HomeMy WebLinkAbout20612
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CITY OF DIAMOND BAR
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DEPJARTII~NT OF COMMUNTfY 8c DEVELOPMENT SERVICES
21825 E. Copley Drive`~
(909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION
PRESS
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APPLICANT TEL.
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OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROfI THE CONTRACTORS L4
CENSE UW FOR THE FOLLOWNG REASON (SEC.7037.5 BUSW ESSAND PROFESSIONS CODE ANY GTY OR
COUNTY WHICH REONRESAPERMRTOCONSTAUCT,ALTER, IMPROVE DEMOLISH, OR REPAIRANY S7RUG
TORE, PRgp TO ITS ISSUANCE. ALSO REOUBiES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMEM TWIT HE OR SHE IS LICENSED PURSUANT TO THE PROWSKNiS OF THE CONTRACTORS LF
CENSE UW (CHAPTER B (COMMENCWG WITH SECTON 7000) OF DIVISION 3 OF THE BUSNESS AND PRG
CESSIONS CODE) OR THAT HE OR SHE IS EXFJJPT THEREFROM AND THE BASIS FOR THE ALLEGED EXELIP-
TX7N, ANVVIOLATION OF SECTION 7031,5 BY ANYADPIICMlT FOR APERMIT SUBJECTS THEAPPLICMIT TO
A CML PENALTY OF NO7 MORE THAN FNE HUNDRED DOLLATiS (f600).):
O L AS OWNER OFTHE PROPERTY, OR MY EMPLOYEES WITH WAGESAS THEIR SOLE COMPENSATpN,
WNL DD THE WORK, AND THE STRUCTURE LS NOT NTENDED OR OFFERED FOR SALE (SEC. 704{, BUSF
NESS MID PROFESSIONS CODE: THE CONTRACTORS LICENSE UW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUMS OR IMPROVES THEREON. AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
1HR000H HIS OR HER OYJN EMPLOYEES, FRONDED THAT SLiCH IMPROYEMENTS ARE NOT NTENDED OR
OFFERED fURSALE IF, FIDWEVER THEBIALOWGORtlAPROYEMENT ISSOLD WRMW ONEYEAROFCOMPI.E•
TION, THE OWNER~l1UDER MILL HAVE THE BURDEN OF PROVNG THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR 7NE PURPOSE OF SALE}
^ I, AS OWNER OF THE PROPERTY. AM FJICLUSIVELY CONTRACTNG WTTN LICENSED CONTRACTORS
T(0 CONSTRUCT THE PROJECT (SEC. 7011, BUSWESS AND PROFESSIONS CODE: THE CONTRACTORS LI-
CENSE UW DOES NO7APPLY TO AN OWNER OFA PROPERTY WHO BUfDS OR IMPROVES THEREON, AND
WHO CONTRACTSFOR SUCH PROTECTS WTMACONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAG
rocs ucENSE uw.).
^ 1 AM EXEMPT UNDER SEC. B. 8 P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PEiUUAY THAT 1 AM LICENSED UNDEA PROVISKNS OF CHAPTER
9 (COMMENGNG VATT1 SECTION 7W0) OF ONISKX~13 OF THE flUSINESS ANLI PROFESSONS f.ODE, MID
MY LK~t15E IS N FULL FORCE A
ND EFFECT.
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-- ~ 1 ~ 3 WORKERS' COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING OECURATK)NS:
_I NAVE ANO WILL MAINTAN A CERTIFICATE OF CONSENT TOSELF-WSURE FOR WORKERS
COMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOFi WHICH THIS PERMIT IS ISSUED.
_ I NAYE AND WILL MAINTAW WORKERS' COMPENSATK7N INSURANCE, AS REQUIRED BY SECTKJN
37000E THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS' COMPENSATKNI INSURANCE CARRIER AND POLICY NUMBER ARE:
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CARRIER i !~1`r~ /t''~ rY ~ n
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POLICY NUMBER DD J ~~~
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STFfs SECTDN NE®NOT BE mAPLEr®OF THE PETif T S FOR Ot'E HUODIiED ODLLMiS gt0o1 OR LF>;sl
I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I
SHALL NOT EMPLOY ANY PERSON W ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS' COMPENSATgN UWS OF CALIFORNIA, ANO AGREE THAT IF 1 SHOULD BEGONE
SUBJECT TO THE NK)RKERS' COMPENSA710N PROVISIONS OF SECTK7N 37x0 OF THE LABOR
DE,ISHALL FORTHWITH COMPLY WITH THOSE PROVISKXJS.
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DATE: / ~->2r'o ~ APPLICANT. ~~ L
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WARNPI~FAILU E TO SECT E WORKE S' COMPENSATION COVERAGE IS UNIAWFU4 AND SHALL BE
SUB.IECT AN EMPLOYER TO CR4INAL PENALTIES AND CTV0. FNES UP TO ONE HUNDRED THOUSAND
DOLl/IRS {ftoo,oooV. W ADDITION TO THE COST OG OOMPENSATK#1, DAMAGES AS PROVIDED FOR N
SECTK)N 3709 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
1 HEREBY AFFIRM UNDER PENALTY OF PERIVRY THAT THERE LS A CONSTRUCTION LENDWG AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT L4 ISSUED (SEC. 3097, GV C.),
LENDER'S NAME
LENDERS ADDRESS
1 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE NF'ORMATDN IS CORRECT.
I AGREE TO COMELY WITH ALL CITY AND COUNTY ORDNANCES AND STATE UWS RELATING TO BU0.DING
CONSTRUCibN. AND HEREBY AUTHORIZE fiEPRESENTATNES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTKINFA PROPERTY FOR INSPECTION PURPOSE
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