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---� CITY OF DIAMOND BAR ���!���
COMMUNITY DEVELOPMENT DEPARTMENT ���� � � ���Q
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3I17 PRESS �
� ,'""' BUILDING PERMIT APPLICATION FIRMLY ,
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� CENSE LAW(CHAPTER 8(COMMENCINO WITH SECTION 70D0)OF DIVISION 30F THE BUSINE33 AND PRO- � Pool/Spa
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� Z WILL�O 7NE WORIC,RNO THE STRUC7URE IS NOT iN7ENDED OR OFFERED FOR SALE(SEC.7044,BUSI- J
� NESSAND PROFESSIONS CODE:THE CONTRACTOHS LICENSE LAW OOES NOT APPLY TO AN OWNER OF ?
PROPEflTV WHO BUILDS OR IMVPOVE57HEREON.AND NM110 DOES SUCH WORK HIMSELF OR HERSEIF OR
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� LICENSED CONTflACTORS DECLARATION W
¢� i HEREBYAFFIRM UNDER PF.NA47V OF PERJl1RV THAT IAA1 LICENSED UNDER PROVISIONS OF CHAPTER �
� d� 9(COMMENCIN6WITHSECTION7000)OFDIVISION30FTHE9USINESSANDPFlOFESSIONSCODE,AND z —
X MV LICENSE IS W FULL FORCE AND EFFECT. m
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� WORKERS'COMPENSATION DECLARATION Q
� I HEREBYAFFIHM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECURATIONS: Z
� __ IHAVEANDWILLMAINTAINACERTIFICATEOFCOPiSENiTOSELFINSUFEFORWORKEf75' a
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� COMPENSATION,AS PROVIOED 6Y SEGTION 37000F TNE 1A90fl CWE.FOR THE PEFWHMMICE w
OF THE WORK fOR WHICH THIS PERAl1T IS ISSUED. �
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w _I HAVE AND WILL 1AAINTAIN WORKERS'COMPENSATION INSURAhCE.AS REOUIRED BY SECTION
Q 31000FTHE LABOR CODE,FOR THE PERFORMANCE OF THE WORK WR WHICH THIS PERMIT 13 ��a �'j �
ISSIlEO.MY WORKEfiS' MVE SATION INSURANCE CARRI R AN�POLICY NUMBERARE: CONSTRUCTION
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C}' SHAIL NO7 EMPLOV ANV PERSON IN ANY MANNER SOAS TO BECOME SUBJECi T07HE
(n WORKER9'COMPENSATIONlAW50FCAUFORNIA,RN�AGREETHATIFISHOULOBECAME INSPECTIONFEE �l:% '�'�`""� __ __
� SUBJECT TO TME WOFKERS'CAMPENSATION PflOVI510NS OF SECTION 37000F iHE LABOR
� CADEr,ISHALLFORTHWITHCAMPLYWITHTHOS' ROVISIONS. ISSUANCE _�' ,.rtc ��
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p DATE:'�[7�� APPLICANT: — .—
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� SECTION 37080F THE LABOR COOE,INTEREST,AND ATTORNEV'5 fEES RETENT�ON FEE:
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� I HEREBY AFFIRM UNOER PENALTY OF PERJURY TNAT THERE IS A CIXJSTRl1CTION LENDING AGENCY _ _
FOHTHE PERWiiMANCE OF 7HE WONK FOR WHICH THIS GERMIT IS ISSl1ED�SEC.3o97,CIV.C.).
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� I AGREE TO COAIPLY WITiIALL CIN AND COl1NTV ORDINMICESAND STATE LAWS REIATING TO&11LDING
� CONSTRUCTIOtyANDHEREBYAUiHORIZEREPRESENTATIVE50FTHISCOUNTVTOENTERUPONTHE
Z ABOVE�MENTIONED PROVEflTY FOH INSPECTION PUHPOSES.
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