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HomeMy WebLinkAbout15039 (20)CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190 (909) 860-3195 Fax (909) 851-3117 BUILDING PERMIT APPLICATION JOBSITE J ADDRESS �D CAM ©/ CIZL-ST APN LOT TRACT OWNER c- E ADDRESS <; fel - CITY ZIP TE APPLICANT'Testi( IL L E TEL CONTRACTOR 113r1-l.ONIi MbT—i jGt ADDRESS Ib to r-bA & (_t' 117 /Z CITY Ti [ /3 ZIP TEI 1 I -7t 14 ARCHIENG/ DESIGNER ADDRESS CITY ZIP TEL OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LL CENSE LAW FOR THE FOLLOWING REASON (SEG 7031.6 SUSINESSAMC PROFESSIONS COOS ANY CITYOR COIANTY WOCH FIEOLARESAPERWTTO CONSTRICT,ALTER OMPROVE-DEMOUSH,OR MPMRANY STR/O TURF PRIOR TO RS ISSUANCE- ALSO RECULAFS THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT TWIT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LL CENSE LAW ICWTER 6 (COMMENCING WITH SECTION 7000) OF DIVISION 3OF THE BUSINESS AND PRO- FESSIONS CODE) ORTHAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED MUN T1CN.ANY VIOLATION OF SECTION 7031.6 BY ANYAPPL CANT FOR A PERMIT SUBJECTS THE APPLICANT TO ACNE PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (650)): ❑ L AS OVMEROFTHE PROPERTY, OR MY EMPLOYEES MTN WAGES ASTHEIR SOLE COMPENSATION. WILL DO THE WOIL MID THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SME (SEC. 70N. BUSF NESS NO PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON. AND WHO DOES SUOF WORK HIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT MENDED OR OFFERED FOR SALE IF, HOWEVER THE BUILDING OR IMPROVEMENT O SOLD WITHIN ONE YEAR OF COUPLE - TICK THE OWNER43UUER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE 00 NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE} O L AS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS - TO CONSTRUCT THE PROJECT (SEG 704-4. BUSINESS AND PROFESSIONS CODE THE CONTRACTORS u. CENSE UW DOESNOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON. AND WRD CONTRACTS FORSUCHPRDJECTS MTHACONTRACTOR(S) LICENSED PURSUANT TO THE COiTRAC- TORS LICENSE LAW.} O 1 AM EXEMPT UNDER SEG B. 6 P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PEFUUFIY THAT 1 AM LICENSED TINDER PROVISIONS OF CHAPTER 0 (OOMMENCNO WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS COOF, AND MY LICENSE S N FULL L FORCE•AZND EFFECT. / 2 7 �7 [� LICENSE CLASS C , �7EFUC. NO. V -/ z - DATE I I 17 AM V CONTRACTOR TT WORKERS' COMPENSATION DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:, .r _I HAYE MID WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELHNSURE FOR WORKERS COMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THOS PERMIT IS ISSUED. I HAVE AND WILL MAINTAIN WORKERS COMPENSATION INSURANCE AS REWIRED BY SECTION 3700 OF THE LABOR COOS. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT S ISSUED. MY WORKERS COMPENSATION INSURANCEACARRIER AND POLICY NUMBER ARE: CARRIER - POLICY NUMBER W 220 (MSSECTIONNE®NOT BEcomFLETEDOFTHE PE RAT s FORONE KSCRFDDOLLARS 01100)CRLESS} I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SMALL NOT EMPLOY ANY PERSON N ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKERS COMPENSATION LAWS OF CALIFORNIA. AND AGREE THAT F 1 SHOULD BECOME SUBJECT TO THE WOPAERS' COMPENSA7ION PROVISIONS OF SECTION 37000E THE LABOR CODE 1 SHALL FORTHWITH COMPLY WITH THOSE PROVISION& DATE c. ( I I &S4 IG --I. 4'--1. WARNING: FAILURE TO SECURE WORKERS COMPENSATION COVERAGE IS UNLAWFUL AND SHALL BE SUEJECTAN EMPLOYER TO CRMNAL PENALTIES AND CML FINES UP 70 ONE HUNDRED THOUSAND DOLLARS IS00 IoD,D} N ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR N SECTION 3708 OF THE LABOR CODE, INTEREST. AND ATTORNEYS FEES CONSTRUCTION LENDING AGENCY 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FDR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEG 3007. GV. G} I LENDERS NAME LENDERSADDRESS 1 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THATTHE ABOVE INFORMATION IS CORRECT. I AGREE TD COMPLY WITH ALL CITY AND COUNTY ORDNANCE$ AND STATE LAWS RELATING TO BULDING N CONSTRUCIK. AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES s I ( ( rj PERMITTEE NAME IF 6IGNATUReGFPENZnEE DATE PRESS FIRMLY APPLICATION1 V0 PERMIT n P!C DATE 1 NUMBER # ISSUE � TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDEISIDE STREET RW ❑ SIDE ❑ PROPOSED USE T c j�r_ 0%X11 I L Wb -0 -I rJ /t . F- rN NO. DWEL NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. 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