HomeMy WebLinkAbout12797 �� CITY OF DIAMOND BAR E�CPIRED
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
W 21660 E.Copley Drive Suite 190 MAY O y ZOO� PRESS
(909)860-3195 Fax(909)861-3117
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� TUR�VRIOR TO ITS ISSUANCE,A150 REW IRES THE APPLICAHT FOR SUCH PERMIT TO FIIE A SIGNED w
STA7EMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTMCTORS LI-
� CENSE UW(CHAPTER Y(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF 7HE BUSINE55 AND PRO• u' Pool/Spa
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NESS AVD PROFESSIONS COOE:THE CONTRACTORS LICENSE UW DOES NOT APPLV TO AN OWNER OF
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� LICENSED CONTRACTOFS DECLARATION W
� I HEREBY 11FFIRM UNDER PENALTY OF PER1UFiY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER �� • .
d Y(COMMENCINO WI7H SECTION 7000)OF DIVISION�OF THE BUSINESS AND PROFESSIONS CADE,AND Z
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� WOFKERS'COMPENSATION DECLARATION �
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� I HEREBY AFFIRM UNDER PENALTV OF PE0.IURV ONE OF THE FOLLOWING DECURA710N5:
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� _I HAVE NID WILL MAINTNN A CERfIFICATE OF CONSENT TO SELF-INSURE FOR N/ORKERS' 2
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�} �f SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECAME SU&IECT TO THE
� {J WORKERS'COMPENSATIONUWSOFCALIFOHNIA,ANDAGREET IFISHOULOBECAME INSPECTIONFEE
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p DATE;��Iu� APPLICANT: •� � SMIP �I'I'Y .
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J SECTION 370E OF THE LABOR CODE,INTEREST,M1D ATTORNEY'S FEES. RETENTION FEE:
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d CONSTRUCTION LENDING AGENCY pRE-ALT FEE:
� I HEREBV AFFIHM UNDER PENALTY OF PERIUFtY THA77HERE IS A CANSTHUCTION LENDING AGENCV
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� 1 CEHTIFV THAT I HAVE REM T115 APPLICA710N AND STATE THA7THE ABOVE INFORMA7pN IS CORRECT. TOTAL FE ES
w 1 AGREE TO COMVLY N7TH ALL CfTV AND COUNTY ORDINANCES AND S7A7E LAWS REUTING TO BUILDING
� CONSTRUCTION,M1D HEREBV AU7HORIZE REPRESENTA71VE5 OF THIS COUN7V 70 ENTER UPON T1E �
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ROOF SHEATHING %2`J �� �I ; � 8 FT. BOND BEAM �
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