HomeMy WebLinkAbout16039 (20) �, _�� CITY OF DIAMOND BAR
� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
( . 21660 E.Copley Drive Suite 190
� ��: (909)860.3195 Fax(909)861-3117 PRESS
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I HEREBY AFFlRM UNDER PEHALTV OF PERIURV THAT I AM EXEMPT FROM THE CONTRACTORS LI- G8f89B/CflfpOR
W CENSEUWFORTMEFOLLOWINOREASON(SEC.7o3t.5BUSINESSANDPROFES510N5CODE:ANVCITYOR (n
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Z TURE,PRIOR TO ITS ISSUANCE,ALSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w Patio/Deck
�l� STATEMENT THAT HE OR SHE IS�ICENSED PURSUANT TO THE PROVISIONS OF THE CANTMCTORS LI- W
� CENSE LAW(pUPTER 0(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF 7HE BUSINESS AND PRO- u' PooVSpa
FESSpNS CODE)OH iHAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALIEGED EXEMP-
TION.ANY VIOUTION OF SECTION 7091.5 8Y ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT T0 Z Re-Roof
� A CIVIL VENALTV OF NOT MORE THAN FNE HUNDRED DOlURS(3500�.):
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YALL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7014,BUSI- _1
� NESS M!D PROFESSIONS COOE:7HE CONTRAC70R5 LICEHSE LAW DOES NOT APPLY 70 AN OWNER OF �
PROPEHTY 1N10 BUILDS OR�MPROVES THEHEON.AND MMO DOES SUCH WORK HIMSELF OR HERSELf OR
Q THi10UGH HIS OR HER ONM EMPLOYEES.FROVIDED 7HAT SUCi1 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 DIO NOT BUILD OH �
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W ❑I,ASONRIEROFTMEPROPERfY,AMEJ(CLUSIVELYCOMRACTINOWITHUCENSEDOONTRACTORS
([ TO CONSTRUCT THE PROJECT(SEC.7a4,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- V31U2llOfl ADJ.AREA
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� I HEREBYAFFIRM UNDER PENALTV Of PERIURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER �r . ��'�
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� I HEREBV AFFIRM UNDER PENALTY OF PERIURY ONE OF THE FOILOWING DECURA7qN5: �
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� I HAVE AND WILL MAINTAIN A CEfiTIFICATE OF CONSENT TO SELF-INSURE FOR VIOFiKERS' 2
� COAIPENSATION,AS PROVIDED BY SECTION 3700 OF 7HE UBOR COOE,FOR THE PERFORMANCE W
OF 7HE WORK fOH WHICH TMIS PERMIT IS ISSUED. �
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W �I HAVE AND WILL MNIMNN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BY SEC710N
Q 37a0 0F T1E L�BOR CWE,FOR THE PERFORMPNCE OF THE WORK FOR WHICH THIS PERMIT 15
ISSUED.MY WORKEflS'COMP NSATION INSURANCE CARqIER AND P^O�L-IC,V�NU+MBE�R E1: CONSTRUCTION
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Z I CERTIFY THAT IN THE PERFOHMANCE OF THE WORK FOH WHICH THIS PERMIT IS ISSUED,I MECHANICAL
C3 SHAl.L NOT EMPLOV ANY PERSON IN ANV MANNER SO AS 70 BECOME SUBJECT TO THE
Vj WORKERS'COMPENSATION UWS OF CALIFORNIA,AND AGREE THAT IF I SHOUL�BECOME INSPECTION FEE 1 �
S SUBJECT TO THE MIORKERS'COMPENSti ION PROVISIONS OF SECTION 3700 OF THE LABOR y N IV � �U � � `�
CODE,1 SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. I SSUANCE py�
p DATE: APPLICANT: SMIP �'�'�y�'��fi�1,�,��v�RYA1C
J WARNINO:FAILUPE TO SECURE MlORKERS'COMPENSATION COVERAGE IS UNUWFUI.AND SHALL BE ENERGY P/C �DT�TT riu T/� A ATT C��
� SU&IECT AN EMPLOVER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDHED 7HOUSAND ENERGY PERMIT
DOLURS(l100.000�,IN ADDITION T07HE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
¢ SECTION 970E OF 7HE UBOR CODE,INTEREST,AND ATfORNE1^S FEES. RETENTION FEE:
a CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
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� I HEREBY AFFIRM UNOER PENALTV OF PERIURY THAT THERE IS A CONS7RUCTION IENDING AGENCV
FOR THE PERFORMANCE OF 7HE WOfiK FOR WHICH THIS PERMIT IS ISSUED(SEC.3oY7,CIV.C.).
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� LENDER'S NAME � �
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w I CERTIFY TMAT I HAVE READ THIS APPLICA710N AND STATE THAT THE ABOVE INFORMATION IS CORRECL TOTAL FE ES � '� �S`J
� I AGREE TO COMPLV WITH ALl CITV AND COUNTV ORDINANCES AND STATE LAWS RELATING TO BUILDING . �� W � , �
� CANSTqUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF 7HI5 COUNTV TO ENTER UPON THE
Z ABOVE-MENTqNED PROPER7V FOR INSPECTION PURPOSES. COMMENTS "
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