HomeMy WebLinkAbout15391 - 2047 1 2 3 GALVIN (2)CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909)860-3195 Fox (909) 861-3117 PRESS
w BUILDING PERMIT APPLICATION FIRMLY
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ARCHlENG1
DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LL
CORSE LAW FOR THE FOLLOWING REASON (SEC. 7031.6 BUSINESS AND PROFESSIONS CODE ANY CITY OR
COUNTY WHICH REOUWESAPEIWRTO CONSTRUCT,ALTERIMPROVE, DEMOUSK OR REPAIRANY S_
TUBE, PRIOR M 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 LL
CENSE LAW (CHAPTER P (COMMENCING WITH SECTION 7WO) OF DIVISION s of THE BUSINESS AND PRO-
FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMIX
TION. ANY VIOLATION OF SECTION 7DT1 A BY ANY APPLICANT
FOR APERMIT SUBJECTS THE APPLICANT 70
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (6S00) ):
01,AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILLDO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7NN, SUSI.
NESS AND PROFESSIONS CODE THE CONTRACTORS LICENSE LAWDOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUJDS OR OWPRDVES THEREON NQVV W ELF DOES SUCH WORN HIMSELFOR HERSOR
THROUDH HIS
S OR HER OWN EMPLOYEES, PROVIDED THATSUCH AIPROVEMENTSAiE NOT MENDED OR
OFFERED FOR SALE F. HOWEVEFLTHE BWDWGGA UPROVEMEMIS SOLDMTM ONEYEAROF COMPLE-
TON, THE OWNERBUIDER WILL HAVE THE BURDEN OF PROVING THAT HE OR ONE 00 NUT BUID OFI
IMPROVE FOR THE PURPOSE OF SALEI
O LAS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC 7014, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS FOR SUCH PHOIECTS WITH ACONHAC70RUS) LICENSED PURSUANT TO THE OONTRAC-
TORS LICENSE LAW4
O 1 AM EXEMPT UNDER SEC. B. A P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIAM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
F ICO M04CM WITH SECTION 7000) OF DIVISION 7 OF THE BUSINESS AND PROFESSIONS CDDE. AND
MY LICENSE IS INFULL FORCE AND EFFECT.
ucENs1: uAss � uG. N.
DATE CONTRACTOR
WORKERS' COMPENSATION D TI N
I HEREBYAFFWMUNDER PENALTY OF PEWITYCNE OFTHE DECLARATIONS:
I HAVE AND WILL MAINTAIN ACERTFK:ATE OF CONSENT TO SELFWSURE FOR WORKERS'
COMPENSATION AS PF13MED BY SECTION 3700 OF THE LABOR CODE, FOR THE FERFOPAVNCE
OF THE WORK FOR WHICH FMCS PERMIT 15ISSUED.
I HAVE AND WILL MAINTAIN WORKERSCOMPENSATION INSURANCE. AS RECUOLED BY SECTION
3700 OF THE LABOR CODES FOR THE pWDRMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS' ODMPENSATON INSURANCE CARRIER AND POLICY NUMBER ARE
CARRIER
IQ
POLICY NUMBER S ^1 C)
UMSB=ONNIEMNOT BECa.FLETEODF RE PEF#OIS FORCNE MN FIEDML ARLS(SIOD)ORLEOOI
1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I
SHALLNOi EMPLOY ANY PERSON N ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS' COMPENSATION LAWS OF CALIFORNIA. AND AGREE THAT F 1 SHOULD BECOME
SUBJECT TO THE VIOWSAS' COMPENSATION PROVISIONS OF SECTION 31W OF THE LABOR
COOL I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE: APPLICANT.
WARNING: FAILURE TO SECURE W'OPAERW COMPENSATION COVERAGE IS UNLAWFUL AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP 70 ONE HUNDRED THOUSAND
DOLLARS (F100.0D0), IN ADDITONTO THE CAST OF COMPENSATION, DAMAGES AS PROVIDED FOR N
1 SECTION 570E OF THE LABOR COOL NTEREST, AND ATTORNETS FEES.
1 CONSTRUCTION LENDING AGENCY
i
1 HEREBY AGF0T11 UNDER PENALLY OF PERAJRY THAT THERE IS A CONSTRICTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED (SEC 0007, UV. C).
j LENDERSHAME �
LENDERSADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 AGREE TO COMPLY VATH ALL CRY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
3 CONSTRUCTION AND HEREBY AUTHORIIE
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