HomeMy WebLinkAbout17790 - 427 N PATINA DR4 CITY OF' MOND BAR
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DEPART21i,_1'1T OF COMMUNITY & DEVELOPMENT SERA . :;S
E. Copley Drive
(909) '�(909) 860-3195 Fax (909) 861.31l7
BUILDING PERMIT APPLICATION
JOBSITE
ADDRESS �% • . !S
APN LOT TRACT
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APPLICANT TEL.
CONTRACTOR
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CITY:
ARCFUENG!
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERMAY THAT I AM EXEMPT FROM THE CONTRACTORS LL
CENSE LAW FORTHE FOLLOWING REASON (SEC. 7031,S BUSINESS AND PROFESSIONS COCE: ANYGTY OR
COUNTY WHICH REOUIRESA PERMIT TO CONSTRUCT, ALTER IMPROVE. DEMOLISH• OR REPAIRANY STRUC•
TIRE PRIOR TO ITS ISSUANCE. ALSO REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE CA SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LF
CENSE LAW (CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION 0 OF THE BUSINESS AND PRO.
FESSIONS CODE) OR THAT NE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THEµLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7031.5 BY ANYAPPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CINI PENALTY OF NOT MORE THAN FIVE HUNDREO DOLLARS ($Wet):
O L AS OWNER OFTHE PROPERTY, OR MY EMPLOYEES WITH WAGESAS THEIR SOLE COMPENSATION,
WILL DO THE WORK. AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 704A SUSI•
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
LN PROPERTYIOBUILDS OR IMPROVES THEREON.AVD WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF. HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAROFCOMPLE-
TION. THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE 010 NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALn
O L AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WATH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 7044. BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI•
CENSE LAW DOES NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON. AND
WHO CONTRACTS FOR SUCH PROJECTS WITHACONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC.
TORS LICENSE LAW.).
O 1 AM EXEMPT UNDER SEC B L PC FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
IT (CDMMENCINO WITH SECTION TWO) OF DIVISION O OF THE BUSINESS AND PROFESSIONS CODE AND
MYUCENSE IS INRAJ. FORCE AND EFFECT.
LICENSE CUSS C a'1--CI� U0. NO. % 0
DATE JQ — cl l CONTRACTOR
WORKERS' COMPENSATION DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
_I NAVE AND WILL MAINTAN A CERTiRCATE OF CONSENT TO SELF -INSURE FOR WORKERS'
COMPENSATION. ASPROVIDED BY SECTION7700 OF THE LABOR CODE. FOR THE PERFORMANCE
�OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
Y 1 HAVE AND WALL MANTAN WORKERS- COMPENSATION INSURANCE, AS REOURED BY SECTION
3700 OF THE LABOR CODE FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS -COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE.
CARRIER •T, r�y�' 1
POLICY NUMBER •S J ^ ,�/
(R6SECA ON NEEDNOTBE OCAilmOF" PERMIT IS FOR ONE HLAMO DOLLARS 3100) OR LM%
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS' COMPENSATION LAWS OF CALIFORNIA. AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE.1 SHALL
LIJFORTHWITH COMPLY WITH THOSE PPRONSIONS.
DATE::: ^ 'F-�il APPLICANT: _ ` 4 S L•-t!L 0
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (st WOW)• N ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN
IO SECTN 3703 OF THE LABOR CODE. INTEREST, AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
1 HEREBY AFFIRM UNDER PENALTY OF PERAIRV THAT THERE IS A CONS rFIUCTICN LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097, CIV C.I.
LENDERS NAME
LENDERS ADDRESS
I CERTIFV THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 AGREE TO COMPLY VATW ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION, AND HE REBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE MENTIONED PROPERTY FOR INSPECTION PURPOSES.
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SIONATUREOF PERMITTEE DATE
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APPLICATION,
DATE/S�'J"
PERMIT -+ PIC
NUMBER 74� M
ISSUE
TYPE
OCC
DATE
CONST.
GROUP
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WHITE —Department Copy, YELLOW—FnanCe Copy. PINK —Assessor Copy. GOLDENROD —File Copy. GREEN—ApplicanCs Copy
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