HomeMy WebLinkAbout16620 _�� CITY OF DIAMOND BAR ��PII���
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190 �UN 1 9 ZOOZ PRESS
(909)860-3195 Faz(909)861-3117
����^� BUILDING PERMIT APPLICATION � MLY i
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� TURE,VRIOH TO ITS ISSUANCE,�L50 REW IqES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO 7HE PROVISIONS OF THE CANTRACTORS LI-
� CENSE UW(CHAPTER Y(COMMENCINQ MATH SECTION 7000)OF OIVISION 3 OF THE BUSINESS AND PRO- � POOVSpO
FESSIDNSCODE)ORTHATNEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXEMP- (�
TIDN.AHV VIOLATqN OF SECTION 7091.6 BY ANV APPLICANT FOR A PERMIT SUBJECTS 7HE APPLICANT 70 Z Re-Root
F, A CIVIL VENALTV OF NOT MORE h1AN FIVE HUNDRED OOLURS(f5oo�.):
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MALL DO THE WORK AND THE STRUCTURE IS NOT IN7ENDED OR OFFERED FOP SALE(SEC.70at,BUSI- J
� NESS AND PROFESSIONS CODE:iHE COHTFiACTOfiS LICENSE LAW DOES NOT APPLY TO AN OWNER OF �
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Q THROUGH HIS OR HER OWN EMPLOYEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR m
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� 1 NEREBV AFFIRAI UNDER PENALTV OF PERIURY 7MAT 1 AM LICENSED UNOER PROVISIONS OF CHAPTER �
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� I HEREBY AFFIfUI UNDER PEN�LTY OF PERIURY ONE OF THE FOLLOWING DECURATIONS: Z
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� _�HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELP-INSURE POR WOfiKERS' 2 ',
COIIPENSATION,AS PROVIDED BY SECTION 37000F THE UBOH CODE,FOR THE PERFOHMANCE U
Q OyTHE WORK FOR WHICH h!IS GERMIT IS ISSUED. �
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d I HAVE AND WILL MAINTAIN WORKERS'COMPENSA710N INSURANCE,AS REOUIRED 8V SECTION
Q 370o OF THE LABOR CO�E.FOq THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
� ISSUED.MYWORKEFj�COMP�SURANCEGARRIER�D�NUMBERARE: CONSTRUCTION
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� (fH16SECIK7NNEFDNOTBEOJF6LEfIDOFhEPERAfTSFORONEMN[)FiED00LL/iRS(5100)ORLESS} PLUMBING '
Z I CERTIFY THAT IN THE PERFORMANCE OF 7HE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
(7 SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SU&IECT TO THE
y WORKE S'COM NSA710N LAWS OF CALIFORNIA,AND AGREE THAT IF 1 SHOULD BECOME INSPECTION FEE
SU&IE TO T WOfiKERS'COMPENS GROVISIONS OF SECTION 7700 0F THE R _ a
s DE SH ORiHWITHCOMPLVWI T PROVISIONS. ISSUANCE !
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p DATE: APPLICANT. .
J WMNINO:FAILURE 70 SECURE WORKERS'CAMPENSATION CAVERAGE IS UNUWFUL,AND SHALL BE ENERGY P/C
� SUBJECTANEMPLOYERTOCRIMINALPENALTIESPNOCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMI
DOLLARS(ft W,Ooo),IN ADDITION TO THE COST OF CAMPENSATION,DAMAGES AS 7ROVIDED FOR IN
J SECTION 3708 OF iHE LABOR CODE,INTEREST,AND ATTORNEYS FEES. flETENTION FE :
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OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: B _ __
� 1 HEREBV AFFIRM UNDER PENALTV OF PEFLIURV THAT TNERE IS ACONSTRUCTION LENDING ACENCY
FOR THE PERFORMANCE OF 7HE WORK FOR WHICH 7HIS PERMIT IS ISSUED(SEC.3oe7,CIV.C.).
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� LENDER'S NAME
F- LENDER'SADORE55
� 1 CERTIFY THA71 HAVE LiEAD THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CARRECT. TOTAL FE ES . i
w I AGREE TO COMPLV WITH ALL CI7V AND CAUNTY ORDINANC���555 AND STA7E UWS REU7ING TO BUILDING
� CONSTRUCTION,AND HEREBY AUTHORIZ REPRESENTATI�OF THIS COUNTV TO ENTER UPON THE D �
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