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CITY OF DIAMOND BAR �
�----��` -- DEPARTIvIENT OF COIvIIv1UNTI'I'&DEVELOPMENT SERVICES � , �/
21825 E.Copley Drive /v� v
'� (909)860-3195 Fax(909)861-3117 RESS
'�'%����W BUILDING PERMIT APPLICATION �� 2� ; FIRMLY
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w TURE,PRIOR TO S ISSUANCE,ALSO REOUIFES THE APPLICANT FOR H PERMIT TO FILE A SIGNED w ail0/ Ck
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A CIVIL PENALTY OF NOT MO HAN FIVE HUNDRED D RS(5500)J:
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Z WILL DO THE WORK,AND THE STR TURE IS NO TENDED OR OFFERED FOR SALE(SEC.70��,BUSI� � CORIm6fCiel -
� NESS PND PROFESSIONS CODE:THE TRA RS LICENSE LAW DOES NOT APPLV TO AN OWNER OF ? 1 _- e`
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2 THROUGH HIS OR HER OWN EMPLOYEE VIDED THAT SUCH IMPROVEMEN7S ARE NOT INTENDED OR m
� OFFEREDFOqSALEIF,HOWEVEFi,TH ILDI RIMPROVEMENTISSOLDWITHINONEVEAROFCAMPLE-
Z 710N,THE OWNER-BUILDER WILL E THE BU N OF PROVING THA7 HE OR SHE DID NOT BUILD OR i
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� LICENSED CONTRACTORS DECLARATION w
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CL I HEREBY AFFIHM UNOER PENALTY OF PEFJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER �
� 6(COMMENCING WITH SECTION 7000)OF DIVISION 3 0F THE BUSINESS AND PROFESSIONS CODE,AND Z
X MV LICENSE IS IN FULL F RCE AND EFFECT�. �`
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� WORKERS'COMPENSATION DECLARATION Q , � S� J
� 1 MEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: Z � ��
Z _I HAVE AND WILL MAINTAIN A CERTIFICATE OF CANSENT TO SELF-INSURE FOR WORNERS' _ '
Q COMPENSATION,AS PROVIDED BV SECTION 3700 OF THE LABOR CODE,FOR THE PERFORMANCE- W
Q OF THE WORK FOR WHICH 7HI5 PERMIT IS ISSUEO. �
w I HAVE AND WILL MAWTAIN WORKERS'COMPENSATION INSURANCE,AS flEOUIRED BV SECTION � O
Q 37oa OF 7HE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED.MV WORKEFiS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CONSTRUCTION
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� CARRIER PLAN REVIEW v
Z POLICY NUMBEFi ELECTRIC 1 � �+
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� (iHISSECiX)NNE�NOTBEOOMPLEfEDOFTIiEPERMITISFORONEHUt�DREDDOLIA0.S(f100)ORLESS). PLUMBING
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Z I CERTIFV THAT IN THE PERFORMANCE OF THE WORN FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
(,'} SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE , C1
� WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME INSPECTION FEE lF�
� SU&IECTTO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 37000F THE LABOR �
CODE,I SHALL FORTHWITH COMPLV WITH THOSE PFOVISIONS. ISSUANCE c�
� SMIP l l\6
p DATE: APPLICANT:
J. WARNING:FAILURETO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE ENERGY P/C
� SU&IECTAN EMPLOVER TO CFIMINAL PENALTIES ANO CIVIL FINES UP TOONE HUNDRED THOUSAND ENERGY PERMIT
DOLLARS(5100,000J,IN ADDITION 70 THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
� SECTION 3708 OF THE LABOR CODE.INTEREST,AND ATTORNEY'S FEES. RETENTION FEE'
� CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
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� I HEREBV AFFIRM UNDER PENALTV OF RJURV THAT THERE IS A CONSTfiUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WO FOR WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.C.).
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� LENDEH'S NAME
� LENDER'SADDRESS
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� I CERTIFV THAT I HAVE REA THIS APPIICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
� I AGREE TO COMPLV WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS flELATING TO BUILDING
� CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF TNIS COUNTY TO ENTEF UPON 7HE
z ABOVE�MENTIONED PROPERTV FOR INSPECTION PURPOSES.,�
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