HomeMy WebLinkAbout16060 � � _1� CITY OF DIAM ND BAR s �
� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �
21660 E.Copley Drive Suite 190
� (909)860.3195 Fax(909)861-3117 � PRESS
� � `^�'+ BUILDING PERMTT APPLICATION FIRMLY .
� rjJOBSITE j APPLICATION � ' �' PERMIT ��� P/C/t�, ,�
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Z NRE,PHpR TO ITS ISSVANCE,ALSO REOUIRES THE APPLICAN7 FOR SUCH PERMIT TO FILE A SIGNED�
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� CENSE UW(CHAPTER Y(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- � POOVSpB
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WILL DO THE WORK,AND THE STRUC7URE IS NOT INTENDED OR OFFERED FOP SALE(SEC.7041,BUSI- J
NESS AND PROFESSIONS CODE:THE COMRACTORS LICENSE UW DOES NOT APPLV TO AN OWNER OF
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Z TqN,THE OMMERAUILDER WILL HAVE THE BURDEN OF PROVING THAT ME OR SHE DID NOT BUItD OR
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� � TO CONSTRUCT THE PR0.JECT(SEC.7041,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- V2111H�1Of1 ADJ.AREA
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� 1 HEREBY AFFIRM UNDEH PENALTI Of PEiLIURV THAT 1 AM IICENSED UNDER PROVISIONS OF CHAPTER �
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� WORKERS'COMPENSATION DECLARATION a
� I HEREBV AFFIRM UN�ER PENAL7V OF PERIURY ONE OF THE FOLLOWING DECURATIONS: �
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O I HAVE AND WILL MAINTA�N A CEfiTIFICATE OF CANSENT TO SELF•INSURE FOR WORKERS' _
� COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE UBOR CODE,FOR THE PERFORMANCE W
OF THE WOHK FOR WHICH THIS PERMIT IS ISSUED. �
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W _I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
Q 37000F THE LABOR CODE,FOR THE PERFORMMlCE OF iHE WORK FOR WHICH 7HIS PERMIT IS � 'I
ISSUEO.MY WORKERS'COMVENSATION INSURANCE CARRIER AND POLICY NUM9ER ARE: CONSTRUCTION I 1
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� POLICY NUMBER ELECTRIC ����7�� �'�
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Z I CER7IFY TMAT IN hiE PERFORMANCE OF THE WORK FOR WHICH THIS PEHMIT IS ISSUED,I
(� SHALL NOT EMPLOV ANY PERSON IN ANV MANNER SO AS TO BECAME SUBJECT TO THE ^ /� (�, �p�y ,
� WORNERS'COMPENSATIONLAWSOFCAIIFORNIA,ANDAGREETHATIF15HOULDBECOME INSPECTIONFEE �C�C�i 11 / � 'W�'�
SU&IEC770 THE WOHKERS'COMGENSATION VROVISIONS OF SECTION 3700 OF THE UBOR � �°� v " I
� ISSUANCE n�n.A��,�,�. �
CODE,1 SHALL FORTHWITTI COMPLY WITH THOSE PROVISIONS.
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LL SU&IECTANEMPLOVERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT
DOLLARS(5100,000).IN A�DITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
J SECTION 37ae OF h1E LABOR CODE,IN7ERE5T,AND A7TORNEI"5 FEES. � RETENTION FEE: /O
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� CONSTRUCTION LENDING AGENCY PRE�ALT FEE:
� I HEREBY AFFIRM UNDER PENALTV OF PERIURY THAT THERE IS A CONSTRUCTION LENOING AGENCV
FOR THE PEfiFORMANCE OF THE WORK FOR WHICH THIS VENMIT IS ISSUED(SEC.3087,CIV.CJ.
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� LENDER'S NAME �
F- LENDER'SADORE55 ��/�
� I CERTIFY T/iAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CARRECT. TOTAL FE ES (,���./� � v� � �
w t AGHEE TO CAMPLV WITH ALL CITV AND CAUNTY ORDINANCES AND STATE UWS REL�TING TO BUILOING '
� CONSTRUCTION,PND HEREBV AU7ViOFiIZE REGRESEN7ATIVES OF THIS COUNTY TO ENTER UPON THE �
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