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��� CITY OF DIAMOND BAR ,
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES JUN 1�' Z06�
a 21660 E.Copley Drive Suite 190
(909)860-3195 F�(909)861-3117 PRESS
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w NRE,PRqR TO ITS ISSUANCE,ALSO flEOUIRES THE APFLICANT FOR SUCH PERMIT TO FILE A SIGNED w
� STATEMENT TNAT HE OR SHE IS LJCENSED PURSUAHT 70 7HE PROVISIONS OF THE CANTRACTORS LI-
� CENSE LAW(CHAPTER Y(COMMENCINO WITN SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- � PooVSpa
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� ACML PENAL7Y OF NOT MORE THAN FNE HUNOREO DOLIARS(t500).):
� OI,ASON?IEROFTHEPROPER7Y,ORMVEMPLOVEESWI7HWAGESASTHEIRSOLECOMPENSATION, � COR1rtIBfClel � �
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.701/,BU51- J
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE UW DOES NOT APPLY TO AN OWNER OF
� PROPERfI'VAiOBURDSORIMPROVES7HEREON,ANDWHO00E55UCHWORKHIMSELFORHERSELFOR m
� hIRODUH HIS OR HER OWN EMPLOVEES,PROVIDED THAT SUp1 IMPROVEMENTS ARE NOT IHfEHDEO OR
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O I,AS ONMER OF THE PROPERTV,AM EXq.USIVELY CANTMCTINO WITH LICENSED COMRACTORS
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F LICENSED CONTRACTORS DECLARATION W
� 1 HEflEBY AFFIRM UNDER PEN/�LTY OF PERIURY THA7 I AM LICENSED UNDER PROVISIONS OF CHAPTER �
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� ORKERS'COMPENSATION DECLARATION a
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� 1 HEREBV AFFIRM UNDER PENAL7Y OF PERIURY ONE OF THE FOLIAWING DECLARATIONS:
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W 1 HAVE M1D VALL MAIMAIN WORKERS'COMPENSATION INSUMNCE.AS REOUIRED BV SEC710N
Q 3700 OF THE LABON ODOE,FOR TNE PERFOFMANCE OF 7HE WORK FOR NM1iICH 7HI5 PERMIT IS
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Z I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
(!'S SHALL NOT EMPLOY ANV PEHSON IN ANV MANNER SOAS TO BECAME SU&IECT TO 7HE • - � "- - " '
y WORKERS'COMPENSA710N UWS OF CALIFOFNIA,AND AGHEE THAT IF I SHOULD BECAME INSPECTION FEE
SU&IEC�TO THE WORNERS'COMPENSATION PFIOVISIONS OF SECTION 37000F THE UBOR
CADE.�f SH FORTHWITH COMPLY WITH T E PROVISIONS �SSUANCE
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DATE: l APPLICANT: I� �
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J WARNIN :FAIL E TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHQL BE
� SUBJECTANEMPLOYERTOCRIMINALPENALTIESANOCIVILFINESUPTOONEHUNDHEDTHOUSAND ENERGYPERMIT - �� 3--"==�-^�
DOIURS(f100,000),IN ADDITION TO7HE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN -
J SECTION 370!OF THE LABOR CODE,MTEREST,AND ATTOpNEV'S FEES. RETENTION FEE:
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� CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBV AFFIRM UNDER PENALTY OF PEFLIURV THAT THERE IS A CONSTRUCTION LENDING AGENCY �
n- FOR THE PERFORMANCE OF TME WORK WR WHICH 7HI5 PEFiM1T IS ISSUED(SEC.3097,CIV.C.). � . '
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� �ENDER'S NAME � �
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� I CERTIFV THAT I HAVE READ THIS APPLICA710N AND STATE THAT THE ABOVE INFORMATION IS CARREC7. TOTAL FE ES ' 3 S•�O
w I AGREE TO CAMPLY WITH ALL CfTY AND COUNTY ORDINANCES AND STATE UWS REU7ING TO BUILDING
� CONSTRUCTION,AND HEREBY AUTFIORIZE REPRESENTA7IVES OF THIS COUNTY TO EMER UPON 7HE -
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