HomeMy WebLinkAbout16570 (28) _�� CITY OF DIAMOND BAR �����E�
DEPARTMENT OF COMMUNITY 8t DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190 J U N 19 20C?
(909)860-3195 Fax(909)861-3117 PRESS
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W TURE,PRIOR TO ITS ISSUANCE,/�LSO RE�UIRES 7HE APPIICANT FOR SUCH PERMIT TO FILE A SIGNED w
STATEMENT THAT HE OH SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CANTRACTORS LI- �
� CENSE UW(CHAPTER Y(COMMENCINO WITH SECTION 7aoo)OF OIVISION 3 OF THE BUSINESS ANO PRO- � PooVSpa �
FESSpNS CODE)OR hIAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANV VIOL.ATION OF SECTION 7031.6 BV ANV APPLICANT FOR A PERMIT SU&IECTS THE APPLICANT T0 Z Re-Rooi
� A CIVIL PENALTY OF NOT MORE 7HAN FIVE HUNDRED DOLURS(f500).):
� ❑I,ASOWNEROfTHEPROPER7Y,ORMYEMPLOVEESWITHWAGESASTHEIRSOLECAMPENSATION, 0 Commercial . -
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENOED OR OFFEREO FOR SALE(SEC.70u,BUSI- J
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE U1W DOES NO7 APPLV TO AN OWNER OF
� PROPERTYMR108UILDSORIMPROVESTHEREON,ANDWHODOESSUCHWORNHIMSELFORHEHSELFOR �
Q 7HROU(W HIS OR HEH OMM EMPLOYEES,PROVIDED 7HAT SUCH IMPROVEMENTS ARE NOT INTENDED OR m
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Z ��TqN,THE OWNER�UILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
� IMPROVE f-0H THE PURPOSE OF SALEJ.
w OI,ASOVMERUFTHEPROPERTV,AME%CLUSIVELYCANTRACTINOWITHLICENSEDCONTRACTORS
� TO CONSTRUCT THE PRQIECT(SEC.70M,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS ll- VHIUellOf7 ADJ.AREA
W CENSE UW DOES NOTAPPLV TO AN ONMER OFA PROPERTY WHO BUILOS OR IMPROVES THEREON,M!D
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� LICENSED CONTRACTORS DECLARATION
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I HEREBY AFFIRII UNDER PENALTV OF PERIURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
d Y(COMMENCINO WIh15ECT10N 7000)OF DIVISION 3 OF THE BUSINESS AND PROfES510NS CO�E.AND
X MY UCENSE IS IN FULL RF RCE AN EFFECT. /�`� m
� LICENSE CLASS v LIC.NO. � / /��� �
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� WORKERS'COMPENSATION DECLARATION
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� I HEREBY AFFIRM UNDER PENALTV OF PERIURV ONE OF THE FOLLOWING DECUMTIONS:
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� _IHAVEANDWILLAWNTAINACERTIFICATEOFCONSENTTOSELF•INSUREFORWOHKERS' 2
COMPENSATqN,AS PROVIDED BV SECTION a7oo OF THE UBOR CODE,FOR THE PERFORMANCE U
Q OF THE WORK FOR WHICH 7HIS PEPMIT IS ISSUED. �
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W _I HAVE MID WILL MAINTAIN WORKERS'COMPENSA710N INSURANCE.AS REOUIRED BY SECTION
Q 37000F THE UBOR CODE,FOR THE PERFOfiMMlCE OF THE WORK FOR WHICH 7HI5 PERMIT IS
ISSUED.MV WORK R'COMPErySAT 4N�RANC�CARRIER AND POLICV NUMBER ARE: CONSTRUCTION
jCARRIER /� 7 �/L� PLAN REVIEW
� POLICYNUMBER "/ W G I S _ ELECTRIC � �
0 (fH165ECilONNE�NOTBE00A�lEfmOF71EPEFiAffiSFORONEFRN�DHEDDOILPAS(5100)OqLESS} PLUMBING`- �
Z I CEHTIFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
(,�} SHALL NOT EMPLOY ANV VERSON IN ANY MANNER SO AS TO BECAME SU&IECT TO THE
Vj WORKERS'COMPENSATION UWS OF CALIFORNI/�AND AGREE THAT IF I SHOULD BECAME INSPECTION FEE
� SU&lECT70THEWORNERS'COMPENSATIONPROVISIONSOFSECTION37000FTHELABOR r i�C�
� CODE ISHALLFORTHWITHCOMPLYWITMTNO PROVI510�` �SSUANCE lJ �/
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p DATE:5l�y101 APPLICANT: �/�//�� �� ,
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J WARNING:FAILURE TO SECUFE WORKERS'COMPENSATION COVERAGE IS UNIAWFUL,AND SHALL BE
� SU&IECT AN EMPLOVER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND ENERGY PERMIT
DOLURS(f700.00D),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PHOVI�ED FOR IN
� SEC710N 3708 OF iNE UBOR CODE.INTEREST,AND ATTORNEY'S FEES. RETENTION FEE:
a CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEPEBV AFFIRM UNDEF PENALTY OF PERJUHV THAT THERE IS A CONSTRUCTION LENDING AGENCV
n- FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.30G7,CIV.C.). �
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� LENDER'S NAME '
F_ LENDER'SADDRESS
� I CERTIFV TNAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CARRECL TOTAL FE ES �i��
w I AGREE TO COMPLV WITH ALL CITY AND COUNTV OHDINANCES AND STATE UWS RELATING TO BUILDING
� CANSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF THIS COUNTV TO ENTER UPON THE �
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