HomeMy WebLinkAbout16857 (25) ----��- --- CTTY OF DIAMOND BAR �X P I R E D
DEPARTMENT OF CONIIvIUNITY&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117 ��N 1 9 ZO�+�PRESS
�`'%���� BUILDING PERMIT APPLICATION FVRMLY �
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Z TURE,PRIOR TO ITS ISSUANCE,ALSO REOUIRES THE APPLICANT FOR SUCH PEFMIT 70 FILE A SIGNED
w STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI� w
� CENSE LAW(CHAPTER 6(CAMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- � POOUSPB
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WILL DO THE WORK,AND THE STRUC7URE IS NOT IN7ENDED OR OFFERED FOR SALE(SEC.7a4I,BU51- J
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� I HEREBY AFFIRM UNDER PENALTY OF PERJURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER �
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X MY LICENSE IS IN F l FORCE AND EFFECT.
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� WORKERS'COMPENSATION DECLARATION Q ,
� I HEREBY AFFIRM UNDER PENALTV OF PERJURV ONE OF THE FOLLOWING DECLARATIONS: Z
Z _IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' S i
CAMPENSA710N,ASPROVIDEDBYSEC710N37ooOF7HELAeORCODE,fORTHEPERFORMANCE U
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w I HAVEAND WILI MAIN7AIN WORKERS'CAMPENSATION INSUFANCE,AS REOUIRED BV SECTION
Q 3700 0F THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOH WHICH 7HI5 PERMI715
ISSUED.MV WORKERS'COMP O INSUR9[JC ARRIF� D P9 LICV U,{B R ARE: CONSTRUCTION
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Z I CERTIFVTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
(�} SHALL NOT EMPLOY ANY PEfiSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
� WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF 1 SHOULD BECAME INSPECTION FEE I
SU&IECT TO THE WORNERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR ` ,\
~ CODE,I SHALL FORTHWITH COMPLV WITH THOSE PROVISIONS. ISSUANCE �"�'��� —� � . )i Uv �
p DATE: APPLICANT: SMIP 1 i L-J� �\\ �� � � —j�
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J WARNING FAILURE TO SECURE WOflKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE ENERGY P/C /� � �',.
� SU&IECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT I r "i �
} DOLLARS(S�W.00o),IN ADDI710N 70 7HE COST OF COMPENSATION,DAMAGES AS PFOVIDED FOF IN �
J� SECTION 3708 OF THE LABOR CODE,INTEFiEST,AND ATTORNEY'S FEES. �RETENTION FEE: (
d CONSTRUCTION LENDING AGENCY PRE-ALT FEE: I �
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Q I HEREBV AFFIRM UNDER PENALTV OF PERJURV THAT THERE IS A CONSTRUCTION LENDING AGENCY ---'
� FOFi THE PERf-0RMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.7087,CIV.C.).
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� LENDER'S NAME
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� ICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETHATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES � S�
w 1 AGREE TO COMPLV WITH ALL CITY AND COUNTV ORDINANCES AND STATE LAWS REUTING TO BUILDING
� CONSTRUCTI N,AND HEREBV AUTHORI2E REPRESENTATIVES OF THIS COUNTV TO ENTER UPON THE
� ABOVE� EN ONEDPROPERTYFORINSPE PURPOSES. �
Z D COMMENTS
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ELECTRIC GROUNQ _� UNDER FLO�R D�CT � _ _
GR�UND PLUMBING � UNQER FLOOR CUI�!DUIT { ___
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SEWER FINAL ENG. �
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