HomeMy WebLinkAbout13385 ��� CITY OF DIAMOND BAR F
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �
21660 E.Copley Drive Suite 190
(909)860-3195 Faz(909)861-3117 PRESS
� �A�^, BUII.DING PERMIT APPLICATION FIRMLY
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Z NRE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED .
� STATEMEHT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTMCTORS LI- w
� CENSE UW(CHAPTER Y(COMMENCINO M/ITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS M1D PRO- � POOVSpB
FESSIONS CODE)OR TNAT HE OR SHE IS EXEMPT THEREFROM AND THE BtiS15 FOR 7HE ALLEOE�E%EMP-
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WILL DO THE WORK AND THE STRUCTURE IS NOT IHTENOED OR OFFERED FOR SALE(SEC.70s1,BUSI- J
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N PROPEHTYNM1pBUIlD50RIMPROVES7HEREON,ANDWHODOESSUCHWORKHIMSELFORHERSELFOR �
Q TNiqUGH HIS OR HER OWN EMPLOYEES,PqOVIDED 7HAT SUp1 IMPROVEMENTS ARE NOT INTENDEO OR m
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Z 'TION,THE OWNERAUIIDER MALL HAVE THE BURDEN OF PROVINO THAT HE OR SHE DID NOT BUIID OR
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� 1 HEREBYAFFIRN UNDER PENALTV OF PERIUM THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER � �`�' . � .
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WORKERS'COMPENSATIONDECLARATION Q � YT 1 llt' ��Aj�4Y
N I HEREBY AFFIRM UNDER PENALTV OF PEiUURY ONE OFTHE FOLLOWING DECLAMTIONS: Z ���i`�C..Y}�i' �A����
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� _IMAVEANDWILLAUINTAINACERTIFIGTEOFCONSEMTOSELF-INSUREFORWORKERS' 2
CONPENSATqH,AS PROVIDED BY SECTION�7000F THE LABOR CODE,FOR 7HE PERWRMANCE U
Q OF THE WORK FOR NRiICH 7H15 PERM�T IS ISSUED. �
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� w _I HAVE AND WILL MAINTAIN WOHI(ERS'COMPENSATION INSURANCE,AS RE�UIRED BV SECTION �
Q 37000F THE UBOR CODE,FOR THE PERPDRMMICE OF h1E WORK FOR WHICH THIS PERMIT IS ny/,�.,y�y��� �
ISSUED.MY WORKERS'COLIPENSATION INSURANCE CARRIER AND POLICY NUMBEH ARE: CONSTRUCTION � �.R/1/� 6�Y/
jc�RRiER PLAN REVIEW . �
� POLICV NUMBER ELECTRIC
0 (fF16SECfpNNE�NpTBEOpLpLEfIDOFhEPERMT6FORONEF0.MJREDD011AR5K100)ORL65} PLUMBING -�•
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Z I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PEFiM1T IS ISSUED.I MECHANICAL
C}' SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS 70 BECOME SU&IECT TO THE
� WORKERS'COMPENSATION UWS OF CAL�FORN10.N10 AGREE THAT IF�SHOULD BECOME INSPECTION FEE
S SUBJECTTO THE V70HKER5'COMPENSA710N PROVISIONS OF SEC7ION 370o OF THE UBOR
CODE,I SHALL FOHTHWIT/COMPLY WITH THOSE PROVISIONS. ISSUANCE
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p DATE: APRICANT. SMIP I�_l 1
� ENERGY P/C
J WARNINO:FAILURE TO SECURE KORKERS'COMPENSATION CAVERAGE IS UNUWFUL,AND SHALL BE
� SU&IECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT
DOLLARS(i100,000�.IN IDDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
� SECTION 370E OF h1E LABOH CODE,INTEREST,AND ATTORNEYS FEES. - RETENTION FEE: �• �
d CONSTRUCTION LENDING AGENCY PHE�p T///F'''EE���: �
� I HEREBVAFFIRM UN�ER PENALTV OF PERIURV THAT THERE IS A CONSTRUCTION LENDINO AGENCV � � 7��
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3oV7,CIV.C.).
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�� LENDEfYS NAME
F- LENDER'SADDRESS
� I CERTIFY 7HAT I HAVE READ 7HI5 APPLiCAT10N ANO STATE THA77HEABOVE INFORMATqN IS CORRECL TOTAL FEES
W I AOREE TO COMPIY WITH ALL CfTV IND COUMY ORDINANCES M!D STATE LAWS RELATINO TO BUILDING
� CONS7RUCTION,AND HEREBY AUhIORIZE REPHESENTATIVES OF 7HI5 COUNTV TO EN7ER UPON 7HE . � . �
� ABOVE-MEHf�OPERTV FOR INSPECT PURPOSES� COMMENTS '
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� RECPT.NO. s� •7 PAID BY VALIDATION
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SLAB GRAQE FIREP � F,OUND TION :''� �.�:. ` • . ,t
TEMP POWER FIREPL'ACE BOND BEAM � ' � '��� ��
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EXT. LATH/SIDING PnOL FENC�NG �
WALL INSULATION POOL FINAL
CEILING INSULATION OFF SITE IMPS.
DRYWALL NAILING DEDICATIONS
SEWER FINAL ENG. •
SEPTIC TANK _ _ , , LANDSCAPE/IRRIG.
SEEP PIT/L.L. . � e �'� ON SITE IMPS.
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FINAL CONST. p �� FIRE QEPT. FINA�
FINAI HEATING HEALTH DEPT. FINAL
FINAL ELECTRIC DEV. FEES PAID
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