HomeMy WebLinkAbout11639 C1TY OF DIAMOND BAR A- �, �\c�I 9
COMMUNITY DEVELOPMENT DEPARTMENT �` L�
21660 E.Copley Drive Suite 190 PRESS
� (909)860-3195 Fax(909)861-311�
'H""• BUII..DING PERMIT APPLICATION FIRMLY
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ADDRESS DATE � I NUMBER #
c� ISSUE TYPE OCC
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I HEREBV AFFIftM UNDER PENALTY OF PERJUFV THAT I AM E%EMPT FROM THE CONTRACTORS LI� G8f8(JB/C3IpOf(
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TUFE,PHIOR TD ITS ISSUANCE,ALSO REOUIRES THE APPI.ICANT FOR SUCH PERMIT TO FIIE A SIGNED
W STATEMENT THAi HE OR SHE IS LICENSED Pt1RSUANT TO THE PqOVISIONS OF THE CONTFACTORS LI- W
� CENSE LAW�CHAPTEP B(COMMENCING WITH SECTION 700�)OF DIVISION 3 OF THE BUSINESS AND PRO- � POOI/SpH
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A CIVIL�ENALTV OF NOT MORE THAN FIVE HUNDHED DOLLARS(S5o0�.):
❑I,AS OWNER OF THE PROPERTV,OR MV EMPLOVEES W ITH WAGES AS 7HEIR SOLE COMPENSATION,
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Z WILL DO THE WORK.PND THE S7RUCTURE IS NO�INTEN�E�OR OFFEREO FOR SALE(SEC.7041,BU51� J
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W CENSE LAW DOES NOTAPPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
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� I HEHEBY AFFIRM UNOER PENALTV OF PERJUPV THAT I AM LICENSED UNDER PqOVI&IONS OF CHAPTER �
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� WORKERS'COMPENSATION DECLARATION Q �
� I HEREBY AFFIRM UI�IDER PENAL7Y OF 7ERJURY ONE OF THE FOLLAW WG DECURATIONS: Z
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Q OFTHEWORNFORWHICHTHISPEFVdITISISSUEO. �
w _1 HAVEAND WILL MAIN7AIN WORHERS'COMPENSATION INSURANCE,AS REOUIREO BY SEC710N //
Q 37ooOF THE LA60R COOE,fOR THE PERFORMANCE OF THE WOPo(FOR WHICH THIS VERMIT IS L �,( /�..�
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Z I CERTIFY THAT IN THE PERFOPMANCE OF THE WOFK FOR WHICH THIS PERMIT IS ISSUE�,I MECHANICAL
(,�J SHALL NOT EMPLOV ANV PERSON IN ANV MANNER SOAS TO BECOME SUBJECT TO THE
V7 WORKEFS'COMPENSATIONLAWSOfCALIFOPNiA,ANOAGFEETHATIFISHOULDBECOME INSPECTIONFEE
SUBJECT TO THE WORKE RS'COMPENSATION PROVISIONS OF SECTION 370o OF THE LABOR
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p �ATE:� APPLICANT:
J WAflNING:FAILUflE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALI.BE ENERGY P/C
� SU&IECTAN EMPLOYER TO CHIMINAL PENALTIES ANO CIVIL FMES UP TO ONE HUNDRED THOUSAN� ENERGY PERMIT �.�
�OLIARS(Sl 00,000),IN ADDITION TO THE COST OF COMPENSATION,OAMAGES AS PROYIDED FOR IN
� SECTION 3708 OF THE UBOR CADE,INTEREST,AND ATTORNEY'S FEES. ' �� `
RETENTION FEE:
OCONSTRUCTION LENDING AGENCY PRE-AlT FEE:
� I HEREBV AFFIRM UNDER PENALTY OF PERJUflV THAT 7HEFE IS A CONSTRUCTION LENDWG AGENCV
FOR THE PERPDRMANGE OFTHE WORK FOR WHIGM THIS PERMIT i5155UED(SEC.3oB�,qV.C.�.
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� LEN�ER'S NAME
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� I CERTIFV THAT 1 HAVE READ THIS APPLICATION AND STA7E THAT 7HE ABOYE INFOFMATION IS CORRECT TOTAL FE ES Z t �
� 1 AGREE TO COMPLV WITH ALL CITY AND COUNTY ORDINANCES AND ST0.TE LAWS RELATING TO BUILDING .
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TEMP POWER FIREPLAGE BOND BEAM " = '
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ROOF SHEATHING � $Ff.BOND BEAM - +
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