HomeMy WebLinkAbout9543 - 3333 BREA CANYON RD (2)CITY OF DIAMOND BAR
COMMUNITY DEVELOPMENT DEPARTMENT
21660 E. Copley Drive Suite 190
909) 860.3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION 1
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OWNER
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CITY ZI -TEL
APPLICANT TEL '
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DESIGNER All
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OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LF
CENSE LAW FOR THE FOLLOWING REASON (SEC 7031.5 BUSNESSAND PROFESSIONS COOS ANY CrTYOR
COU IM M41CH REOUIRESA PERIAITTO CONSTRUCT,ALTER.IMPROVE, DEMOUSN.OR REPMRANYSTRIJG
TIME, PRIOR TO ITS ISSUANCE. ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE R LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LF
CENSE LAW (CHAPTER s (COMMENCMM WITH SECTION Yam) OF DIVISION S OF THE BUSINESS AND PRO.
FESSION3 CODE) ORTHAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
IOTN. ANY VIOLATION OF SECTION 7071.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (5500)k
O L A$OWNER OFTHE PROPERTY, OR MY EMPLOYEES MATH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK, ANO THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSF
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTYVNO BULL# OR IMPROVES THEREON, AND WHO DOES SUCH WOR( HIMSELF OR HERSELF OR
THROUGH HIS 09 HER OYM EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFEREDFORSALE IF.HOY/EVER THE WILDING OR MPROVEMENT IS SOLD INTMNONEYEAROFODMPLE-
TION, THE OWNER BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE 010 NOT BURR OR
IMPROVE FOR THE PURPOSE OF MEL
0 L AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEG 7044. BUSINESS AND PROFESSIONS CODE THE CONTRACTORS ti.
CENSE LAW DOES NOT APPLY TO AN OWNER OFA PROPERTY W40 BUILDS OR IMPROVES THEREON. AND
WHOCXNTRACTS FOR SUCH PROJECTS NTH ACONTRACTOKS) LICENSED PURSUANT TO THE OCNTRAG
TORS LICENSE LAW).
O 1 AM EXEMPT LANDER SEG B. A PC FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AAL LICENSED CINDER PROVISIONS OF CHAPTER
e (OOMMENCNO MAIN SECTION 7000) OF DIVISION 7 OF THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS IN FURL FORCE AND EFFECT.
LICENSESS'ox'rw i-•LIc. 1No. „I
DATE
T
CONTRACTOR .
WORKERS! COMPENSATION DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MANTAIN ACERTIFICATE OF CONSENT TO SELF -INSURE FOR YORKERS'
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 WALL MAINTAIN WORKERS' COMPENSATION INSURANCE. AS REOUIRED BY SECTION
3700 OF THE LABOR OWE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
EtSED. YY ERS' COIAPENSATION INSURANCE CARRIER M/At)POLICY MNBER ME:
fjn'Y "
ICYNUMBER ``
DSS MORN EDNOTBE OOMPLETEDOF7FE PERMIT 0 PORCINE HUNDRM DOLLARS MOMOR LESSI
1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I
SHALL NOTEMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS' COMPENSATION LAWS OF CALIFORNIA AND AGREE THAT IF 1 SHOULD BECOME
SUBJECT TD THE WORKERS' COMPENSATION PP W SXWS OF SECTION 3700 OF THE LABOR
CODE.I SWILL FORTHWITH COMPLY WITH THOSE PROVISIONS.
GATE: APPLICANT:
WARNING, FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE
SIRJECTAN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (31 00,000). INADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN
SECTION 37% OF THE LABOR COOS. INTEREST, AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
I HERESY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FDR THE PERFORMANCE OF THE YORK FOR WHICH THIS PERMIT IS ISSUED (SEC 3W. CIV. G).
LENDERS NAME
LENDER ADDRESS
1 CERTIFY THAT I HAVE READTHS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 AGREE TO OOMPLY WITH ALL CRY AND COUNTY ORDNAlNCES AND STATE LAWS RELATING TO BUILDINQ
CONSTRUCTION. AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE MENTIONED PROPERTY FOR INSPECTION PURPOSES.
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PERI TTE (PRINT)
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