HomeMy WebLinkAbout15047 (20)CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUELDI NG PERMIT APPLICATION
JOBSITE
ADDRESS CA I b0 V rr► Q r'
APN LOT TRACT
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CITY
YCITY DIA,,,,I l,.,r ZIP Si� TEL 909 .'79 Y3,U
APPLICANT-)Ay,Br A.,e«rWY,WJr_ TEL $167015'03'7
CONTRACTOR Q_ Q r,& I e Re>r j 'tom
ADDRESS
CITY 0 O1"ci D•,s- r ZIP _CQ_ TEL $TS 70 ISOJ7
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DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION
I HEREBY AFF04 UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FRCM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7071.6 BUSINESS ANO PROFESSIONS ODDE:ANY CITYOR
COUNTY VI4KN REQUIRES APERMITTO OONSTRUCT,ALTER, IMPROVEDEMOUSH, OR REPAIR ANY STRUG
TU1RE PRIOR TO ITS ISSUANCE ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FEE A SIGNED
STATEMENT TWAT HE OR SHE /S LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LF
CENSE LAW (CHAPTER 6 (COMMENCM WITH SECTION 7000) OF DIVISION S OF THE BUSINESS AND PRO•
FUSION$ CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EKEMP-
..ANY VIOLATION OF SECTION 7041,6 BY ANY APPLICANT FOR A PERMIT SVBJECTS THE APPLICANT TO
ACRALPENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (25W).}
C1 LAS OWNER 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. 7044, BUST.
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
THRDUDH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED CR
OFFERED FOR SAE IF, HOWEVEFL THE BUILDING OR IMPROVEMENT LS SOLO WIT"ONE YEAR OFCOMPLE-
TION, THE OWNEROUILDER WILL HAYE THE BURDEN OF PROVPO THAT HE OR SHE 00 NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE}
O L AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTNO WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEG 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U-
CERSE LAW DOESNOTAPPLY To AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON. AND
WH OCOHTRACrS FOR SUCH PROJECTS WITHA CONTRACTOR(S) LICENSED PURSUANT 70714E CONTRAC-
TORS UCENSE LAW.).
O 1 AM D(EMPT UNDER SEC B. I P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIFM UNDER PENALTY OF PERRURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
I (COMMENCED WITH SECTION 7000) OF DIVISION S OF THE BUSINESS AND PROFESSIONS CODE. AND
MY LICENSE IS N FULL FORCE AND EFFECT.
LICENSE CLASS 9 LIC. NO. v
DATE I I 1 CONTRACTOR
WORKERS' COMPENSATION DECLARATION
1 HERESY AFFIRM UNDER PENALTY OF PERAXTL' ONE OF THE FOLLOWING DE a
_I HAVE AND WELMANTANACERnFICATE OF CONSENTTO SELF-INFFRS'
COMPENSATION. AS PROVIDED BY SECTION 4700 OF THE LABOR CODE, FFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
_I HAVE AND WILLMANTAN WORKERS COMPENSATION INSURANCEAS RECUR YSECTON/
3700 OF THE LABOR COLE FOR THE PERFORMANCE OFTHE WORK FOR THISPERMRIS
ISSUED, MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLI ]NLUBERARE'.,-�
CARRIER
POLICY NUMBER O S / a1 O
(IFLSSECTIONlEEDNOTBECOMPETEDOFTFE POW S FOR on£Wt370-OOF
tLABOR
I CERTIFY THAT N THE PERFORMANCE OF THE WORK FCR WHICH THI
SHALLIOT EMPLOYANY PERSON NANT MANNER SOAS TO BECOMEWORKERS' COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT ISUBJECTTOTHE WORKER5COMPENSATION PROVISIONS OF SECTIO
CODE I SHALL FORTHWITH COMPLY WITH THOSE PP S S.
DATE: �' / o O APPLOANT: //-
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL BE
SIRUECTAN EMPLOYER
PRESS
FIRMLY
APPLICATION l PERMIT 5011 /C
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