HomeMy WebLinkAbout16759 (19) CITY OF DIAMOND BAR '
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'� "''%.���'�� BUILDING PERMIT APPLICATION FIRMLY �
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Z TURE,PRIOR 70 ITS ISSUANCE,ALSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
w STATEMENT THAT HE OR SHE IS LICENSED PUfiSUANT TO THE PROVISIONS OF 7HE CONTRACTORS LI� w
� CENSE LAW(CHAPTER 9(CAMMENCING WI7H SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- � POOUSp3
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Z WILL DO THE WORN,AND THE STRUC7URE IS NOT INTENDEO OR OFFEREO FOR SALE(SEC.7o4d,BU51� J
N NE55 AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPIV TO AN OWNER OF �
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2 I HEREBY AFFIRM UNDER PENALTY OF PERIURY THA71 AM LICENSED UNDER PROVISIONS OF CHAPTER � •
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X MY LICENSE IS IN FULL FORCE AND EFFECT.
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� WORKERS'COMPENSATION DECLARATION Q / D GI � `'—�
� I HEREBV AFFIfiM UNDER PENAL7Y OF PERIURV ONE OF 7HE FOLLOWING DECURATIONS: Z
� I HAVE AND WILL MAINTAIN A CERTIFICA7E OF CONSENT TO SELF-INSURE FOR WORKERS' a
¢ CAMPENSATION,AS PROVIDED BV SECTION 370o OF THE UBOR CODE,FOR 7HE PERFORMANCE
QLTHE WOFK FOR WHICH THIS PERMIT IS ISSUED.
W ��HAVE AND WILL MAINTAIN WORKERS'COMPENSA710N INSURANCE,AS REQUIRED BY SEC710N
Q 37000F THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH 7HI5 PERMI7IS
ISSUED.MY WORI 'COMPENSATION INSURANCE CARRIER A�ID POLICY NUMBERARE: CONSTRUCTION
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= SUBJECTTO THE WORKERS'COMPENSATION PROVISIONS F SECTION 37000F THE LABOR �:. I u�✓, �,\� i I T
CODE,I SHALL FORTHWITH COMPLV WITH THOSE PROV N5. ISSUANCE V ��
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WARNING:FAILURETO SECURE WOFKERS'COMPENSATION CAVERAGE IS UNLAWFUL,AND SHALLBE /` /�
LL SU&IECTANEMPLOVEHTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENEFiGYPERMIT / �! 7 I
DOILARS(5700.000).IN ADDITION TO THE COST OF fAMPENSATION,DAMAGES AS PHOVIDED FOR IN 7�
J SECTION 3708 OF THE LABOfl CODE,INTEREST,AND ATTORNEV'S FEES. RETENTION FEE: P��� I
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� CONSTRUCTION LENDING AGENCY PRE-ALT FEE: 'V�J� � ��� -'
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Q I HEREBVAFFIRM UNDER PENALN OF PERJURV 7HAT7HERE IS ACONS7RUC710N LENDING AGENCY
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� LENDER'S NAME
� LENDER'S ADDRESS
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� I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. TOTAL F E ES �• �
w I AGREE TO COMPLV WITH AL ITY AND COUNTV ORDINANCES AND STATE LAWS RELATING TO BUILDINCa
� CONSTRUCTION,AND HERE AUTHORIZE REPRESENTATIVES OF THIS COUNTV TO ENTER UPON THE
ZABOVE�MENTIONED PROP TY FOR INSPECTION PURP sEs. COMMENTS �
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~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy
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SLABGRADE - -_� ,_. _FI�EPLACEF{jUNDATION_.--
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TEMP POWER FIREPLACE BOND BEAM
WATEFi SERVICE � MID HT. BOND BEAM
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FRAMlNGNENTILIATION i FINAL BOND BEAM �
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ROOF COVER PRE-GRADING
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