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_1� CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY 8Y DEVSLOPMENT SERVI ES �
w 21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117 � PRESS
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LICENSE CLASS
DATE
CONTRACTOR
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVI 21660 E. Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION
APPLICATION
DATE PERMIT
ri NUMBEA 1 # --•
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ISSUE TYPE OCC
DATE CONST. GROUP
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I AGREE TO Com PLY WITH ALL CiTy A CoUNTY oRDiNANCES AND STATE LAWS RELATING TO BUILDING CoNsTRUCTION,AND
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PERMITTEE NAME(PR1N
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OWNER-BUILDER DECLARATION
CI I HEREBY AFFIFtM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-LLI CENSE LAW
FOR THE FOLLOWING REASON (SEC 7031 5 BUSINESS AND PROFESSIONS CODE.ANY CITYOR
2 COUNTY WHICH REOUIRESA PERMIT TO CONSTRUCT,ALTER IMPRoVE,DEMOLISH,OR REPAIR ANY STRUC-TURE,PRIOR TO
ITS ISSUANCE,ALSO FtEOUIRES THE APpLICANT FOR SUCH PERMIT TO FILE A SIGNED LII STATEMENT THAT HE OR SHE IS
UCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
§CENSE LAW(CHAPTER 9(CoMMENCING WITH SECTION 7000)OF DIVISION)OF THE BUSINESS AND PRO-FESSIONS CODE)OR
THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP,TION.ANY VIOLATION OF SECTION 7031.5
By ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A IVI PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS
P00) )I,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
• VALL THE WORK,AND THE STRUCTURE IS t40T INTENDED OFI OFFERED FOR SALE(SEC 7044, BUSI-
NESS AND PROFESSIONS CODE THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
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PROPERTY WHO BUILDS OR IMPROVES THEREON,AND VA40 DOES SUCH WORK HIMSELF OR HERSELF OR CC THROUGH HIS OR
HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR IJJ OFFERED FOR SALE IF, HOWEVER.
THE BUILDING OR IMPROVENIENT IS SOLD WITHIN ONE y EAR OF COMPLE-C:1 TION,THE OWNER-BUILDER NALL HAVE THE
BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
IJU 0 I,AS OWNER OF THE PROPERTY,Am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS cc TO
CONSTRUCT THE PROJECT(SEc. 7044,BusiNESs AND PRoFESSIONs CODE THE CONTRACTORS LI-
UJ CENSE LAW DOES NOT APPLy TO AN OWNER OF A PFIOPERTY W r UILDs OR IMPROVES THEREON,AND
• WHO COt4TFIACTS FOR SUCH PROJECTS WITH ACONTRACTOR L ENSED PURSUANT TO THE CONTRAC-
TORS UCENSE LAW.).
?E
, HEREBY AFFIRM UNDER pENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 171-_9(COMMENCING
WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONs CODE,AND ti MY LICENSE IS IN FULL FORCE AND
EFFECT
• FOR THIS REASON
DATE
OWNER
LICENSED CONTRACTORS DECLARATION
LLI
CC sa
LU
I HAVE AND WILL MAINTAIN A CERT/FICATE OF CONSENT TO SELF-INSURE FOR woRKERS'COMPENSATION.AS PROVIDED By
SECTION 370o OF THE LABOR CODE, FOR THE pERFORMANcE OF THE WORK FoR WHICH THIS pERMIT IS ISSUED
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION WISURANcE,AS REQUIRED BY SECTION 3700 OF THE LABOR CODE,
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIs PERMIT IS LSSUED. MY WORKERS'COMPENSATION INSURANCE
CARRIER AND POUCY NUMBER ARE
CARRIER
POLICY NUMBER
(THIS SECTION NEED NOT BE COMPLETED OFTHE PERMIT IS FOR ONE HUNDREDDCLLARS(SICO)OR LESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLoy ANY PERSON
IN ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I
SHOULD BECOME SUBJECT TO THE wORKERs'cOMPENSATION ROVISIONS oF SEcTiON 3700 OF THE LABOR coDE,I SHALL
FORTHW/TH coMpLY WI PROVISIONS
DATE: APPLICANT
WARNING FAILuRE TO SECURE wORKERS'COMPENSATIoN coVERAGE IS UNLAWFUL,AND SHALL BE SUBJECT AN EMPLOYER To
CFum INAL PENALTIES AND CIVIL FINES uP TO ONE HUNDRED THousAND DOLLARS($i 93,000).IN ADDITIoN TO THE cosT OF
COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABoR CODE,INTEREST,AND ATToRNEY'S FEES
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF pERJURy THAT THERE IS A CONsTRUCTION LENDING AGENCY FOR THE PERFORMANcE
OF THE Wq K FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV C)
LENDER'S NAME
LENDER'S ADDREsS
LIC NO
CITY OF DIAMOND BAR INSPECTION RECORD
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