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_��� CITY OF DIAMOND BAR �
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES ^
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(909)860-3195 Faa(909)861-3117 PRES$
���M^� BUII.DING PERMIT APPLICATION FIRMLY
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STATEMENT 7HAT HE OR SHE IS LICENSED PURSUAHT TO THE PROVISIONS OF THE CONTMCTORS LI� -
� CENSE UW(CHAPTER Y(COMMENCINO WI7H SECTION 7000)OF DIVISqN�OF THE BUSINESS AND PRO- u' POOVSpe ' '
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VALL DO THE WORIC M1D THE S7RUCTURE IS NOT INTENOED OR OFFERED FOR SALE(SEC.7ou,BU51� J
� NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE UW DOES NOT APPLV TO AN OWNER OF � . ,/ , . � �
PROPEHTY NM1IO&11LD5 Ofi MPROVES THEREON,M1D NMO DOE3 SUCH WORK HIMSELF OR HERSELF OR '
2 THqIX1OH HIS OR MER OMM EAIPIOVEES,PHOVIDED T/AT SUCH fMPROVEMENTS ARE N,OT INTEHDED OR m -
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DATE OWNER U .
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� �� WORKERS'COMPENSATIONDECLARATION � f^
� 1 HER AFFlRM UNDER PENALTV Of PERNRv ONE OF THE FOLLOWIN�OECLARA710NS: Z �` ' A y�
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� I NAVE AHD NALL MAINTAIN A CEi1TIFICATE OF CONSENT TO SELF-INSURE FOR NORKERS' 2 i I� $
COMPENSATION,AS PROVIDED BY SECTION�70o Of THE LABOH CODE.FOR THE PERFORMANCE U
Q F iHE WORI(FOR WHICN THIS PERMIT IS ISSUED. �
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I H�VE AND WILL MAINTAM WORKERS'COMPENSATION INSUMNCE,AS REW IRED BV SECTION ♦� �
Q 370o OF 7HE LA80R CODE.FOR 7HE PERFORMANCE OF TME WORK WR�WHICH THIS PERMR IS
ISSUED.IIV ELJSAT 9URANC /C��+RIERAND VN ERA : CONSTRUCTION
� CARRIER �' ��/ � � PLAN REVIEW
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Z I CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH 7HI5 PERMIT IS ISSUEO.1 MECHANICAL Y .�� I ,'� �
�J SFiALL NO7 EMPLOY ANV PERSON IN ANV MANNER 50 AS TO BECAME SU&IECT TO THE
Vj WORKERS'COMPENSATION UWS OF CALIFORNIA,AND ACREE THAT IF I SHWLO BECOME INSPECTION FEE
SUBJECT TO THE WORKERS'COM7ENSATION PROVISIONS OF SECTqN 370o OF THE UBOR
rj e.��n�wirri ca,�a�r wi E Paovisar�s. ISSUANCE �� O �
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p DATE: APPLICANT. � j�
w ENERGY P/C v C.
� WARNIN(i:FARURE TO SECURE WORNER5 COMPENSATION COVERA(iE IS UNLAWFUL,AND SNALL BE �
LL SUaIECT AN EMPLOVER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND ENERGY PERMIT
DOILARS(i1ao.000).IN ADDITION TO THE COST OF COMPENSATION,DAMAOES AS PROVIDED FO{i IN +��( ���•
� SECTION 370!OF 7HE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. RETENTION FEE: _ /L]�\JC]
a CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
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� I HEREBV AFFIRM UN�ER PENALTV OF PEFiJURV THAT THERE IS A CONSTRUCTION LENDWG AOENCV
d f-0H THE PERFORMANCE OF THE WORK FOR WHICH 7HIS PERMIT IS I�C.�pe7,CIV.C.�. . �
� LENDER'SNAME ��,~CG lJL��� �lA S 7 �
F=- LENDER'SADDRESS /�
� TOTAL FEES /�
� I CERTIFY THAT I HAVE RF1D THIS APPLICATbN AND STATE TMAT TME ABOVE INFOH/AATqN IS CORRECT. \ �
� I AGREE TO COMPLV N7TM ALL CfTY AND COUNTV ORDWANCES AND STATE UWS REUTINO TO BUILDINO �' �
� CONSTRUCTION,M1D HEREBV AUTHORIZE REPRESENTATIVES OF hIIS COUNTY TO ENTER UPON 7HE �
Z ABOVE-MEMIONED PROFEHTV(-0R INSPECTION PURPOSES. .
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� s�oN RE OF PERM , E DATE RECPT.NO. PAID BY VALIDATION
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