HomeMy WebLinkAbout14970- CrrY OF DIAMOND BAR `
COMMiINITY DEVELOPMENT DEPAtt'iMENt ° "
21660 E Copley Drive Suite 190
(909) 8603195 Fax (909) $61-3117- -.' { _ PRESS
BUTUANGPERMTi'APPLICATiO14 I / FIRMIY
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DESIGNER
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CITY ZIP TEL
OWNER -BUILDER DECLARATION
I HERESY AFFI W UNDER PENALTY OF ►ERAJM THAT I AM EXEMPT FROM ME C CNM%CiORA LA
CENSE LAW FOR THE FOLLOVRNO REASON (SEG Mils BVBHESSANO ►ADFEU31>4000E:AIO017YOR
COUNTY VA MCH AECCUIESA PEAWTOCOM57RUCT.ALTER NPROYE DEMOUSK ORAEPAUI ANY S11SAC.
TUBE PAIOR TO ITS ISSUA CE ALSO REQUIRES THE APPLICANT FDA V-01 PEAM? TO FILE A SIGNED
STATEMEPT THAT NE OR SHE IS UCENSED PURSUANT TO THE PAOVLSIONS OF THE CNRfRACT00.4 4A
CENSE LAW COLAPTER r VOOMUENCNG VAT" -SECTION 70m) OF OTYLSIOM TCF THE SUS&ESS AMO FRO
FESSIONS OWE)Oft THAT HE OR SNE IS EXEMPT THEREFAOUANO THE BASIS FOR THEALLEGEOEXEMA.
TION. ANY VYYATIONOF SECTION 7OStJ SYANYAPMUCAHT FDI A PERMIT SUBJECTS TNEAPFuCANT t0
A CN'L PENALTY OF NOT MORE THAN FNE K04RED OCILLUIS (SUM)):
0 L ASOWNEAOFTHEPAOPERIY, OA MYEMPLOYEEs WAIN WAGES AS THEIR SUE COWPENUTXV4.
WILL DO THE WORK. AHD THE STRUCTURE t5 NOT wmNOED OR OFFERED FOR SHE (SEG lou, BUS
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NESS AND PROFESS+ONS COO;: THE CONTRACTORS UCE)ASE LAW COE$ NOT APPLY TO AN OWNER OF
PROPERTY VMO WILDS OI IMPROVES THEAEOKANO WHODOCS SUCH WORK WAtSEtFdt PIERSELFOA
THROUGH HIS OA HEA OWN EMPLOYEES. PROVIDEDPROFO THAT SUCH BIPROVEUENTS ARE NOT MTLM0ED OR
OFFERED FOR SALE 6. NOWIEVER THE BURDNO OR IMMOVEMEW IS SOLDLVITFWOHE YF AA OFODMPL[.
TION, THE ONNER1K"EA VAU. HAVE THE BURDEN OF PR'WO THAT HE OR SHE DID NOT a" OR
IMPROVE FOR THE PVRP03E OF SAIF}
O LAS OWN FROF THE PAOPERTY.AM F-ACLUS(VEIY CONTMCnmO WITH LICENSED CQNTRACTOAS
TO OOASTPUCT THE PROTECT (SEC 70N, BUSINESS AND PROFESSIONS OOOE 7), E CONTRACTORS Ll
CENSE LAW DOES)IOTAPPLY TO AN OW/IER OF A PROPERTY WrO WILDS OR W PROVES THERECH. ANO
VMOOONTMCTS FOR SUCHPROIECTS WITH A CONTRACTORS) L.IC040 PURSUANRTOTHE ODIfTRAO.
TORS LICENSE LAW J
0 1 AM EXEMPT UNOER SEC. B. S P,C. FOR TM RFASOJ
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HERESY AFFIRM LMEA PENALTY OF PERJURY TROT IAM UCENSED UNDER PROVISIONS OFCHAPT;a
F (COMMENCND WLT}I SECTK7H )000) OF OMSION i OF M£ aUSINFSS ANO 1ROFFSSS'.YNS CODE, AIA
MT LICENSE LS N FLLL FOACE ANO EFFECL
LICENSEE CLASS LK, NO.
DATE----- COItTRACTOR - __
WORKERS COMPENSATION DECLARATION
1 HEREBY AFFIRM LACER /ENMITY OF PERJURY ONE OF THE FOLLOWING DECLARATIONAFFIRM
`_I HAVE AND WV.L UAW TANA CERTIF)CATE OF CONSEMTO SELFiNSUM FOR WORKERS
COUPENSATCN,AS PROVKTEO SYSECTION S)OOOF THELABOR OWE FORTHEIIERFORM NCE
OF THE WORM FOR VI)POi MLS PEAA4T tl l33UED.
_„_ I NAVE AND MALL L(AWTAN WORKERS COUPEHSAT?ON a1SNRA7KE AS PEOUfgEB BT SECTION
a700 OF THE LABOR CODE FOR THE PERFORMANCE OF WORK FOR WHICH THO PERMIT LS
ISSUED. MY WCrIXEAT COMPENSATION NSURANCE GARNER AND POLICY "SER AR[;
POLICY NUMBER
(INS SECTUI.1cmNOT BE CG.FLETEOCFTIE PEPW S FORCPEH-PDAM 03JAPS cum ORLESSL
I CERTIFY TKAT W THE PERFORM. JWC OF THE WORX Fop wHKx TMS PEAtr1T IS ISSUED.I
SH
UNOT EMPLOY ANY PERSCN N ANI' FANNER$OAS TO BECOME SU&ICT TO THE
YYORKERT COMPENSATION LAWS OF CALIFOAML ARO AGREETNAT IFI SHOULD BECOME
SUBJECT TO THE WORKERS COMPENSATION PAOVISCNS OF SECTION 0700 OF THC LABOR
DODEI SHALL FORTHWITH COMPLY VARY TRIOSE PACVISCNSI
DATE: APPLrCANT.
WMWtNG: FALVRE TO SECURE WORKEAS COUPSMSAT30H COVERAGE IS UNLAWFUL ANO SMALL BE
SUBJECT AH EUPLOYER TO CAVA W) PENALTIES ANO CML F&FS UP TO ONE KINDRED IYIOUSANO
DOLLARS (I I Oe.000T, N ADDITION TO ME COST OF COMPENSATION, DAMAGE$ AS PROVIOEO FQR &
SECTION 5704 OF THE LABOR CODE NTEREST. MID ATTOINM FEES
CONSTRUCTION LENDING AGENCY
1HEREBYA PPMUOER►ENALTYOFPERA/MTNATTHEREtSAODNSTRUCTIONL M04AGENCY
FOq THE ►EAFORMUICE OF THE W'DAK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3OP7, CN C.).
LENDERS NAW E
LENDERS ADDRESS
1 CEATIFY THAT 1 HAVE READ MTN K
THIS ANO STATE THAT THE ABOVE &FORMATIOCORRECT.
1 AGREE TO COMPLY WITH ALL CRY ANO COUKTY ORO WANCEI AMO STATE LAMS AELAY&O To SL/D&C
CONSTRUCTION. AAA HEREBY AUTHORIZE AEPRESEMATNES OF MIS COUNTY TO ENTER UPON ME
ABOVF•UENTICNED PROPERTY FOA MPEC1TION PURPOSE
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