HomeMy WebLinkAbout11437CITY OF DIAMOND BAR
COMMUNITY DEVELOPMENT DEPARTMENT PRESS
21660 E. Copley Drive Suite 190 FIRMLY
(909) 960-3195 Fax (909) 861-3117
v BUILDING PERMIT APPLICATION / �/1
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cn OWNER -BUILDER DECLARATION
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® I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT i :S EXEMPT FROM THE CONTRACTORS LI-
U COUNTY WHICH REDUIRESA PERMTETO CONSTRUCT,ALTERSON ISEC. !MPROVE,DEMOLISAND SHIOORREPAIR ANY STRUC-
WTUBE, PRIOR T 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 U.
FCENSr LAW (CHAPTER 9 ESSIONS CODE)ORTHATHE OR SHE IS EXEMPT THMMENCING WITH IEN 7000) OF DIVISION 3 OF THE BUSINESS AND PRO -
REF OM AND THE ASISF R THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7031.E BY ANY APPLICANT FORAPERMIT SUBJECTS THE APPLICANT TO
h ACIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($
SOo).):
O ❑I, AS OWNEROFTHE PROPERTY, OR MY EMPLOYEES WITH WAGESAS THEIR SOLE COMPENSATION,
WILL Do THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSI-
CENSE LAW DOES NOT APPLY TO AN (n PNEss AND ROP RTYWNER OF
PROFESSIONS CODE: THE CONTRACTORS WHO BUILDS OR IMPROVE THEREON, AND IWHO DOES SUCH WORK HIM ELF OR ECRSELFOR
CC_DED Tl
W THROUGH HIS OR OFFERED FORSALE.EIF,HOWEVER, THE BUILDINGR OWN EMPLOYEES IOR IMPROVEM NIAT SUCH ITISSOLDWITHINONEYAROFCOMPLMPROVEMENTS ARE NOT INTENDED OE-
M TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
❑ 1. AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 7044. BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U,
LU CENSE LAW DOES NOTAPPLY TO AN Z WHO CONTACTS FOR SUCH ROJECOVES THEREON, AND
OTS WITH A ONTRACT RS) LTY LIICENSED PURSUBUILDS OR RANTTOTHE CONTRAG
TORS LICENSE LAW.).
B. & P.C, FOR THIS REASON
O ❑ 1 AM EXEMPT UNDER SEC.
V-' DATE OWNER
O 1 LICENSED CONTRACTORS DECLARATION
ISSUE
DATE_
TYPE OCC
CONST. GROUP
ZONING SETBACKS RW ❑
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ONT El
AR
DE/SIDE STREET RW
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N NO.
UNITS STORIES BEDROOMS
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTE
0-9(COMMENCING WITH SECTION 7000)OF DIVISION 30F THE BUSINESS AND PROFESSIONS CODE. AND
X MY LICENSE IS IN FULL FORCE AND EFFECT.
W
O LICENSE CLASS UC. NO.
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t-'_ CONTRACTOR
DATE
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WORKERS' COMPENSATION DECLARATION
U) I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
CQ inI HAVE AND WILL MAINTAIN ACERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS'
ZCOMPENSATION, AS PROVIDED BY SECTION
@ 37000FTHE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,
ci
LLJ __I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE, AS REQUIRED BY SECTION
37GO OF THE LABOR CODEFOR THE PERFORMANCE F THE WORK FOR
ISSUED.
WHICH
ED. MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:MIT IS
J
CARRIER
p POLICY NUMBER
Q (IRIS SECTION NEED NOT BE OOMPLETEDOFTHE PERMIT SFRONE HUNDRED DOLLARS (5100)RLESSI
W I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECTTO THE
U) WORKERS' COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF 1 SHOULD BECOME
CODE,CI SHCATHE LL FORTHWITH ' GotPLY WITH THOSE PROVISIONS. jsjolqs OF SECTION 37000E THE LABOR
ZD
0 APPLICANT:
m DATE:
J
J WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL, AND SHALLB
IES
DREDTHOUSAND
W DOLLARS (51oo,000) IN ADDITION TOATHE COST OF CI COMPENSATION, DAMAGES ASNPROVIDED FOR IN
J SECTION 3708OFTHELABORCODE, INTEREST, AND ATTORNEYS FEES.
w CONSTRUCTION LENDING AGENCY
d
IHREBY AFFIRM UNDER PENALTYOF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY
cc FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097. CIV. C.).
Z
W
S LENDER'S NAME
{— LENDER'S ADDRESS
W I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THATTHE ABOVE INFORMATION IS CORRECT.
Cl- CONSTRUCOMPLY WITH ALL CITY AND COUNTY ORDINANCES AND CCOM
TION. AND HEREBY AUTHORIZER REPRESENTATIVES OF THIS ACO COUNTY TTE LAWS OENTERUPON THE
NG TO NG
U ABOVE -MENTIONED PROPERTY FOR INSPECTION PURPOSES.
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ED PERMITTEE NAME (PRINT)
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U) DATE
CO SIGNATURE OF PERMI II
_ —Finance Copy,
DESCRIPTION SQ. FT. FACTOR PSF ADJ. Aht_A/VALUMI lulu
SFR/ADD/REM
C0 Garage/Carport
WPatio/Deck
U- Pool/Spa
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Valuation ADJ.AREA
QUANTITY
DESCRIPTION FEE
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ELECTRIC
PLUMBING
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INSPECTION FEE t
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES
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COMMENTS
RECPT NO. PAID BY