HomeMy WebLinkAbout17700 (46) CITY OF DIAMOND BAR
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'"'%.��»� BUILDING PERMIT APPLICATION FIRMLY
� JOBSITE APPLICATION �� � PERMIT P/C
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1 HEREBV AFFIRM UNDER PENALTY OF PERIURY THAT I AM E%EMPT FROM THE CONTRACTORS LI- G8f89B/C2fpOR
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W TURE,PRIOR TO ITS ISSUANCE,AL50 REQUIHES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNE� W Patio/Deck
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CON7RACTORS LI�
� CENSE LAW(CHAPTER e(COMMENCING WITH SEC710N 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- � PooVSpa �
� FESSIONSCADE)ORTHATHEOFSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXEMP� (�
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� ❑I,ASOWNEROFTHEPROPER7Y,ORMVEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, � CORIrtI0fC181 -
Z WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.70�a,BUSI- J
� NESS AND PROFESSIONS CADE:THE CANTRACTORS LICENSE UW DOES NOT APPLV TO AN OWNER OF �
PqOPERTY HM1iO BUILOS OR IMPROVES h1EREON,AND NTiO DOES SUCH WORN HIMSELF OR HERSEIF OR
Q THROUGH HIS OR HER OWN EMPLOYEES,PROVIDED THAT SUCH IMPROVEMEN7S ARE NO71N7ENDED OR m
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LICENSED CONTRACTORS DECLARATION W
� I HEREBY AFFIRM UNDER PENALTY OF PERJURV THAT I AM LICENSED UNDER PROVISIONS OF CHAP7ER �
d e(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESSAND PROFESSIONS CODE,AND Z
X MY LICENSE IS IN FULL FORCE ANO EFFECT. /
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� WORKERS'COMPENSATION DECLARATION Q '
� � I HEREBV AFFIRM UNDEH PENALTV OF PERJURV ONE OF THE FOLLOWING DECLARATIONS: Z
� IHAVEANDWILLMAMTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWO{iKERS' a '
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¢ CAMPENSATION,AS PROVIDED BV SECTION 3700 OF THE LABOR CODE,FOR THE PERFORMANCE W 'I
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. � ,
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� _I HAVE AN�WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTION I
QQ 370o OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMI7IS /�� �O
ISSUED.MY WORKE 'CAMPENSATION INSUHANCE CARRIER AND POUCY NUMBER ARE: CONSTRUCTION
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(iHISSEC�%JNNEmNOTBE�MREfEDOFTFIEPERAYTISFORONEHUPAREDD0I.LARS(f100)ORLESS} PLUMBING ` �
Z I CERTIFV THAT IN THE PERFORMANCE OF THE WORK FOF WHICH THIS PERMIT IS ISSUED.I MECHANICAL I ��J/"=\ TI_ �f'�\
�} SHAIL NOT EMPLOV ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE �' ' -� ���_J
�/j WORKERS'COMPENSATION UWS OF CALIFORNIA,AN�AGFEE THAT IF I SHOULD BECOME INSPECTION FEE
� SU&IECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF TI1E LABOR - r� � '
CADE,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. ISSUANCE F F R r /n I�7
p DATE: APPLICANT: SM�P I y� I 'd
� ENERGY P/C I1L�t r i
J WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVEfiAGE IS UNLAWFUL,AND SHALLBE L,4. f
LL SUBJECTANEMPLOVERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT ��----__
r DOLLARS(f7a0,00aJ,IN ADDITION 70 THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN _... _.,�,_�_ o�y
J� SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEV'S FEES. RETENTION FEE: I�
� CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
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� I HEREBV AFFIRM UNDER PENALTY OF PERJURV 7HAT THERE IS A CONSTHUCTION LENDING AGENCY
FOR THE PERF-0RMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3087,CIV.C.�.
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� LENDER'S NAME
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� I CERTIFV THAT I HAVE READ THIS APPLICATION AND STATE THAT TNE ABOVE INFORMATION IS CORRECT. TOTAL FE ES /7 / 3`�
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� CONSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OFTHIS COUNTYTO ENTER UPON THE
� ABOVE-MENTIONED PROPEFTV FOR INSPECTION PURPOSES.
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= RECPT.NO. � PAID BY JQ VALIDATION
~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—A,sessor Copy,GOLOENR06—File Copy,GREEN—Applicant's Copy
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DRYVilALL NAILING � DEDICA7lONS
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