HomeMy WebLinkAbout15859 CITY OF DIAMOND BAbt EXPIRED
--�� DEPARTMENT OF COMMUNITY 8t DEVELOPMENT SERVICES Mqy 0 9 2003
21660 E.Copley Drive Suite 190
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�����'� BUILDING PERMTT APPLICATION FIR Y
Q D R'ESS ��y� Si�se� C•�o,�i!rC,tN./ �/T APPLICATION �" /\�, PERMIT � P/C
p DATE_ � V NUMBER #
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cn DESCRIPTION S�.FT. FACTOR PSF ADJ.AREANALUATION
Q OWNEFi-BUILDER DECLARATION SFR/ADD/REM
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I HEREBY AFFlRM UNDER PENALTV OF PERNRY THAT I AM EXEMPT FHOM THE CONTRACTORS LI� GHfegB/C9fpOR
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TUHE,PHIOR TO ITS ISSUANCE,�L50 REQUIHES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
W STATEMEM THAT HE OR SHE IS LICEHSEO PURSUAHT TO THE PROVISIONS OF THE CANTRACTORS LI� w
� CENSE UW(qUPTER i(COMMENCIN�WI7H SECTION 7000)OF DIVISION 3 OF THE BUSINE55 AND PR0. � PooUSpa
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� ❑1,/�SONMEROFTHEPROPERTV,ORMVEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, � COR1rt18fClel . �
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTEN�E�OR OFFEFIED FOR SALE(SEC.70��,BU51� J
� NE55 AND PROFESSIONS CWE:THE CONTMCTORS LICENSE UW DOES NOT A7PLV TO AN OWNER OF �
PROPERTY MM1iO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSEIF OR HERSELF OH
Q 7HROUGH HIS OR HER OMM EMVLOYEES,PROVIDED THAT SUGi IMPROVEMENTS ARE NOT INTENDED OR m -
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w ❑I,tiS OVMER OF 7HE PROPEHTY,AM IXQUSIVELY CONTMCTIN4 WfTH LICENSED CONTRACTORS
� TO CONSTRUCT THE PRQIECT(SEC.70M,BUSINESS AND PROFESSIONS CODE:7HE CONTFUCTORS LI� V81U8110f1 ADJ.AREA
W CENSE UW DOES NOTAPPLY TO AN ONMER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
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� O I AM EXEMPT UNDER SEC. B.8 P.C.FOR THIS HEASON Q
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DATE OVMER �
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� LICENSED CONTRACTORS DECLARATION W
� 1 HEREBY AFFIpM UNDER PEN/�LTY OF PERIURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER �
p. Y(COMMENCINO WIiH SECTION 7000)OF DNISION 3 OF THE BUSINESS AND PROFESSIONS COOE.AND Z
X, MY UCENSE IS IN FULL FORCE AND EFFECT. m
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V DATE �� (/ CONTRACTOR �-
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� WORKERS'COMPENSATION DECLARATION ���I �� Q G l
� I HEREBY AFFIRM UNDER PENALTY OF PEFLIURY ONE OF THE FOLLOWING DECURATIONS: Z
� _I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS' _
COMPENSATION,AS PROVIDED BY SECTON 370o OF THE UBOR CODE,FOR 7HE PERFORMANCE U
Q OF 7HE WORK FOR WHICH THIS PERMIT IS ISSUED. �
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W _I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS RE4UIRED BY SECTION
Q 3700 OF THE UBOR CODE,FOR THE PERFORMMICE OF THE WORK FOF WNICH THIS PERMIT IS
ISSUED.MY WORKERS' MPENS ION INSURANCE CARRIER AND POLICY NUMBER ARE: CONSTRUCTION
jCARRIER e PLAN REVIEW
Z POLICV NUMBER ELECTRIC
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� (MssEcfqHPlE�wiBE00MRElEoOFi}iEPEaMisFCiioNEt4x�DRED K��1���1� PLUMBING
Z 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOH WHICH THIS PERMIT IS ISSUED,I MECHANICAL ` L'
(�}� SHALL NOT EMPLOV ANV PERSON IN ANY MANNER SO AS TO BECOME SU&IEC7 TO 7HE
� WORKERS'COMPENSATION UWS Of CALIFORNIA AND AGHEE TMAT IF I SHOULD BECAME INSPECTION FEE
S SU&IECT TO THE WORKERS'CAMPENSATION 7ROVISIONS OF SECTION 3700 OF THE LABOR �
cooe,isHuiForrrHwin+ca.�a�rvnn�n��owsioNs. ��i� ISSUANCE
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p DATE:�G� APPLICANT:5. - . .
J WARNINO:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE ENERGY P/C
� SU&IECTAN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNOflED THOUSAND ENERGY PERMIT
DOLLARS(L7o0,o00�.IN ADDITION 70 7HE COST OF COMPENSA710N,DAMAGES AS PROVIDED FOR IN
� SECTqN 370E OF h1E LABOR CODE,INTEREST,AND ATfORNEV'S FEES. RETENTION FEE:
d CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
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� t HEREBY AFFIRM UNDER PENALTY OF PERIURV THA7 7HERE IS A CONSTRUCTION LENDING AGENCV -
FOR THE PERFORMANCE OF THE WORK FOR WHICH TMIS PERMIT IS ISSUED(SEC.30G7,CIV.C.).
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� LENDER'S NAME �
F= LENDERSADDRESS �
� 1 CERTIFV THAT 1 HAVE READ THIS APPLICATION AND STATE THATTHE ABOVE INFORMATION IS CORRECT. TOTAL FE ES . �`-'� �
w 1 AGREE TO CAMPLV WITH ALL qTV AND CAUNTV ORDINANCES AND STATE UWS REUTING TO BUILOING
� CONSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF THIS COUNTV TO ENTER UPON THE '
ZABOVE-MENTIONED PROPER7Y FOR INSPEC7ION PURPOSES. COMMENTS � '
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� RECPT.NO. PAID BY VALIDATION
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