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� �� CITY OF DIAMOND BAR (�J
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES `-��
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117 PRESS
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Z TUHE,PRIOH TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
w STATEMEM THAT ME OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- w
� CENSE UW(CHAPTER Y(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- � POOVSp2
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YALL DO THE WORK,AND THE STRUCTURE i5 NOT INTENDED OR OFFERED FOR SALE(SEC.7011,BUSI� J
� NESS AND PqOFESSIONS CODE:TNE CONTRACTORS LICENSE UW DOES NOT APPLV TO AN OWNER OF �
PROPEHfY WFIO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
Q TMROU(3H HIS OR HER ONM EMPLOYEES,PROVIDED hIAT SUCH IMPROVEMENTS AHE NOT INTENDED OR m
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L11 CEN9E UW DOES NOTAPPLV TO AN OHMER OF A PROPERTY WHO BUILDS OR IMPROVES 7HEREON,AND
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� I HEREBY AFF�RM UNDER PENALTY OF PERIURV THAT I AM LICENSED UNDER 7ROVISIONS OF CHAPTER �
d Y(COMMENCWO WITH SECTION 7000)OF DIVI510N 9 0F THE BUSINESS AND PROFES510N5 CADE,AND Z �
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� WORKERS'COMPENSATION DECLARATION �
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N 1 HEHEBV AFFIRM UNDER PENKTY OF PERIURY ONE OF THE FOLLOWING DECUMTIONS: �
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� _I HAVE AND WILL AWNTAIH A CEt7�IFICATE OF CONSENT 70 SELF-INSURE FOR WORKERS' 2
CONPENSATION,AS PROVIDED BV SECTION 3l0o OF THE LABOR CODE,FOR THE PEHFORMMICE U
Q OF 7HE WORN FOR WHIW THIS PERMIT IS ISSUED. �
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W _1 HAVE AND WILL MAIHTAIN WORKERS'COMPENSATION INSURANCE.AS REQUIRED BY SECTION
Q 3700 OF THE LABOR CODE,FOR THE PERFORMANCE OF TNE WORK f-0R WHICH 7HI5 PEHMIT IS
ISSUED.MV WOHKERS'COMPENSATION INSUiUNCE CARRIER AND POLICV NUMBER ME: CONSTRUCTION
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Z 1 CERTIFV THAT IN THE PERFORMANCE OF THE NlORN FOR WHICH 7HI5 PEHMIT IS ISSUED,I MECHANICAL
(�} SHALL NOT EMP�OY AHY PERSON IN ANY MANNER SOAS TO BECAME SUBJEC7 TO THE
� WORKERS'COMPENSATION LAWS OF C/�LIFORNIA,AND AGREE THAT IF I SHOULD BECOME INSPECTION FEE
SU&IECT TO THE WORKERS'COMPENSA710N PROVISIONS OF SECTION 370o OF THE LABOR �
s CODE,ISHALLFOHTHWITHCOMP�YWITITHOSEPROVISIONS. ISSUANCE _
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p DATE: APPLICANT: - .,,,,� .
J WMNINO:FAIWRE TO SECURE WORKERS'CAMPENSATION CAVERAGE IS UNLAWFUL,AND SHALL 8E ENERGY P/C
� SU&IECTAN EMPLOVER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED 7HOUSAND ENERGY PERMIT
DOLLARS(f100,000).IN ADDITION TO THE COST Of COMPENSATION,DAMAGES AS PROVIDED FOR IN
� SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEV'S FEES. ' RETENTION FEE:
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: C�n�'�����$��
� I HEREBV AFFIRM UNDER PENALTY OF PERIURV THQ THERE IS ACANS7RUCTION LENDING AGENCY I�T TTY 41�T/'� A ��(�p �TR) �
fOR THE FERWRMMICE OF 7HE WORK FOR WHICH 7HI5 PERMIT IS ISSUED(SEC.3oY1,CIV.C.). `��II�TD.Jl1-C��—•
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� LENDER'S NAME �
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� I CER7IFY THAT I HAVE READ THIS APPLICA710N AND STATE THA7 THE ABOVE INFORMATION IS CAHRECi TOTAL FE ES � 1.�. v �
w I AGNEE TO CAMPLV WITH ALL CITV AND COUN7Y ORDINANCES AND STATE UWS REUTING TO BUILDING
� CONSTRUCTION,AND HEREBV AU7F10RIZE REPRESEN7A71VE5 OF THIS COUN7Y 70 ENTER UPON 7HE �/� � �
Z ABOVE�MENTIONED PROPERTV POR INS7ECTION PURPOSES. COMMENTS � I v '""
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