HomeMy WebLinkAbout15316 - 2047 1 2 3 GALVIN (2)CITY OF DIAMOND BAR I
' DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 F_ Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION .
JOBSITE I
ADDRESS?,(�- � Li l�t -7, ', 20141 - 3 GAL
APN LOT TRA T
OWNER yjA AD • � A
ADDRESS
CITY ZIP TEL
APPLICANT TEL
CONTRACTOR _
ADDRESS
CITY - ' ZIP / TE Ya)y1�'' N0
ARCWENG/
DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FPOM THE CONTRACTORS LF
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.6 BUSW ESSAND PROFESSIONS CODE ANY CITY OR
GOUTY WHICH REOLARESAPEP►4aM CONSTRUCT,ALTER ILPROVE DEMOUS{ OR REPARANY STRUG
TURF 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 P SHE WITH SECTION TOM) OF DIVISION 3 OF THE BUSINESS AND PRO-
FESa10NSCODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7031.6 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (MW 4
O L AS OWN EROFTHE PIOPERTYOR MY EMPLOYEES WITH WAGESAS THEIR SOLE COMPENSATION,
WALL DO THE WORK( AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC 7041 BUSI-
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO DOES SUCH WORT( HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT MENDED OR
OFFEREDOFFEFlFOR SALE IF HOWEVER THE GULDiNO OR IMPROVEMENT ISSOLID WITHIN ONE YEAR OFCOMPLE-
TION. THE OWNETFBUJDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF E) SAL
O L AS OWNER OF THE PROPERTY AA EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC, 7044, BUSINESS AID PROFESSIONS CODE THE CONTRACTORS Li.
CENSE LAW DOES NOTAPPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO OONTRACTS FDA SUCH PROJECTS WITHAC.ONTRACTOR(S) LICENSED PURSUAHTTO THE CONTRAG
TOWS LICENSE LAW}
01 AM EXEMPT UNDER SEC. B. E P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAA LICENSED TINDER PROVISIONS OF CHAPTER
3 (COMMENCING WITH SECTION TOM) OF DIVISION S OF THE BUSINESS AND PROFESSIONS CODE. AND
;;:;�;r_n
FECT.DATE —b CONTRACTOR1-9
i
WORKERS' COMPENSATION DECLARATION
I
I HEiEBYAFFYW UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS
I _I HAVE AND WILL MANTA"ACERTIFiCATE OF CONSENT TO SELF-WCURE FOR WORKERT
COMPENSATION, AS PI OMED BY SECTION 3700 OF THE LABOR CODE FOR THE PERFORMANCE
OF THE WORK FOR WNNN THIS PERMIT IS ISSUED.
i
_I HAVE AO WILL "WAN WORKERS' COMPENSATION INSURANCE AS REQUIRED BY SECTION
3700 OF THE LABOR CODE. FOR THE PERFOrMANCE OF THE WORK FOR WHICH THIS PERMIT IS
fISSUEa MY COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
f:AfiiLTA �✓Tr' &)D
! POLICY NUMBER OD 157, gn—
(TMSECDCNIEEDWT8E0OIR OF4f PERMD OFORONER*CfiEDMIARSa1001ORLES 4
I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I
3 SMALL NOT EMPLOY ANY PERSON N ANY MANNER 50 AS TO BECOME SUBJECT TO THE
j WORKERS COMPENSAT CN LAWS OF CALIFORNIA. AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKER& COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE — - APPLICANT: s
WARNING: FAAURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL BE
SUBJECT AN EMPLOYER TO GUMWAL PENALTIES AND CPAL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS ISIo0,om). IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR N
J SECTXNN 37060E THE LABOR CODE INTEREST, ANDATTORNEYS FEES,
J CONSTRUCTION LENDING AGENCY
1 HEREBY AFFIRM LINGER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3007, CIV. GI.
3
LENDER'S NAME
LENOERSADDRESS
z
U (CERTIFY COMPLY
ALLTHIS CITY ANDCUNTY ORDATETHATND STATE
T CORRECT.
L IAOREETO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING iO BUILDING
L CONSTRUCTION. AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
3 �W� kwr/A)C TivC .
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