HomeMy WebLinkAbout11948 (5) A . .. . .. . . ... ... .. .. � . . ._ . .
- CITY OF DIAMOND BAR � -�
COMMUNITY DEVEI;O�I�i�IVT�EP.�R�'1'1NENT
.;,,.,: . 21660 E.Copley Drive Suite]90 PRES•S•
(909)8603195 Fax(909)8G1-3117
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� CENSE LAW(CHAPTEfl 9(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINE55 AND PRO� LL' POOVSpB
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Z WILL 00 THE WORK,AN�THE S7RUCTURE IS NOT INTENOED OR OFFERED FOR SALE(SEC.T044,BUSI- J
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� I HEHEBVAFFIRM UNDER PENAITY OF PERJURYTHAi I AM UCENSED UNDEq PROVISIONS OF CHAPTER �
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� WORKERS'COMPENSATION DECLARATION Q
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� i HEREBY AFFIRM UNDER PENALTV OF PERJURV ONE OF THE FOLLOWING�ECURATIONS: Z
� _I HAVE ANO W�LL MAINTAIN ACERTIGICATE DF CONSENT TO SEIF�INSUqE FOR WORKEFS' a
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Q COMPENSA710N,AS PROVI�E�BY SECTION 3700 OF iHE LABOR CODE.FOR THE PERFORMPNCE �U
OF TNE WOHK FOR WHICH THIS PERMIT IS ISSUED. �
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w �I HAVE AND WILL M0.INTAIN WORKERS'COMPENSATION MSURANCE,AS REQUIRED BV SECTION O
Q 3'/o00i'TNELABORCODE,FORTHEPERFORMANCEOFTHEWORK(-0FWHIdiTHISPERMITIS
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(J SHALL NOT EMPLOYANV FERSON IN ANY MANNER SO AS TO BECOME SUBJECTTp THE
� WORKERS'COMPENSAT�ONLAWS OFCAUFORNIA,ANDAGREETHATIFISHOULDBECOME INSPECTION FEE
= SUBJECT TO TY.E WORKERS'COMPENSATION PROVISIONS OF SECTION 37000F THE LA80R
CODE,ISHALLFORTMWITHCOMPLYWITHTHOSEPROVISIONS. �SSUANCE L P
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p DATE: APPLICANT:
J WAPNING:FAIWRE TO SECURE WORKERS'COMPENSAiION CAVERAGE IS UNUIWFUL,AND SHALL BE ENERGY PJC
�y SU&IECTlWEMPLOVERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNOHEDTHOUSAND ENERGYPERMIT
�OLL4RS(5100.000},IN AD�ITION TO THE COSTOF COMPENSATION,OAMAGES AS Pi70VIDE0 FOR IN
� SECTION 37080F THE LABOq CODE,INTEREST,AND ATTORNEY'S FEES. RETENTION FEE: �
d CONSTRUC?ION LENDING AGENCY PRE-ALT FEEt
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� I HEREBYAFfIRM UNDEfl PENALTY OF PERIURY THATTHERE IS ACONSTRUCTION LEN�ING AGENCY
FOfi THE PERFOqMANCE OF THE WORK f-0R WHICH TH5 PERM�T�5 ISSUED(SEC.3097,CIV.C.),
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� LENDER'S NAME
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W I CERTIFYTHA71 HAVE READ THIS APPL�CATION ANO STATE THATTHE ABOVE INFORMATION IS CORRECT. TOTAL FE ES �y
� I AGREETO CAMPLY'MTH ALL CITV AN�COUNTY OROINANCES ANO S7A7E LAWS REIA7ING TO BUIL�ING �
� GONSTRUCTION,ANpHEREBYAUTHORIZEREPflESENTATIYESOFTHISCOUNTYTOENTERUGONTHE
Z ABOVE�MEN7IPVE�PROPEFTY FOR INSPECTbN PURPOSES.
o COMMENTS
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m P MIttEF NAME(PRINTJ
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� S�GNANRE OF PERMI E DATE �
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WHITE—Department Copy,YELLOW—Financa Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanPs Copy �
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S�AB GRADE ' " --' � ' FIREPLACE FOUNDATION _ __
TEMP POWER -: FIREPL.ACE BOND BEAM ,� �:'
WAYER SERVICE __ _ `�ti MID HT. BOND BEAM ` :'
ROOF SHEATHING � 8 F`T. BONq BEAM -- ';'�"
FRAMINGNENTiLIATION '`�' �`,, FINAL BQND SEAM – _---_ __... _ �
ROi�F COVER _ _ _ PRE-GRADWG __ _. � �
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