HomeMy WebLinkAboutPR20210000295EMcc # 1690652463
5/12/21
PERMIT i$: PR202100t00295
OWNER.BUII.DER DICLARATION
I herel:y affirm under penalty of perjury that I am e(empt from the contractor's state License Law for the rr:asc,n(s) indir::atedbelow by the checkrnark(s) I have placed ne)ft to th(: applicable item(s) [Section 70:1j..5, Business and profe:;sions code: /\ny
city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also
require:; the applicant for the permit to file a signed statement that he or she is licensed pursuant to the provisions of the
contrilctors'State License Law (Chapter 9, Commerrcingwith section 7000 of Division 3 of the Business and professions r3ode)
or thal he or she is L'xempt from licensure arrd the trasis for the alleged exemption. Any violation of Section 703L.5 by any
applic;lnt for a pernrit subjects the applicant to a civ'il penalty of not more than five hundred dojlars (9500).1:
(-) las owner of the property, or my employees with wages as their sole compensation, will do (_) all of or li_) F,ortions of thework, arrd the struclure is not intended or offered frrr sale. (Section 7044, Business iand professions Code: The contractors'
'State I icense Law does not apply to an owner of property who, through employees' or personal effort, builcts or improvcs theprope|ty, provided that the improvements are not intended or offered for sale. lf hr:wever, the building or improvement is
:;old within one year of completion, the Owner-Buikler will have the burden of proving that it was not built or improved 1'ort:he purpose of sale.l
{-) l, a:; owner of the property, am exclusivel,/ contrtcting wrth licensed Contractors to construct the projecl.. (Section 70.44,
Ilusines$ and Professions code: The Contractcrs'State License Law does not apply to an owner of property who builds orimprot'es thereon, and who contracts for the projects with a licensed contractor pursuant to the contractors,state License
l-aw.)
(-) | anr exempt from licensure under the Contractor's State License law for the follcrwing reason(s):
tly my sBnature below I acknowledge that, except for my personal residence in rarhich I must have resided for at teast oneyear plior to completion of the improvements coverred by this permit, I cannot legally sell a structure that I have built as an
owner'builder if it has not been constructed in its eltirety by licensed contractors. I understancl that a copy ofthe appl cable
law, Sec'tion 7044 of the Business and Profes:;ions Ccde is available upon request when this application is submitted or at thefollowi rlq Web site: frttp/www.leginfo.ca.govTicalaw. htm I
S]GNAI LIRE OF PROPERTY oWNER oR AUTHcIRIZED AGENT:DATE:
LICEIlSED CONTRACTOR'S DECLARATION
I hereb / affirm under penalty of perjury that I am licr:nsed under provisions of Chapter 9 (commencing with ljection 7000 j ofDivisiorr .3 of the Business and professions cocle, and my license is in full force and effect.
LICENSI: CLASS: C39 _ LTCENSE NUMBER: 916982
\,I/ARNIII]6: FAILURT TO SECURE WORKERS' COMPEN;ATION COVERAGE IS UNLAWFLJL, AND SHALL SUBJECT,AN IMPLOYE'R TOcRIMINAL PENALTIES Al\D clvlL FINEs uP To (lNE H|.JNDRED THOUSAND DoLLARS (:;i00,000), tN ADDtTtoN To'rHE cos-ti oFCOMPENSATION, DAIVAGES AS PROVIDED I.OR IN SECTION 3705 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
I IIEREBY AFFIRM UNDER PENALTY OF PERJURY ONE CF THE FOLLOWING DECLARATIONS:
I have and will maintain a certilficate of consent to self-lnsure for workers' compensation, issued Lry the
Director of Industrial Relations as provided for by Section 3700 ofthe Labor Code, for the perl,ormance oflhe,z work f or which this permit is is:;ued,
l/ I have and will maintain workers'compensation insurance, as requireri by Section 37oo of the Labor code, forthe performance of the work for which this permit is issued. My workers' compensation insur;lnce carrier andpolicy number are:
cARRrElt: state compensation Insurance PoLlCy #: '1 /l 3/-Zt'+o EXptRAloN DA!E, io { I f ).. I
, --::::----:-:---I{AME OF AGENT:97L3725
EX p I RA f l o N pArE : :-6Tr;r r>_.*=*ffi #ry==*
lcertifythat,intheperforrnanceoftheworkforwhichtt.i,o",';;;Til:il
subject t'l lhe workers'1:ornpensation laws of California, arrd agree that, if I should become subject to the workers,compensatronprovisiors ot section 3700 of the Labor Code, I shall forthwith comply with those provisions,
STGNATURE oF APPLIcANT:
DE.LARAT'or,r REGARDTTT.,G cor\rsrRrJcro*ofltio,r,, AGEr,rcy
-
I hereby;lffirm under penalty of perjury that there s a conr;truction lending agency for the performance oflhe work for which this per nit isissued (So(tion 8172, Civil Code).
LENDER'!i h]AME:
LENDER'5 /\DDRESS
By nry slgnature below, I ce'rtify to each of the foilorvirrg
I arn Ihe I)roperty owner or ;ruthorized t.J act on thF property owner s behali.
I have re.d this applicati0n and tire informatjon I have provicJed is correct.
I aiqree to comply with aii applicable city and county ordinaaces and state iaws relating to building construction.
I authorize representatives of the city of Diamond Bar to erter tl.re above-icientified property fcl]QlnNlATt OC nE bd^hrnrSIGNATL F,E OF PROPERTY oWNER oR AUTHoFIIZED AGENT: J