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�� CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117 PRE$$
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W CEHSE UW fORTHE FOLLOWINO REASON(SEC.7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITYOR
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Z NRE,PRIOR TO ITS ISSUANCE,QSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SI�NED W
� STATEMENT THAT HE OR SHE IS LICENSED PURSUANT 70 7HE PROVISIONS OF THE CONTRACTORS LI�
� CENSE UW(CHAPTER Y(COMMENCINO WITH SEC710N�000)OF DIVISION 3 OF THE BUSINESS AND PRO- � PooVSpa
FESSqHS COOE)OH TT1AT HE OR SHE IS E%EMPT THEREFROM AND TNE BASIS FOR THE ALLEGED EXEM�-
TION.ANV VIOLATION OF SECTION 703t.6 BV ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT T0 Z Re-Roof
� ACIVIL VENALTY OF NOT MOfiE THAN FIVE MUNDRED OOLURS(f500).):
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WILL DO THE WORK AND THE STRUCTURE IS NOT IHTENDED OR OFFERED FOR SALE(SEC.70aI,BUSI• J
NESS AND PROFESSIONS CODE:THE COHiRACTORS LICENSE UW DOES NOT APPLY TO AN OWNER OF
� PROPERf1'WFiOBUILD50RIMFROVESTHEREON,ANDVAiODOE55UCHWORKHIMSELFORHERSELFOR �
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Z �TION,THE OMMER-BUILDEH WILL HAVE THE BURDEN OF PROVING THA7 HE OR SHE DID NOT BUIID OR
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❑i,AS OWNER OF THE PROPEHTY,AM EXCLUSIVELY CONTRACTINO WITH LICENSED CONT(lACTORS
� TO CONSTRUCT TME PRQIECT(SEC.7041,BUSINESS AND PROFESSIONS CUDE:7HE CANTRAC70R5�I- VelU3�i0n ADJ.AREA
W CENSE LAW DOES NOTAPPLY 70AN OWNER OFA PROPERTV WHO BUILDS OR IMPROVES THEREON,AND
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� I HEREBV AFFIFUI UNDER PENALTY OF PERIURY 7HAT I AA1 LICENSED UNDER PROVISIONS Of CHAP7ER �
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� WORKERS'COMPENSATION DECLARATION �
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� I HEfiEBV AFFIRM UNOER PENALTY OF PE0.IURV ONE OF THE FOLLOWING DECURATIONS: Z
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� _I HAVE AND WILL MAINTAIN A CER?IfICATE OF CONSENT TO SELF•INSURE FOR NORKERS' _ � .
COMPENSATION,AS PROVIDED BV SECTION 370o OF 7HE LABOR CODE,FOR THE PERFORMANCE C.1
Q OF 7HE WORK FOfi WHICH THIS PERMIT IS ISSUEO. �
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I HAVE AND MALL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTION
Q 37000F 7HE UBOH CODE,FOR THE PERFORMMlCE OF THE WORK FOR WHICH THIS PERMIT IS
0 ISSUEO.MY WORKERS' �.��//W�ANCE C�RR/IER)AND PO�CY NUMBER ARE: CONSTRUCTION �1
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0 (IFUSSECTqNNE�NO78EWM4'IETmOF7HEPEAAfT6R'%iaNEHIA�DfimDOIIARS(f10D)ORL65} PLUMBING
Z 1 CERTIFV THAT IN THE PERFORMANCE OF TNE N'ORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
(f} SHALL NOT EMPLOY ANY FERSON IN ANV MANNEF SO AS TO BECOME SUBJECT TO 7HE [[U /� �,j .u �
N WORKERS'CAMPENSATION UWS OF CALIFORNIA NdD AGFEE TMAT�F I SHOUID BECOME INSPECTION FEE r r �i �� �7—
S SUBJECT TO THE WOiiKERS'COMPENSATION PROVISIONS OF SECTION 37000F THE UBOR � � �)�-
CA�E,I SHALL FOFRHWITH COMPLY WRH THOSE PROVISIONS. ISSUANCE t�r T1 A lT i � �
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p DATE: APPLICANE . 1 1 -
� ENERGY P/C
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LL SU&IECTAN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND ENERGY PERMIT
Oq1J�RS(i�00.0001,IN/�DDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN �!-�`
J SECTION97oBOFTHEIABORCODE,MTERE57,ANDAITORNEV'SFEES. RETENTIONFEE: • v
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pw_, CONSTRUCTION LENDING AGENCY PRE•ALT FEE:
� I HEREBV AFFIRM UNDER PENALN OF PERIURV THAT THERE IS A CANSTRUCTION LENDING AGENCV
FOR THE PERFORMANCE OF 7HE WORK FOR WHICH THIS PERMI715155UED(SEC.3oD7,CIV.C.).
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� LENDER'S NAME
!_- LENDER'SADORESS
� � I�� I CERTIFY THAT I HAVE READ THIS APPLICATION PND STATE THAT THE ABOVE INFORMATION IS CARRECT. TOTAL FE ES
w I AGREE TO COMPLV WITH PLL CITY AND CAUN7V OFDINANCES AND STATE LAWS RELATING TO BUILDING ^
� CONSTRUCTION,M1D HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTV TO ENTER UPON THE ��,{/) (/�/1
ZABOVE-MENTqNEO PROPERN FOH INSPEC710N PUHPOSES. COMMENTS �1 v_�� �� �
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