HomeMy WebLinkAbout14923 (19)DIVIONU IIAK
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
ADDRIEE / 1� �,� �i Tis
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APN LOT T Y TRACT
OWNER �.
ADDRESS S
CITY ZIP TEL
APPLICANT TEL
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DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERURY THAT 1 AM EXEMPT FROM THE CONTRACTORS UI
CENSE LAW FOR THE FOLLOWING REASON (SEC 7031.6 BUSNESSAND PROFESSIONS CODE ANY CJTYOR
CCLOM V"CH REOUIRESAPEWrTM OONSTRUCTALTER IMPROVE DEMOUSH.OR REPAIR ANYSTRUC.
-TURF, PRIOR TO ITS ISSUANCE ALSO REQUIRES THE APPLICANT FOR SUCH PERAMT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LL
CENSE LAW (CHAPTER. (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO.
FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7031.6 BY ANY APPLIJ1Nr FORA PERMIT SUBJECTS THE APPLICANT TO
A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (SSW)l:
D LASOWNER OF THE PROPERTY. OR MY EMPLOYEES WITH WAG ES AS THEIR SOLE COWENUTIDN,
WALL DO THE WORIL AND THE STRUCTURE IS NOT NTENOED OR OFFERED FOR SALE (SEC. 7044. BUS4
NESS AND PROFESSIONS COOS THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BULDS OR IMPROVES THEREOKAND VA40 DOES SUCH WORK HIMSELF OR HERSELF OR
TINOIOH HIS DR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT MENDED OR
OFFERED FOR SALE IF HOWEYER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE Y EAROF COUPLE.
TION, THE OWMERBUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE 00 NOT BUILD OR
NPROVE FOR THE PURPOSE OF SALE)
O LAS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CDNSTRUCT THE PADJECT (SEC. 70". BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI
CENSE UW DOES NOT APRT TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON. AND
YYf10 CON(IRACTS FOR SUCH PROJECTS WITH LICENSED PURSUANT TO THE CONT RA-
TORS UCENsE LAW.),
D IAM EXEMPT UNDER SEG B. S P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER
B (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE AND
MY LICENSE IS N FLAT FORCE AND EFFECT. (�� -
LICENSE G UC. NO. -
DAIS
CONTRACTORSX. (�l�Nf'%(�F1NR17ni
WORKERS' COMPENSATION DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS
-I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELFdNSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BY SECTION 37W OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE IO
AS REQUIRED BY SECT
37000E THE LABOR CODE FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS' NSATION INSURANCE CARRIER AND POLICY NUMBER ARE. -
6
CARWER ^ O
POLICY NUMBER ,..F fir' "-
(THSSECRDN NDONOTSECCLF ETEDOF TK PLFMT S F0RCM HL.ELIReDDaLARS (5100)CRLES4
I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS SSUED.I
SHALL NOT EMPLOY ANY FEPSON N ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS' COMPENSATION LAMS OF CALIFORNIA AND AGREE THAT IF I SHOULD BECOME
SUaJECTTO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
LODE. SINML TMYITH COINPLY WITH INCISE PR SI�ONS.F�
IDA
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE
SUBJECT AN EMPLOYER WAINM
TO CAL PENALTIES AND CL F W ES UP 70 ONE HUNDRED THOUSAND
DOLLARS (3100,(IoOt N ADDITION TO THE COSTOF OOMPENSATION. DAMAOE3AS PROVIDED FOR N
SECTION 3700 OF THE LABOR CODE. INTEREST. AND ATTORNEYS FEES,
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCT" LENDING AGENCY
FOR THE PERFORMANCE OFR WHICH THI�RM/1fVI ,IS ISSUED (SFC. 3097, GV. C}
LENDERS NAME
LE NO ERS ADDRESS tE
1 CERTIFY THAT I HAYE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 AGREE TO COMPLY WITH ALL CRY AND COUNTY ORDINANCES AND STATE LAWS RE ATWO TO BUILDING
CONS7RUCTK)K AND HEREBY AUTHORIZE REPRESENTATIVES OF TNS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPS TY FOR INSPECTION PURPOSES
PERAUTTEE NAME ( RINT) —
SIGNATURE OF PEHMNTEE V OA
PRESS
FIRMLY
APPLICATION Q 0J PERMPic
DATE �J �4l �� VV NUMBER
ISSUETYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ❑
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SIDE/SIDE STREET RW ❑
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P POSED US
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NO. DWEL NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF ADJ. AREAIVALUATION
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QUANTITY DESCRIPTION FEE
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RETENTION FEE:
PRE -ALT FEE:
TOTAL FEES IT6_
COMMENTS
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RECPT. NO. PAID B VAUDATION
WHITE--Depenment Copy, YELLOW—Fnenca Copy, PINK—,Assessor Copy, GOLDENROD—File Copy, GREEN—AppikarA'S Copy
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