HomeMy WebLinkAbout19265.pdfCITYOFDIAMONDBAR ~ X ~ ~ ~~~
DEPARTMENTOFCOIvIlvIUNTI'Y & DEVELOPMENT SERVICES
21825E. CopleyDrive
909) 860-3195Fax (909) 861-3117
BUILDINGPERMITAPPLICATION
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OWNER-BUILDER DECLARATION
IHEREBYAFFIRMUNDERPENALTYOFPERJURYTHATIAMEXEMPTFROMTHECONTRACTORSLI~
CENSECAWFORTHEFOLLOWINGREASON (SEC. 7031.5BUSINESSANDPROFESSKKJSCODE: ANYCITYOR
CWNTYWHICHREOUIRESAPERMITTOCONSTRUCT, ALTER, IMPROVE, DEMOLISH, ORREPAIRANVSTRUC-
TURE, PRIORTOITSISSUANCE. ALSOREQUIRESTHEAPPLICANT FORSUCHPERMITTOFILEASIGNED
STATEMENTTHATHEORSHEISLICENSEDPURSUANTTOTHEPROVISIONSOFTHECONTRACTORS LI-
CENSELAW (CHAPTERa (COMMENCINGWITHSECTION7000) OFDIVISION3OFTHEBUSINESS ANDPRO-
FESSIONSCODE) ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXEMP-
TK)N. ANVVIOLATKXJ OFSECTION7031.5BVANVAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANT TO
ACIVILPENALTYOFNOTMORETHANFIVEHUNDREDDOLLARS (5500).):
I, ASOWNEROFTHEPROPERTY, ORMVEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION,
WILLDOTHEWORK, ANDTHESTRUCTUREISNOTINTENDEDOROFFEREDFORSALE (SEC. 7044, BUSi~
NESSANDPROFESSIONS CODE: THECONTRACTORSLICENSE LAWDOESNOTAPPLYTOANOWNEROF
PROPERTYWHOBUILDSORIMPROVES THEREON, ANDWHODOESSUCHWORKHIMSELFORHERSELFOR
THROUGHHISORHEROWNEMPLOYEES, PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTENDEDOR
OFFEREDFORSALEIF, HOWEVERTHEBUILDINGORIMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE-
TKXI, THEOWNER-BUILDERWILLHAVETHEBURDEN OFPROVINGTHATHEORSHEDIDNOTBUILDOR
IMPROVEFOP1HEPURPOSEOFSALE).
I, ASOWNEROFTHEPROPERTY, AMEXCLUSIVELY CONTRACTINGWITHLICENSEDCONTRACTORS
TOCONSTRUCTTHEPROJECT (SEC. 7044, BUSINESSANDPROFESSIONSCODE: THECONTRACTORSLI-
CENSELAWDOESNOTAPPIVTOANOWNEROFAPROPERTYWHOBUILDSORIMPROVESTHEREON, AND
WHOCONTRACTSFORSUCHPROJECTSWITHACONTRACTOR(S) LICENSEDPURSUANTTOTHECONTRAC-
TORSLICENSELAW.).
IAME%EMPTUNDERSEC. _ B. 8P.C. FORTHISREASON
DATEOWNER
LICENSEDCONTRACTORSDECLARATION
IHEREBYAFFIRMUNDER PENALTYOFPERJURYTHATIAMLICENSEDUNDER PROVISIONSOFCHAPTER
e (COMMENCINGWITHSECTK)N7000) OFDIVISION3OFTHEBUSINESSANDPROFESSIONS CODE. AND
MVLICENSEISINFULLFOEANDEFFECT. CX/
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LIC. NO.
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CONTRACTOR
DATE
WORKERS' COMPENSATION DECLARATION
IHEREBYAFFIRMUNDERPENALTYOFPERJURYONEOFTHEFOLLOWINGDECLARATIONS:
IHAVEANDWILLMAINTAINACERTIFICATE OFCONSENTTOSELF-INSUREFOPWORKERS'
MPENSATION, ASPROVIDEDBVSECTION37000ETHELABOR CODE, FORTHEPERFORMANCE
OTHEWORKFORWHICHTHISPERMITISISSUED
IHAVEANDWILLMAINTAINWORKERS' COMPENSATIONINSURANCE, ASREQUIREDBVSECTION
3700OFTHELABOCODE, FOEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS
ISSUED. MVWHOS' COMPSATIONINSURANCARJRANDPOLICYNUMBER ARE/
CARRIER ~ LE7,` ~,r,t/'`-+'~~
POLICI' NUMBER
fHLSSECDONNE®NOTBEOOMPLETEDOFTHEPERIMISFORONEHUNDREDDOLLARS (E100) ORLESS).
ICERTIFYTHATINTHEPERFORMANCE OFTHEWORKFORWHICHTHISPERMITISISSUED, I
SHALLNOTEMPLOYANYPERSONINANVMANNER50ASTOBECOMESUBJECTTOTHE
WORKERS' COMPENSATION LAWSOFCALIFORNIA, ANDAGREETHTIF1SHOULDBECOME
SUBJECTOTHEWORKERS'COMPENSATR /ISIONSOFS10D0FTJHEL~.BOR
E, IHTITHCOMPLYWITHOSOINS.
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DATE: -. _ APPLICANT
WARNINGFA .URETOSECUREWORKERS' COMPENSATIONCOVERAISUNLAWFUL, ANDSHALLBE
SURJECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFINESUGONEHUNDREDTHOUSAND
DOLLARS (51011,000), INADDITIONTOTHECOSTOFCOMPENSATKN, AMAGESASPROVIDEDFORIN
ISECTION3709OFTHELABORCODE, INTEREST, ANDATTORNEY'SFEES.
ICONSTRUCTION LENDINGAGENCY
i
1HEREBYAFFIRMUNDER PENALTYOFPERJURYTHATTHEREISACONSTRUCTION LENDINGAGENCY
FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITISISSUED (SEC. 309\], CIV. C.).
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LENDER'SNAME
LENDER'SADDRESS
ICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETHATTHEABOVEINFORMATIONISCORRECT.
1AGREETDCOMPLYWITHALLCITYANDCOUNTYORDINANCESANDSTATELAWSRELATINGTOBUILDING
ANOHEREBYAUTHORIZEREPRESENTATIVES OFTHISCOUNTYTOENTERUPONTHE
CONSTRUCTION
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