HomeMy WebLinkAbout16746 (25) �� CITYOFDIAMONDBAbt EXPIF�ED
, DEPARTMENT OF COMMUNITY�DEVELOPMENT SERVICES
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APN LOT TRACT DATE CONST. GROUP
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Z TURE,PRpR TO ITS ISSUANCE,I1LS0 RE�UIHES TiE APPIICANT FOR SUCH PEHMIT TO FILE A SIGNED I
w STATELIENT iHAT HE OR SHE IS LJCENSED PURSUANT TO iHE PROVISIONS OF THE CONTMCTORS LI- w
� CENSE UW(CHAPTER Y(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND Pq0- � POOVSpB
FESSqNS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANY VIOUTION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SU&IECTS THE APPLICANT TO Z Re-Roof
� ACIVIL PENAL7Y OF NOT MORE THAN FNE HUNDRE�DOLURS(i5ao).):
� OI,ASOWNEROFTHEPROPERTV,ORMVEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, 0 COff1ff10fCi81 �
WILL DO TME WORK.AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.701�,BUSI� J
� NESS M1D VROFESSIONS CODE:hIE CANTRACTORS LICENSE UW DOES NO7 APPLY 70 AN OWNER OF �
PiqPERTY WFIO BUILDS OR IMPROVES THEREON,AND NM110 DOES SUCH WORK HIMSELF OR HERSELF OR
C[ iHROU(3H HIS OR HER OHM EMPLOYEES,PROVIDED THAT SUCH IMPROVEMEN75 ARE NO7INTENDED OR m .
0 OFFEREDFORSALEIF,HOWEVEiLT1EBUILDINOORIMPROVEMFNTIS50lDWITHINONEVEAROFCOMPLE-
Z ��TION,THE OWNER�UILDER WILL HAVE THE BURDEN OF PROVINO 7HA7 HE OR SHE DID NOT BUIID OR
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❑I,AS OMMER OF h1E PROPEHTV,AM E%CLUSIVELY CONTRACTINO Wlhl LICENSED CONTRACTORS
� TO CONSTRUCT THE PRQIECT(SEC.ION,BUSINESS AND PROFESSIONS CADE:THE CONTRACTORS LI- V8IU8110l1 ADJ.AREA
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� I HEREBY AFFIRM UNDER PENALTY OF PERIURY THAT I AM LICENSEO UNDER PROVISIONS OF CHAPTER � .
d Y(COMMENCINO WITH SECTION 70a0)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CADE,AND Z
MV IICENSE IS IN FULL FORCE AND EFFECT.
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� WOAKERS'COMPENSATION DECLARATION -�
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� I HEREBV AFFIRM UNOER PENALTV OF CERIURV ONE OF THE FOLLOWING DECLARATIONS: U
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� IHAVEANDWILIMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWOHKERS' 2
� COLIPENSATION,AS PROVIDEO 8Y SECTION 3700 OF THE LABOR CODE,FOR THE PERFORMANCE �U
LEFTHE WORK FOfi WHICH THIS PERMIT IS ISSUED. � .
O �� I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIHED BY SECTION
Q 370a OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED.MY WORKE/R�S'COMPENS/ATION INSURANCE CARRIER AND POLICY NUMBEfi ARE: CONSTRUCTION
� CAARIER �a,qo'eH C44I�L,/� �+ PLANREVIEW
� POUCY NUMBER"�� y 7 3 7 7�7 ELECTRIC C
0 (I}GSSECf10NNE�NOTBE00APLEfIDOFhEPERAf�ISFORONEFiIMDREDDOl1J�A5(5100)OqLESS) PLUMBING _ ��•✓�
Z I CERTIFY THAT�N THE PERFORMANCE OF hIE WORK FOR WHICH THIS PERMI715ISSUED,I MECHANICAL
(J SHALL NO7 EMPLOY ANY PERSON IN ANY MANNER SO AS 70 BECOME SUBJECT TO THE �
� WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME INSPECTION FEE � .
SU&IECT TO THE WORKEtiS'COMPENSATION PROVISIONS OF SECTIO 3700 OF THE LABOR (""" � /�q
S CADE,I SHALL FORTHWITH COMPLV WITH T SE PROVI 4Ns. ISSUANCE � (�(��I •V V
p DATEY_���/ APPUCANT, r"�`^ ����� �SMIP I .I I I I �-�1 I 1 I I
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J WARNING:FAILURE TO SECURE WORKERS'COMPENSATION CAVERAGE IS UNLAWFUL,AND SHALL BE
LL SUBJECT AN EMPLOVER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND �/�`
DOI.URS(5700.0o0),INADDITIONTOTHECOSTOFCOMPENSATION,DAMAGESASPROVIDEDFORIN ENEFGYPERMIT E,;.�_r a`
� SECTION 37oe OF hiE LABOR CODE,M7EREST,AND A770RNEPS FEES. � � ' �� • __
RETENTION FEE::.._::__.� _�_-�
� CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBY AFFIRM UNDER PENALTV OF PERJURV THAT THERE IS A CONSTRUCTION LENDING AGENCV
FOfi THE PERFORMANCE OF 7HE WORK FOR WHICH THIS 7EFMIT IS ISSUEO(SEC.3097,CIV.C.�.
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� LENDER'S NAME � .
� LENDER'SADORE55 , ��
� 1 CERTIFY TNAT I HAVE READ THIS APPLICA710N AND STATE THAT THE ABOVE INFOHMA710N IS CORRECT. TOTAL FE ES
w I AGFiEE 70 CAMPLV WITH ALL CI7Y/WD CAUN7Y ORDINANCES AND S7ATE LAWS REUTING TO BUILDING '
� CONSTRUCTION,AND HEREBV AUTFiORIZE FiEPRESENTATIVES OF THIS COUNTV TO ENTER UPON THE [I � ' �
Z �BOVE-MENTIONED PROPER7Y FOR INSPEC710N PURPOSES. COMMENTS Ln�i I'I GC B✓� rc.��T r ,,�,�ST r �
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� IGNATURE OF P MI77EE DATE
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~ WHITE--0epartment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENRO ile Copy,GREEN—Applicant's Copy
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SLAB GRA�JE FIREPLXIGE'FOUNDATION �-
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TEMP POWER I FIREPLACE'BOND BEAM
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EXT. LATH/SIDING POOL FENCING
WALL INSULATI�N P�OL FINAL
GElLING INSUV�TION OFF SITE IMPS.
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