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Home My WebLink About17301 - 23702 SILVER SPRAY (2)- CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES a ¢ 21825 E. Copley hive (909) 860-3195 Fax (909) 861-3117 \' BUILDING PERMIT APPLICATION TE ADDRESS .23 U- OJ� — APN LOT TRACT OWNER ADDRESS � "- ' CITY�IP TEL APPLIC N yt��' TEL. CONTRACTOR ADDRESS --- ::: -7:::�J� CITY ZIP TEL. ARCH/ENG/ DESIGNER ADDRESS CITY ZIP _ TEL. OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS 1 I1 CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANYCITYon COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT, ALTER, IMPROVE, DEMOLISH, OR REPAIRANY STRUC- TURF, PRIOR TO ITS ISSUANCE, ALSO REQUmES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS U- CENSE LAW (CHAPTER 9 SHE WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESSAND PRO. FESSIONS CODE) OR THAT HE OR SHE 15 EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TK)N. ANY VIOLATION OF SECTION 7031.5 BYANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT 70 A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($SW).)! ❑ 1, AS OWNER OFTHE PROPERTY, OR MY EMPLOYEES WITH -WAGES AS THEIR SOLE COMPENSATION, WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSI- NESSAND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOTAPPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED SALE, IF, HOWEVER, THE 13UI'LDINGOR IMPROVEMENTIS SOLD WITHIN ONEYEAROF COMPLE. TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE. DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). n I, AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI- DENSE LAW DOES NOTAPPLYTOAN OWNER OFAPROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH.A CONTRACTORS) LICENSED PURSUANTTO THE CONTRAC- TORS LICENSE LAW.). ❑ T AM EXEMPT UNDER SEC. —B. 9 RC-FORTHIS EASON DATE L OWNER -r _ LICENSED COMLRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS IN FULL FORCE AND EFFECT. LICENSE CLASS LIC. NO. DATE CONTRACTOR WORKERS' COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' COMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LA13OR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. _I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY SECTION 3700 OF THE LABOR 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 (THIS SECTION NEED NOT BE OOMPLETEDOF7HE PERMIT IS FOR CNE HUNDRED DOLLARS (S1 DD)OR LESS). I CERTIFYTHAT IN THE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKERS' CCMPENSATION LAWS OF CALIFORNIA, AND AGREETHAT IF I 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: FAILURETO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (5700,0W), IN ADDITION TOTHE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, ANDATTORNEY'S FEES, CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED (SEC. 3097. CIV. C.), LENDER'S NAME LENDERSADDRESS CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OFTHIS COUNTY TO ENTER UPON THE ABOVE -MENTIONED PROPERTY FOR INSPECTION PURPOSES. -PERMITTEE N E (P SIGNA O DATE t PRESS FIRMLY APPLICATION (y� PERMIT A' Q P/C DATE i� ttti NUMBER it ISSUE /'► TYPE OCC DATE C.� CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR Cl SIDE/SIDESTREET RW ❑ SIDE ❑ PROPOSED USE g I NO. DWEL, NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. 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