HomeMy WebLinkAbout15328 - 2119 1 2 3 DUBLIN (2)CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION .
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DESIGNER
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OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS aDENSE LAW FOR THE FOLLOWING REASON (SEC.7031.5 BUSW ESSAND PROFESSIONS CODE: ANY CITY OR
COUNTY WHiCHREOUIRUAPEFOaTO CONSTRUCT,ALTER, IMPROVE. DEMOUSK OR REPNRANY STRUC-
TURE PRIOR TO ITS ISSUANCE ALSO REQUIRES THE APPLICANT FOR SUCH PE WAIT TO FILE A SIGNED
STATEMENT T1AT HE OR SHE IS LICENSED PURSUAM TO THE PROVISIONS OF THE CON7RACTORS U
DENSE LAW (CHAPTER
/ (COMMENCI G WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PR0-
FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP•
TUN. ANY VIOLATION OF SECTION 7031.5 BY ANY APPLIGMT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (UN).):
O L AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORT( AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC, 7044, BUSH
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTYHO WBUILDS OR M/PROVES THEREON, ADIWFO DOES SUCH W ORKHMSELF ORHERSELF OR
HR TOUGH HS OR HER OWN EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT NTENOED OR
OFFEREDFORSALE F,HOWEVEFLTHE KkoiV0OR IMPROVEMENT IS SOLD WITHIN ONE YEAROF COMPLE-
TION. THE OWNERa=FR WALL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BOLO OR
IMPROVE FORTHE PURPOSE OF SALE}
O L AS OWNEROF THE PROPERTY. AM EXCLUSIVELVCONTRACTNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 7044. BUSINESS NO PROFESSIONS CODE THE CONTRACTORS LH
CENSE LAW DOES Nor APPLY TO AN OWNER OF APROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHOCONTRACTS FOR SUCH PROJECTS YATHACOMRACTOR(S) LICENSED PURSUANT TO THE CONTRAC.
TORSUCEHSELAW),
O 1 AM EXEMPT UNDER SEC, B. 5 P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBYAFFAM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
I (COMMENCING WITH SECTION ROOD) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS COOS, AND
MY LICENSE IS N FILL FORCE AND EFFECT.
LICENSE CLASS �Yyy-�Y L1C. NO.
DATE 'I — ( — c/ CONTRACT
WORKERS' COMPENSATION DECLARATION
I HEREBYAFFIRM UNDER PENALTY OF PEFLURY ONE OF THE FOLLOWING DECLARATIONS.
-1 HAVE AND WILLMA MAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS'
CONPENSATION,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE. FOR THE PERFORMANCE
OF THE WOW( FOR WHICH THIS PERMIT M ISSUED.
1 HAVE AND WILL LLWAN WORKERS' COMPENSATION INSURANCE. AS REQUIRED BY SECTION
3700 OF THE LABOR COOS. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS COMPENSATION INSURANCE GABBER AND POLICY NUMBER ARE
CARVER bwW�'Y1yrc FU XDD
POLICY MMBER 5 _) I p
? 1 n -l J
IT -m SECTION K®NOT DC=FiFTEDDFTH E PEFMTIS FOR ONIEhUDREDDDWAS (ILIA ORLESS)
1 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 70 BECAME SUBJECT TO THE
WORKERS' COMPENSATION LAWS OF CALIFORNIA. AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE. I SHALL/ FORTHWITH COMPLY WITH THOSE PROVISIONS.
PATE; - 00 APPLICANT.
WARNING: FALURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL BE
SUBJECT AN EMPLOYER TO CRMNAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (3100,om), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3704 OF THE LABOR CODE. INTEREST. AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
1 HEREBY AFFIRM LXOER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THS PERMIT IS ISSUED (SEC 3997, CIY, C.T.
LENDERS NAME
LENDERSADDRESS
1 CERTIFY THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION 15 CORRECT.
I AGREE TO COMPLY WITH ALLCITY AND COUNTY ORDNANCESAND STATE LAWS RELATING TO BUILDING
CONSTRUCTION, AND HEREBYAUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOYEMEMDNEO PROPERTY FOR WSPECTION PURPOSES.
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PETr E NAME (PWNT) —/v' 9 —OV
SIGNATURECFPEF"TTEE DATE
PRESS
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DATE .00 NUMBER «
ISSUE �' 1 TYPE OCC
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