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HomeMy WebLinkAbout12-758 (8)U3 CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21810 Copley Drive, Diamond Bar, CA 91765 (909)839-7020 Fax (909) 861-3117 Building Inspection Hotline (909) 839-7027 PRESS BUILDING PERMIT APPLICATION FIRMLY JOBSITE ADDRESS APNLOT— TRACT, OWNER,` a ADDRESS CITY ZIP TEL APPLICANT TEL. j CONTRACTOR ADDRESS CITY ZIP TEL."'C," "'f ARCH/ENG/,' DESIGNER,' ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSE LAW FORTHE FOLLOWING REASON (SEC. 7031.6 BUSINESSAND PROFESSIONS CODE: ANY CITY OR COUNTY WHICH REQUIRESAPERMITTOOC>NSTRUCTALTER, IMPROVE, DEMOLISH, OR REPAIRANY STRUc_ TUBE, PRIOR To ITS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- CENSE LAW (CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO- FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION. ANY VIOLATION OF SECTION 7031.6 BYANYAPPLICANT FORA PERMIT SUBJECTS THE APPLICANT TO A CIVILPENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($500),): 0 IASOWNER OFTHE PROPERTY, OR MY EMPLOYEES WITHWAGESAS THEIR SOLE COMPENSATION, WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSI- NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOTAPPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE. IF, HOWEVER, THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONEYEAR OF rOMPLE- TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). 0 1, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS To CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI- CENSE LAW DOES NOTAPPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S) LICENSED PURSUANTTO THE OONTRAC- TORS LICENSE LAW.). ,!dl AM EXEMPT UNDER SEC. B. & P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION j HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS IN FULL FORCE AND EFFECT. LICE14SE CLASS lAiE', CONTRACTOR WORKERS' COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: I HAVE AND WILL MAINTAIN A CERTII( F CATE OF CONSENT TO S ELF -INSURE FOR WORKEWORKERS'COMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY SECTION .1700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER POLICY NUMBER (THISSECTION NEED NOTBECaMPLETEDOF THE PERMTIS FORONEHUNDREDDOU"($100)08LESS} I I CERTIFY THAT IN THE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TOTHE WORKERS' COMPENSATION LAWS OF CALIFORNIA, ANDAGREE THAT IF I SHOULD BECOME SUBJECT TOTHE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR CODE. I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS., DATE APPLICANT: WARNING: FAILURE TO SECURE WORKERTOOMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100.000), IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTOANEY'S FEES. CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097. civ. C.). LENDER'S NAME LENDERSADDRESS CERTIFY THAT I HAVE READ THIS APPLICATIONIAND STATE THATTHEABOVE INFORMATION IS CORRECT. AGRrETO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENnONED PROPERTY FOR INSPECTION PURPOSES. PER611TTEE NAME (PRINT) SIGNATURE OF PERMITrEC DATE APPLICATION, DATE ISSUE DATE PERMIT i NUMBER TYPE '-CONST. J,- P/C # OCC GROUP ZONING SETBACKS FRONT RW El REAR 0 SIDE/SIDE STREET RW El SIDE ❑ PROPOSED USE NO. DWEL. NO. NO. UNITS STORIES BEDROOMS SFR/ADDIREM U) Garage/Carport W Patio/Dock w LL Pool/Spa 0 Z Re -Roof Commercial Ib Valuation", ADJ.AREA QUANTITY DESCRIPTION FEE < w 7 7 7777— J�, < 0 z CONSTRUCTION PLAN REVIEW f ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ISSUANCE SMIP ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE-ALT FEE: TOTAL FEES COMMENTS RECPT, NO. PAID BY VALIDATION 4K—Assessor CODY. GOLDENROD —File Coix GREEN—AimlicanVs Copy VVnj t ­Py, T —T-11111— ­Fy, I'