HomeMy WebLinkAbout13211 CITY OF DIAMOND BAR �
--� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
W 21660 E.Copley Drive Suite 190
(909)86Q3195 Faz(909)861-3117 , PRE$$
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u� DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION
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� ❑4�OWNEROF7HEPROPEHTY,AMEXClU51VELYCONTMCTRIOWITHLICENSEDCONTRACTORS
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�z DATE ONRJER �
F UCENSED CONTRACTORS DECLAAATION W I
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� I HEREBV AFFlRM UNDER PENALTY OF PERIUHV THAT I AM LICENSED UNDER GROVISIONS OF CNAPTER �
� Y(COA4IENCWO WITH SECTION 7000)OF OMSION 3 OF hiE BUSINESS M!D VROFESSIONS CADE,AND Z
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� WORKERS'COMPENSATION DECLARATION t D'a ¢
� I HEREBY AFFIRM UNDER oEIULTY OF PERIUfiY ONE OF THE F0110WING DECURATqNS: Z
� _I HAVE AHD WILL AWNTNN A CEHTIFlCATE OF CONSENT TO SELF-INSURE FOR VqRKERS' _
Q COMPENSATIOH,A9 PROVIDED BY SECTION 9700 OF THE UBOR CODE.FOF THE PERFORMANCE U
Q OF THE WOR)(FOR WHICH THIS PERMIT IS ISSUED. �
� _1 HAVE M1D WILL MAINTNH WORKEfiS'COMPENSATION INSURANCE,AS RC-0UIRED BY SECTION
Q 37000F THE LABOR CODE,FOR THE PERFORMNICE OF iHE WORK FOR WHIq/THIS PERMIT 15
� ISSUED.A1Y W�DHKERS'COMPEN9ATION INSURANCE CAHRIERAND POLIC�V1NUMBERARE: CONSTRUCTION
� CAFiRIER�����,t A�!/ PLAN REVIEW
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Z I CERTIFV THAT Pl THE PERFORAIANCE OF THE WORK FOR WHICH THIS PERMI71515SUED,I MECHANICAL
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(n WORKERS'COMPENSATION LAW$OF GLIFORNIti AND AOREE THA71F I SHOUID BECOME INSPECTION FEE
SUBIECT T THE WORKERS'COMPENSATION PfiOVI510NS OF SECTION 3700 TME UBOR (�
s CODE,ISH FORTNWITHCOMPLVWITHTHOSEPR�IYSIONS. ISSUANCE /�_p2_ �l V�
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p DATE: APPLICANT: . SMIP S.,�,reTfi�!j��`
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� WARNINO:FAIL RETOSECUFEWOFiKERS'COMPENSATION RAGEISUNUWFUL, BE ENEFGYP�- ...._� - ��;�TV
SUBJECT Ml EMPLOVER TO CRIMINAL PENAL71E5 M1D CIVI ES UP TO ONE HUNDR SAND T�T 7 ~I r" � v L� �`"
� DOLLARS(i100,000),INPODITIONTOTHECOSTOFCOMPENSA710N,DAMAGESASPR DEDFOHIN ENERGYPEFIMR��'-��"�
J SECTION 3708 OF 7HE UBOH CODE,INTEREST,AND ATTORNEV'S FEES. -
Q RETENTION FEE:
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBV AFFIqM UNDER PEN/LTV OF PEFiJURV 7HAT THERE IS A CONSTRUCTION IENDWO AOENCV
FOR THE PERi'OiUTANCE OF THE WORK FOR NRiICH THIS PERMIT IS ISSUED(SEC.30D7,CIV.C.),
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¢ I CERTIFV iHAT I HAVE READ THIS APPLICATION AND STATE THAT THE A80VE INFORMATqN IS CORRECT.
� I AGREE TO COMPLV WITH ALL CITV ANO COUNTY ORDINNICES AND STATE LAWS RELATIN(i TO W0.DIN0
CONSTRUCTION,MID MEREBV AUTF10iiRE REPRESEN7A7NE5 OF 7HI5 COUNTV 70 ENTER UPON THE /1 (� � �
ZPBOVE-MEMIONED FROPERTV FOR INSPEC7ION PURPOSES. COMMEN S� v�v�, � �
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FRAMING/VENTILIATION FINAI:BOND BEAM • '
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ROUGH HEATiNG BENCHING
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SHOWER/TUS TEST �OOL ELECTRIC
EXi: LATH/SIDING PQQL FENCING
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