HomeMy WebLinkAbout17456 (25) CITY OE DIA.'vIOND BAR
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� ����� BUILDING PERMIT APPLICATION JUN 19 2002 FIRMLY �
y� JOBSITE�3600 Nionument Canyon APPLICATION �, ' . PERMIT Pic
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w TURE,PRIOR TO ITS ISSUANCE,AL50 REOUIRES 7HE APPLICAN7 FOR SUCH PERMIT TO FILE A SIGNED W
� STATEMENT hiAT HE OR SHE IS IICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI� �
� CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 9 OF THE BUSINESS AND PRO- POOVSpO
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V TION.ANY VIOLATION OF SECTION 7031.5 BY ANY APPUCANT FOR A PERMIT SU&lECTS THE APPLICANT T0 Z Re-Raof
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Q THROUGH HIS ON HEF OWN EMPLOYEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR m
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� I HEREBV AFFIRM UN�ER PENALTV OF PERJURV ONE OFTHE FOLLOWING DECLARATIONS: Z
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¢ CAM�ENSATION,AS PHOVIDED BV SECTION 370o OF THE LABOR CODE,FOR THE PERFORMANCE U
Q OFTFIE WORK FOR WHICH THIS FEFMIT IS ISSUED. � . .
� �_I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BV SECTION �
Q3700 OF THE UBOR COOE,FOR THE PERfORMANCE OF THE WOFN FOR WHICH THIS PERMIT IS Cl �J..Z V
ISSUED.MV WORKERS'CAMPENSATION INSURANCE CARRIER AND POIICY NUMBER ARE: CONSTRUCTION �) /
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Z I CERTIFV THAT IN THE PERFORIAANCE OFTHE M/ORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
C} SHALL NOT EMPIOV ANV PERSON IN ANV MANNER SO AS TO BECOME SUBJECT TO THE
� WORKERS'COMPENSATION LAWS OF CLL�FORNIA.AN�AGREE THAT IF�SHOULD BECOME INSPECTION FEE _
'� SU&IECT TO THE WORKERS'COYPENSATION PROVISIONS OF SECTION 97000F THE LABOR � ,y7 �i, '- " ""'�` C--"
� CODE,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. ISSUANCE I� ��- �_-� I �l � �y �1 ��•-
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� WARNING:FAILUPE TO SECURE WORKERS'COMiENSATION COVERAGE IS UNI.AWFUL,AND SHALL BE ENERGY P/C I (l F� n 5 �_ n�
� SUBJECTAN EMPLOVER TO CRIMINAL PENALTIESAND CIVIL FMES UP TOONE HUNDRED THOUSAND ENERGY PERMIT I
DOLLARS(f100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
J SECTION]7oe OF THE LABOF CODE.INTEREST,AND ATTORNEY'S FEES. ,�� a�
p� RETENTION FEE: �"' I.
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: L,�-==_.._ ---
� I HEFEBV AFFIRM UN�ER PENALTV OF PERJURV THAT THEqE IS A CONSTRl1CTION LENDING AGENCV
� FOR THE GEi1FORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.7097,CIV.C.).
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� LENDER'S NAME
F— LENDER'SADDRE55
� TOTAL FEES ��3 7�
� I CEFTIFV THAT I HAVE READ THIS APPLICATION AND STATE iHAT THE ABOVE INFORMATION IS CARRECT.
w I AGREE TO COMPLV WITH ALL CITV AND COUNTV ORDINANCES AND STATE LAWS REIATING TO 9UILOING
� CONSTRUCTION,AND HEREBY AUTHORIIE REPfiESENTATIVES OF TFi15 COUNTV TO ENTER UPON THE
� ABOVE-MENTIONED PROPERTV FOR INSPECTION PURPOSES. �
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� SIGNATUREOF PERMITfEE - DATE RECPT.NO. O, Z PAID BY L� �� VALIDATION
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