IN THE PERFORMANCE OF THE WOHK FOR WHICH T IS PER ir is issuEo,i MECHANICAL _—__--
(.�} SHALL NOT EMPLOY ANV PERS V MANNER O AS TO E SUBJ CT TO THE rl � �._� �_\ �l ' I I � � �
� WORKERS'COMPENSATION LAWS OF C RNIA AND A E TH F I SH ULD BECOM INSPECTION FEE
� SU&IECTTO THE WORKEHS'COMPENSATIO!PR ISION OF SE TION 37 OF THE LA �`�
� CODE 1 SH FORTHWITH COMPLV ITH OS RO I IONS. �SSUANCE
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p DATE: �O ' 0 I APPLICANT: SMIP
J WARNING FAILURE TO SECURE M/ORKER' MPENSATION COVERAGE IS NUWFUL, D HALL BE ENERGY P/C I
� SU&IECTANEMPLOVERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDRE T USAND ENERGYPERMIT I-.-.�..� '
DOLLARS(f100.000),IN ADDITION TO THE COST OF CAMPENSATION,DAMAGES AS PRO FOR IN
� SECTION 3708 OF THE LABOR CADE.INTEREST,AND ATTORNEY'S FEES. �,�.:--_ -_ ' - - e�
RETENTION FEE: I•
a CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
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� I HEREBV AFFIRM UNDER PENA�TY OF PERIURV THAT THEHE IS A CONSTRUCTION LENDWG AGENCY
FOP THE GERF-0RMANCE OF THE WORN FOR WHICH THIS PERMIT IS ISSUED(SEC.3097,qV.C.).
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� LENDER'S NAME
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� I CEFTIFV THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORFECT. TOTAL FE ES //w / /V
w I AGFEE TO COMPLV WITH ALL CITY AND COUNTV ORDINANCES AND STATE UWS RELATING TO BUILDING { v�{�
� CONSTRUCTION,AND HEREBY AUTHOFIZE REPRESENTATIVES OF THIS COUNTV TO ENTER UPON THE
ZA80 E-MENTIONED PROPERTY FOR INSPECTION PURPOSES. COMMENTS
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SLAB GRADE FIREPLACE FOUND�ATION
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GAS AIR TEST FINAL ZONlNG
FINAL CONST. � FIRE DEPT. FINAL
FINAL HEATING HEALTH DEPT. FINAL
FINAL ELECTRIC DEV. FEES PAID
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