HomeMy WebLinkAbout16947 (25) CITY OF DIAMOND BAR �S�f � ` ,
^----��`-- DEPARTMENT OF COIvA�UNITY 8r,DEVELOPIvIENT SERVICES �
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117 PRESS
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w 7UflE,PRIOR TO RS ISSUANCE.ALSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w Patio/Dedc
� STATEMENT 7HAT HE OR SHE IS LICENSED PURSUANT TO THE PqOVI510NS OF THE CONTRACTORS LI- �
g CENSE LAW(CHAPTER o(COMMENCWO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINE55 AND PRO- POOUSPB
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Z WILL DO TFIE WORK,MID 7HE S7RUCNRE IS NO7 INTENDED OR OFFERED FOq SALE(SEC.701�,BUSI� J �
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PROPERTY Vrt/0 BUILDS OR IM7ROVE5 THERE-0N,AND NTIO DOES SUCH WORK HIMSELF OR HERSELF OR
Q THROUGH HIS OR HER OWN EMPLOVEES,FflOVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR m
� OFFEREDFORS�LEIF,HOWEVERTMEWILDINOORIMPROVEMEMISSOLDWRHINONEVEAROFCOMPLE�
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w ❑I,AS ON?!ER OF THE PROPERTV,AM EXCLUSNELV CANTRACTINO N7TH LICENSED CONTRACTORS
� TO CONSTRUCT THE PRQIECT(SEC.704/,BUSINESS AND PROFESSIONS CODE:h1E CONTRACTORS�I- V8IU9lI0f1 ADJ.AREA
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� I HEREBYAFFIRM UNDER PEWLLTV OF PERIUpV THAT IAM UCENSED UNDER PROVISIONS OF CHAPTER � -
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��� AIV LICENSE IS IN FULL FORCE AND EFFECT. m
� LICENSE CLASS LIC.NO. �
V DATE CONTRACTOR d
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� WORKERS'COMPENSATION DECLARATION Q
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� I HEREBY AFFIRM UNDER PENALTY OF PERIURV ONE OF TFIE FOLLOW WG DECLARATKKJS: Z
� _I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF�INSURE FOR WORNERS' _
COMPENSATION,AS PROVIDED BY SECTION 37a0 OF THE L/�BOR CODE,FOR THE PERFORMANCE U
OF THE WORK FOR WHICH THIS PERIAIT IS ISSUED. w
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Qw _I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BV SECTION
37000F THE L�BOR CADE,FOR THE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS
ISSUED.MV WORKERS'COMPENSATION INSURANCE CARRIER AND POLICV NUMBER ARE: CONSTRUCTION
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Z I CERTIFV 7H�T IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
C} SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SU&IECT TO THE
(/� WORKERS'COMPENSATION UWS OF CALIFORNIq AND AGREE THAT IF I SHOULD BECOME INSPECTION FEE
SUBJECT TO THE WORKERS'COMPENSATqN 7ROVISIONS OF SECTION 3700 OF THE UBOR
'~j CODE,1 SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. ISSUANCE 1
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p DATE: APPLICANT: SMIP �
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J WARNIN(1:FAILURE TO SECURE WORNERS'COMPENSATION CAVERAGE IS UNUWFUL,AND SHALL BE ENERGY P/C
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� SU&IECTANEMPLOVERTOCRIMINALPENALTIESANDCIVIIFINESUPTOONEHUNDREDTHWSANO ENERGYPERMIT
DOLLARS(f100.000),IN/�D�IiION TO THE COST OF CAMPENSATpN,DAMAGES AS PROVIDED FOR IN
� J SECTION370BOFTHELABORCODE,MTEREST,ANDATTORNEV'SFEES.
� RETENTION FEE:
pCONSTRUCTION LENDING AGENCY PRE•ALT FEE:
� I HEFEBV AFFIRM UNDER 7ENPLTV OF PERIURY THAT THERE IS A CqNSTRUCTION LENDING AGENCV
FOR THE PERFOflMANCE OF THE WORN FOR WHICH THIS PERMIT IS ISSUED(SEC.3oY7,CIV.C.).
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� LENDER'S NAME
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w I CERTIFY THAT I HAVE READ TMIS APPUCATION AND STATE THAT THE ABOVE INPoHMATION IS CARRECT. TOTAL FE ES �n
� I AGREE TO COMPLV WITH ALL CITV AND COUNTY ORDWANCES AND STATE LAWS RELATING TO BUILDING V��
� CONSTRUCTION,AND HEREBV AUTHORIZE REPRESE ATNES OF THIS COUNTV TO ENTER UPON THE
Z ABOVE�MENTIONED PROPERN FOR INSPECTIO P aosEs. COMMENTS
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WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanYs Copy
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