HomeMy WebLinkAbout15012 (17)J� 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
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APPLICANT WLi l `'f�B-G. h!
CONTRACTOR
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CITY ZIP TEL
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DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LL
CENSE LAW FOR THE FOLLOWING REASON (SEG 7031.6 BUSINESS AND PFIOFESSIONS CODE. -ANY CITY OR
COUNTY WHICH REWAFSAPU"T TOCONSTRUCT,ALTER IMPROVE, DEMOLISH, OR REPAIR ANY STRUG
TURF, PRIOR TO ITS ISSUANCE, ALSO REQUARES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LF
CENM LAW M
(CHAPTER 3 (COMMENCING WITH SECTION 7000) OF DSION 3 OF THE BUSINESS AND PRO.
FESSONS CODE) OR THAT HE OR SHE IS EXEMPTTHEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7031.6 BY ANY APPLICANT FOR A PEWIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (Ism)),
O L AS ONNEROF THE PROPERTY,OR MY EMPLOYEES WITH WAGESAS THEW SOLE COMPENSATION,
WILL DO THE Wow AND
THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEG 70µ BUSI-
NEID PE
SS AND CODTHE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON. AND WHO DOES SUCH WORN HIMSELF OR HERSELF OR
TFYLOIIGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFB1m FOR
SALE G. HOWEVER THE BUILDING OR IMPROVEMENTISSOLD WITHIN ONE YEAR OFCOUPLE.
TICK THE OWNER9UBDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DO NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE),
O L AS OWNER OF THE PROPERTY, Al EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEG 704, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BU LOS OR IMPROVES THEREON. AND
WHO CONTRACTS FOR SUCH PRIQ ECTS WITH ACOW RACTORIS) LICENSED PURSUANT TO THE CONTRA&
TORS UCENSE LAW).
CI IAM EXEMPT UNDER SEG B. 6 P.C. FOR THIS REASON
DATE O
LICENSED CONTRA TORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
6 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE MIO
MY LICENSE IS N FULL FORCE AND EFFECT.
LICENSE CLASS LIC. NO.
DATE CONTRACTOR
WORKERS' COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
_1 HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS•
COMPENSATION, AS PROVIDED BY SECTION 37M OF THE LABOR CODE FOR THE PERFORMANCE
OF THE WORK FOR WINCH THIS PERMIT IS ISSUED.
_I HAVE AND WILL MAINTAIN WORKERS• COMPCNSATON INSURANCE, AS REQUIRED BY SECTION
5700 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
POLICY NUMBER
"SECTION REM NOT BE UJLFLETEDOF THE KAMIT6 FOR ONE HUNDRED DOLLARS R100) OR LESS),
I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I
SHALL NOT EMPLOY ANY PERSON N ANY MANNER $O AS TO BECOME SUBJECT TO THE
WORKERSCOMPENSATION LAWS OF CALIFORNIA AND AGREE THAT IF 1 SHOULD BECOME
SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE: APPLICANT:
WARNING FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL BE
SUBJECTAN EMPLOYER TO CRIM WK M
PENALTIES AND CL F WES UP TO ONE HUNDRED THOUSAND
DOLLARS (3100,0001. N ADOITON TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FORIN
SECTION 3703 OF THE LABOR CODE. INTEREST. AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
I HEREBYAFFIRM URGER PENALTY EN
OF PERJURY THAT THERE IS A CONSTRUCTION LCNGAGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC 3097. GV. G).
LENDER'S NAME
LENDERS ADDRESS
1 CERTIFY THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT
1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELIT WG TO BUILDING
CONSTRUCTION. AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE#RENTONED PROPERTY FOR INSPECTION PURPOSES.
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SO RE OF PERMITTEE /1 DATE
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RETENTION FEE CITY
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