HomeMy WebLinkAbout15023 (8)CITY OF DIAMOND BAR
DEPART14ENT OF COMMUNITY & DEVELOPMENT SERVICES
e 21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
BUILEIING PERMIT APPLICATION
JOBSITE
ADDRESS ( 5 Z / x/
APN LOT- TRACT
OWNER - i
ADDRESS Z .D
C 4fL1,16,A9 :60 IP TEL C3
APPLICANT TEL
CONTRACTOR C y
ADDRESS L
CITY ILES ZIP TEL
ARCVUENGI
DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION
I HEREBY AFFBW UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS U.
DENSE LAW FOR THE FOLLOWING REASON (SEC. MIS BUSNESSAND PROFESSIONS CODE ANYCITYOR
COUNTY YMICHREOUIRESAPEWARTO CONSTRUCT.ALTER WPROVE DEMOL:St OR REPAIR ANY STRUC-
TURE. POOR TO OS ISSUANCE. ALSO REQUIRES THE APPLICANT FOR SUCH PEAWT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LL
CENSE LAW (OWTER a (OOMMENCINO VATH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO.
FESSIONS CODE) ORTHAT HE OR SHE IS EXEMPT THEREFROMAND THE BASIS FORTHE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 70316 BY ANY APPLICANT FOR A PERMIT SUB.IECTS THE APPLICANTTO
A CIVIL PENALTY OF HOT MORE THAN FIVE HUNDRED DOLLARS
0 k AS OMNER OF THE 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. 70a4. 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 WORK HIMSELF OR HERSELFOR
THROIXN HIS OR HER OWN EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT MENDED OR
OFFERED FOR SALE IF. HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITWN ONE YEAR OF COUPLE-
• TION. THE OWNERIFULDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
"PROVE FOR THE PURPOSE OF SALE,
❑ I. AS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 70N, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS U.
DENSE LAW DOES NOT APPLY TO AN OWNER OF APROPERTY WHO BOLDS OR IMPROVES THEREON. AND
INTO CONTRACTS FOR SUCH PROJECTS WI TH A CONT RACTOR(S) LICENSED PURSUANT To THE CONTRW,
TORS LICENSE LAW.).
O NAM EXEA6PT UNDER SEC. B. 3 P.C.FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
THEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER
S ICOLBMENDNO WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE AND
MY LICENSE IS N FULL FORCE AND EFFECT. �j /
LICENSE CUSS LID. NO. & , LL
DATE 10 CO
NTRACTOR L-
WORKERS' COMPENSATION DEC ON
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FO110 NO DECLARATION /
�IHAVE AND WILL MANTANACERTIFICATE 6FCOHSEM TOS YSURE FOR IW7fLCEriS'
DOMPEWATION. AS PROVIDED BY SECTION 3700 OF THE LIBOR RTHE PERFO
OF THE WORK FOR V&XM THIS PERMIT IS ISSUED.
_I HAVE MIND WALL MAINTAIN WORKERS' COMPENSATION INSURANCE. AS REWIRED BY SECTION
3700 OF THE LABOR CODE FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
155UFA W WORKER ' COMPENSATION NSLTANCE CARRIER AND
POLICY NU MBE
CARRER
POLICY NUMBER
(i)65SECf1CNNE®NOT 6EQJAPIETEDOF TLEPFir.ETBFOfiONE14,NOtiFD RI )OR,
1 CERTIFY THAT N THE PENFORIMNCE OF THE WORK FOR WHICH THIS PERMIT
SHALL NOT EMPLOY ANY PERSON N ANY MANNER 50 AS TO BECOME SUBJECT TO THE
WORKERS' COMPENSATION LAWS OF CAUFORNIA AND AGREE THAT IF I SHOLtD BECOME
SUBJECT TO THE W'ORI(F0.S COMPENSATION PROVISIONS OF SECTOR 7700 OF THE LABOR
COOE.1 iORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE: APPLIDATIT: L
WARNING: FALURET SECURE WORKERS' COMPENSATION COVERAGE U WRA. AN S BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP T HUNDRED OUS iD
DOLLARS(i100.000). N ADOITIONTO THE COST OF COMPENSATON.D ASPROVO W
SECTION 3709 OF THE LABOR CODE NTEREST. AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
1 HEREBY AFFIRM USER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. MI. CIV. C.).
LENDERS NAME
LENDERSADORESS
1 CERTIFY THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 AGREE TO COMPLY WITH ALL CRY AND COUNTY ORDINANCES AND STATE LAWS P-ELA7 WG TO BUILDING
CONSTRICTION. AND HERESY AUTHOWE OWE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE -MENTIONED PROPERTY FOR INSPECTION PURPOSES.
PERIITTEENAME(PRI" I
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SNGNAH)REOFp EE DATE
PRESS
FIRMLY
APPLICATION vO PERMIT P/C Q 671a
DATE NUMBER #
ISSUE �jj_�1 ,{ TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
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PROPOSED USE
NO. DWEL NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION
SO. FT.
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RETENTION FEE:
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COMMENTS
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RECPL NO. PAID BY VALIDATION
WHITE Ktment Copy. YELLOW—Fhance Copy, PINK —Assessor Copy. GOLDENRODL-File Copy. GREEN—Appiicant's Copy
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