HomeMy WebLinkAbout15098CITY OF DIAMOND BAR
DEPART?BENT OF COMMUNITY &DEVELOPMENT SERVICES
21660 E. COplcy Drive Suite 190
(909)860 3195 Fax (909)651-3117
BUILDING PERMIT APPLICATION
JOBSITE (� .
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OWNER
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DESIGNER
ADDRESS
CITY ZIP TEL,
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRAC70RS LI-
CENSE LAW FORTHE FOLLOWING REASON ISEC. 7031.5 BUSNESS AND PROFESSIONS CODE ANY CRY OR
COUNTY WHICH REOUIRESA PERMIT TOCONSTRUCT,ALTER FAPROVE. DEMOUSK OR REPAIR ANY STRU(,
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 F (COMMENCING WITH SECTION 7DOO) OF DIVISION A OF THE BUSINESS AND PRO-
FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THEALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION ?WI.5 BY ANY APPLICANT FORA PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (3500).):
O L AsOWNER OF THE PROPERTY. OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION.
WALL 00 THE WORK. AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044. BUSI-
NESSANDPROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY VINO BUILDS OR IMPROVES THEREON, AND WHO DOES SUCH WORK MIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF. HOWEVER THE BUILDING ON IMPROVEMENT IS SOLD WITHIN ONE YEAR OFCOMPLE
`TION, THE OWNERNBURDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
O L AS OWNER OFTHE PROPERTY. AM EXCLUSNELY CONTRNCTNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 70AN. BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U.CENSE UAW DOES NOTAPPLY TORN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON. AND
WAD CONTRACTS FOR SUCH PROJECTS WITHACONTRACTORIS) LICENSED PURSUANT TO THE CONTRA(,
TORE LICENSE LAW.),
O 1 AM EXEMPT UNDER SEC. B. L P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBYAFFI M UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER
• (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE AND
MY LICENSE IS N FULL FORCE AND EFFECT.
LICENSE CLASS LIC. NO.
DATE CONTRACTOR
WORKERS' COMPENSATION DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
_I NAVE AND WALL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS
COMPENSATION. AS PROVIDED BY SECTION 3700 CF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHCH THIS PERMIT IS ISSUED.
_I HAVE AND WILL MAINTAIN WORKERS' COMIPENSATION INSURANCE. AS REQUIRED BY SECTION
37D0 OF THE LABDR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15
ISSUED. MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER
POLICY NUMBER
PHIS SECTION E. NDT BE COM PLETFIIOFTHE PEW.TTISFOR ONE HUNDRED WIUVS RIOO) OnLEs4
I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1
SHALL NOT EMPLOY ANY PERSON N ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS' COMPENSATION LAWS OF CALIFORNIA. AND AGREE THAT IF 1 SHOULD BECOME
SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE.I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE: APPLICANT.
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL• AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS IS 100.000). IN ADDITION TO THE COST OF COMPEN SATION• DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
1 HEREBY AFFIRM UNDER PENALTY OF PENURY THAT THERE 15 A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3007. CIY. C.).
I
LENDERS NAME
LENDERS ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE TENT THE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUDDING
CONSTRUCTION. AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UR(N/THE, A
ABOVEJAENRONED PROPERTY FOR INSPECTION PURPOSES. /WI `A•M•- 1�� `NVL
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APPLICATIO PERMIT P/C
DATE NUMBER M
ISSUE TYPE OCC
DATE CONST, GROUP
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UNITS STORIES BEDROOMS
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RETENTION FEE:
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TOTAL FEES
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RECPT. NO.
PAID BY VALIDATION
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'— WHITE —Department Copy, YELLOW —finance Copy, PINK—Aseesaor Copy, GOLDENROD —File copy, GF E COPY -