HomeMy WebLinkAbout13212 (17)CITY OF DIAMOND BAR
COMMUNTfY DEVELAPMENT DEPARTMENT
21660E Copley Driwftite 190 -
(909)860.3195 Pax(909)861-3117 PRESS
BUILDING PERMTf APPLICATION FIRMLY
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APPLICANT TEN.
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DESIGNER
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OWNER-WLDER DECLARATOR
.. L HERMY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AN EXEMPT. FROM THE COFiTR+1CTOfiS Ll'`
CENSE LAW FORTHEFOLLOWNO REASON (SEG 7037.6 BUSNESSAND PROFESSIONS CODE:ANYCTYOA
iDUNTYWHOH REd11RESAPEfM"TOCONSTRUCT,ALTER SAPROYE, oEA1DUSH.ORifEPA1RANrsTIN7G -
TURE; PRIORTO ITS ISSUANCE, ALSO REQUIRES THE APPLICANTFORSUCH PERMIT TO FILE A SIGNED,
STATEMENT THAT HE OR SHE L5 LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS U
CENSE LAW ry7UPTER a =MMENCM WITH SECTION 7088) OF DIVISION 3 O THE "NESS AND PRN
FESSONS CODE) ORTHAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP
TION. ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
_ANVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS
O LAS OWNER OFTHE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL 00 THE WOFOL AND THE STRUCTURE S NOT INTENDED OR OFFERED FOR SALE (SEG 70µ BASF
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOTAPPLY TO AN'OVRER OF
PROPERTY WHO SIUILOS OR IMPROVE$TIEREON, AND VA400M SUCH WORKHM89.FKR HERSELF 0R
THROUGH HIS OR HER OWN EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOTNTENDED OR
OFFS EDFOR SALE IF, HOWEVER THE BWIDINBOR WF40VEMBR S SOLD WITHNONEYEAROFOO MPLE.
TION. THE OWNER-Bl/&DER WILL HAVE THE BURDEN OF PROVINGTHAT HE OR SHE DD NOT BUND OR -
IMPROVE FOR THE PURPOSE OF SALE} '
- .t3LAS OYMEROFTHE PROPERTY. AMEXCLUSIVELY CONTRACTING WITH LASED CONTRACTORS
70 CONSTRUCT THE PROECT (SEC. 7W BUSINESS AND PROFESSIONS CODE THE OONIAACTORS LL
CENSE UW (TOES NOTAPPLYTOAN OWNER OFA PROPERTY *`HD BUILDS OR IMPROVES THEREON, AHD
WHOOONTNACTS FOR SUCOHPROUECTS YMACONTRACIORjS)LICENSED PURSLWFr To THE CONI'RAG
TORS LICENSE LAW.).
O IAM EXEMPT UNDER SEG S. i PC FOR7M F*ASON
DATE OWNER -
LICENSED CONTRACTORSDECLARATION
1 HERESYAFFM LRDER POULTYOF PENURY nMTIAM LEMED ODER PROVSOIIS OFOVPIVA
TH(COMMENCING WITH SECTION 7000) OF DIVISION OF THE BUSINESS ND PROFE39ONa OBOE,AM
MY LICENSE S N FULL FORM AND EFFECT.
LICENSE CLASS � � _ Lr_ NO, 3
DATE .. ";!:z - CCNTRACTDR
WORKERS COMPENSATION DECLARATION
1 HERBY AFFIRM UNDER PENALTY OF PERARY ONE OFTHE FOLLOWING DECLARATIONS.
-=IHNVEADWILL MAINTAN##RTHFICATE-OFtONSENT TOSELF4INSUREE FOR WORERr-' -.
OOMPE NSRIOK AS PROVIDED BY SECTION 3MOOFTHE LAMA CODE, FORTE PERFORMAmee _F
YOFTHE WORK PDRWHICH,TIHIS PERMIT IS ISSUED.
-1HAVEAND WILL MAINTAIN WORKERS' COMPENSATION NBURANC:E, AS REOURED BY SEC TON-
CO-
- 37M OF THE LABOR DE HE RM
FOR TPERFORMANCE OFTHE WORK FOR WHICH THIS PERMTS
. .. -. ISSUED. MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE.-
POLICY
REPOLICY NUMBER
-- - - fMBEMMNEL PWOECMVtEMDOFTKPBWISFOROFEH tVWDOUARSRt"ORLES8j..
1 CERTIFYTHAT N7HE PERFORAOE OF THE WORK FOR YROCNTHI3 PE
-. SNAIL NOT EMPLOY ANY PERSON N ANY MANNER BOAS OT JECMA� ECTTOTHE _
WORKERS (OMPEN = LAWS OF GUFORNJ-L►.AN EE THAT E 1 SHOULD BECOME
SIIBIECTTO THE WORK ERS' CON P ROVISIONS OF SECTION 37000E THE
CODE, I SHALL WITH THOSE PROVISI M
DATE:_
*ARNINO: FAILURE TO StCUmWORKEPW EN T COVERAGE - U SHALL BE
SURJECTAN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (11100.004 N ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR N
SECTION SM OF THE LABOR CODE. INTEREST,, AND ATTORNEY'S FEES. - .. ... -._. _.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE S AtONSTRJCTON LOMNG AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 1S ISSUED (SEG 3087. CIV. C.).
UNDERS NAME
LRDER'SADDRESS _ --
1 CERTIFY THAT i HAVE READ THIS JPPUCATON AND STATETMATTHE ABOVE NFORMA mSoome TT
I I AGREETO COMPLY WITH ALL CTYANO CIXNTYORONANCES AND STATE LAWS AH,ATNG TO BUILDING
CONSTRUCTION, AND HEREBY AUTHORZE REPRESENTATIVES OF THIS C MWTY(0 ENTER UPON THE
NLB VC4,11ENNTIOEDPROPERTY FOR NSPE ES I
NATUREOFPERV,d -- - DATE - -
`
APPLICATION t i PERMIT
DATE —` NUMBER 4
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ISSUE TYPE
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RETENTION FEE:. _ .- ... _. .•_, _
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TOTAL.FEES-5 13.1
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. _ WHITE--DepaRmenL Copy, YELLOW--Frw" Coq,. PINK-AssesaT Copy, GOLDENROD -Rb
COPY. GREEN -Applicant's Copy .