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HomeMy WebLinkAbout24896.pdfCITYOFDIAMONDBAR DEPARTMENT OFCOMMUNITY & DEVELOPMENTSERVICES 21825CopleyDrive, DiamondBar, CA91765 909) 839-7020Fax (909) 861-3117BuildingInspectionHotline (909) 839-7027 BUILDINGPERMITAPPLICA~ JOBSITE ADDRESSfi ~ - APNLOT TRACT _ OWNERJLI/~C11. {milV~-I~ ~JII~ y1 ~ rA ~I ADDRESSZ CITYZIP~,~ TEL. /~Tf,y-~~,~+ APPLICANTTEL. !' CONTRACTORi < ~.. LC.~tC ~IrY ~J- 1 ~ I`1 ADDRESSl ~L~dtU~ (x"11 _ -i--• S'cIy~ CITY ~fY~ ~~~(~ ZIP \[ 9~ TEL. ~a ~ 7. -(Ll~ ARCH/ENG/ DESIGNERf~-~ a ADDRESS T CITYZIPTEL. OWNER-BUILDER DECLARATION IHEREBYAFFIRM UNDERPENALTYOFPERJURYTHA71AMEXEMPTFROMTHECONTRACTORSLI- CENSELAWFORTHEFOLLOWING REASON (SEC. 7031.5BUSINESSANDPROFESSIONSCODE: ANVCITYOR COUNTYWHICHREQUIRES APEf1M1TTOCONSTRUCT, ALTER, IMPROVE, DEMOLISH, ORREPAIRANYSTRUC~ TORE, PRIORTOITSISSUANCE, ALSOREQUIRESTHEAPPLICANT FORSUCHPERMITTOFILEASIGNED STATEMENTTHATHEORSHEISLICENSEDPURSUANTTOTHEPROVISIONSOFTHECONTRACTORS LI- CENSELAW (CHAPTERa (COMMENCINGWITHSECTION7000) OFDIVISION3OFTHEBUSINESSANDPRO FESSIONSCODE) ORTHATHEOaSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXEMP~ TION. ANVVIOLATIONOFSECTION7031.5BVANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO ACIVILPENALTYOFNOTMORETHANFIVEHUNDREDDOLLARSIS500).): I, ASOWNEROFTHEPROPERTY, ORMVEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, WILLDOTHEWORK, ANDTHESTRUCTUREISNOTINTENDEDOROFFEREDFORSALE (SEC. 7044, BUSI- NESSANDPROFESSIONS CODE: THECONTRACTORSLICENSE LAWDOESNOTAPPLYTOANOWNEROF PROPERTYWHOBUILDSORIMPROVES THEREON, ANDWHODOESSUCHWORKHIMSELFORHERSELFOR THROUGHHISORHEROWNEMPLOYEES, PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTENDEDOR OFFEREDFORSALEIF, HOWEVER, THEBUILDINGORIMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE- TION, THEOWNER-BUILDERWIl1HAVETHEBURDENOFPROVINGTHATHEORSHEDIDNOTBUILDOR IMPROVEFORTHEPURPOSEOFSALE). I, ASOWNEROFTHEPROPERTY, AME%CLUSIVELYCONTRACTINGWITHLICENSEDCONTRACTORS TOCONSTRUCTTHEPRQIECT ;SEC. 7044, BUSINESSANDPROFESSIONSCODE: THECONTRACTORSLI- CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUILDSORIMPROVESTHEREON, AND WHOCONTRACTSFORSUCHPROJECTSWITHACONTRACTOR(S) LICENSEDPURSUANTTOTHECONTRAC- TORSLICENSELAW.). IAMEXEMPTUNDERSEC. B. & P.C. FORTHISREASON DATEOWNER LICEIJSEDCONTRACTORSDECLARATION IHEREBYAFFIRMUNDERPENAI.TVOFPERJURVTHAT1AMLICENSEDUNDERPROVISIONSOFCHAPTER 9 (COMMENCINGWITHSECTION7000) OFDIVISION3OFTHEBUSINESSANDPROFESSIONS CODE, AND MYLICENSEISINFULLFORCEP.NDEFFECT. 7 r LICENSE CLASS LIC. NO. y~ ~ DATE >/ ~ Z ~ ~ OrCONTRACTOR /Y'tAr' 1L.•'~" L ~ NJ WORF:ERS' COMPENSATION DECLARATION IH EBYAFFIRMUNDERPENALTVOFPERJURYONEOFTHEFOLLOWINGDECLARATIONS: E R j IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF~INSUREFORWORKERS' 111~~~ COMPENSATION, ASPROVIDEDBVSECTION3700OFTHELABORCODE, FORTHEPERFORMANCE OFTHEWORKFORWHI~HTHISPERMITISISSUED. IHAVEANDWILLMAINT,IINWORKERS' COMPENSATIONINSURANCE, ASREQUIREDBYSECTION 37000ETHELABORCODE, FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS ENSATIONINSCECARRIE ISSUED. MVWORNERS CO MP R ANDPOLICYNUMBERARE: CARRIER _~ l^t/ frLf~I !/ POLICYNUMBER _'_-_T- i}iISSECTIONNEEDNOTdECOMPLETEDOFTHEPERMiISFORONEHUNDREDDOLIAiYS (5100) ORLESS). ICERTIFYTHATINTHEPERFORMANCE OFTHEWORKFORWHICHTHISPERMITISISSUED, 1 SHALLNOTEMPLOYAN'/PERSONINANYMANNERSOASTOBECOMESUBJECTTOTHE WORKERS' COMPENSAIIONLAWSOFCALIFORNIA, ANDAGREETHATIFISHOULDBECOME SUBJECTTOTHEWORKERS' COMPENSATION PROVISIONSOFSECTION37000ETHELABOR CODE, ISHALLFORTHWITHCOMPLYWITHTHOSEPROVISIONS. DATE: APPLICANT: WARNING: FAILURETOSECUREWORKERS' COMPENSATIONCOVERAGE ISUNLAWFUL, ANDSHALLBE SUBJECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND DOLLARS (5700,000), INADDITIONTOTHECOSTOFCOMPENSATION, DAMAGESASPROVIDEDFORIN SECTION3708OFTHELABORO)DE, INTEREST. ANDATTORNEY'SFEES. C~JNSTRUCTIONLENDINGAGENCY IHEREBYAFFIRMUNDERPENAL-TVOFPERJURYTHATTHEREISACONSTRUCTION LENDINGAGENCY FORTHEPERFORMANCE OFTHEWORKFORWHICHTHISPERMITISISSUED (SEC. 3097, CIV. C.). LENDER'SNAME LENDER'SADDRESS ICERTIFYTHAT1HAVEREADTHISAPPLICATIONANDSTATETHATTHEABOVEINFORMATKJNISCORRECT. IAGREETOCOMPLYWITHALLC:ITVANDCOUNTYORDINANCESANDSTATELAWSRELATINGTOBUILDING CONSTRUCTION. ANDHEREBYAUTHORIZEREPRESENTATIVES OFTHISCOUNTYTOENTERUPONTHE ABOVE-MENTIONEDPROPERTYFORINSPECTION PURPOSES. PERMITTE (PRINT) SIGNATUREOFPERMITTEE DATE ION J~$ - aat_Copy, YELLOW--FinanceCopy, PINK-AssessorCopy, GOLDENROD-FileCopy, GREEN-Applicant'sCopy a 0 0 0 w z O 0 Z tr O D w U Z w O U H O Z z O a x w O U W O Z Q w 0 z 0 w z cs O 0 w J J J W tl O d Z w 2 w C7 z 0 J_ m Q CITYOFDIAMONDBAR ~ N / l ~•3r DEPARTMENTOFCOMMUNITY & DEVELOPMENT SERVICES 21825CopleyDrive, DiamondBar, CA91765 909) 839-7020Fax (909) 861-3117BuildingInspectionHotline (909) 839-7027 ~~___ BUILDINGPERMITAPPLICATION PRESS FIRMLY WHITE-DepartmentCopy, YELLOW--FinanceCopy, PINK-AssessorCopy, GOLDENROD-FileCopy, GREEN-Applicant'sCopy INS DATE INSPECTI. Ftx INSPECTIONDATE INSPECTOR