HomeMy WebLinkAbout16101 (9) � CITY OF DIAMOND BAR
- ��`"� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
r 21660 E.Copley Drive Suite 190
(909)860-3195 Fa�c(909)861-3117 /� PRESS
�'��° BUILDING PERMIT APPLICATION ��.YS(GS Pr�u\ 3 H' FIRMLY
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I MEREBV 11FFIRM UPIDER PENALTY OF PERNRY THAT I AM EXEMPT FROM THE CONTRACTORS LI- Gd�e B/C3 R
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S� COUNiVNMICHREOUIRESAPERIAITTOCONSTRUCT.ALTER.IMPRoVE,DEMOUSH,ORREPAIRANvSTRUC. W pafi0/DBCk
� TURE,PRIOR TO ITS ISSUANCE.ALSO REUUIRES THE APPLICANT FOR SUCH PEPMIT TO FILE A SIGNED
� STATEMENT THAT HE OR SHE IS UCENSED PURSUANT TO THE PRONSIONS OF THE CANTRAC70RS LI�
� CENSE UW(CHMTEP V(CAAIAIENCINO WITH SECTION 7000)OF DIVISION 30F THE BUSINESS AND PftO� u' POOVS(J3
FESSqNSCODE)ORiHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEAILEGEDEXEMP� �
TION.ANYVIOLATIONOFSECTION7031.5BVANYAPPLICANTFORAPERMITSUBJECT57MEAPPUGANTTO Z Re-Roof
� ACML PENALTY OF NOT MOqE THAN FNE HUNDRED DOLURS(5500).):
� ❑I,ASOWNEROFTHEPROPER7V,ORMYEMPLOYEESWITHWAGESASTHEIfi50LECOMPENSATION, 0 COfTimOfCidl
MALL DO THE wORI(,AND 7HE STRUCTURE IS NOT INTENDED OR OFFERED FOfl SALE(SEC.7ola,BUSI� J
� NE55 AND VROFESSIONS CODE:THE CONTqACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF �
PFqPEfliY NM1iO BUNDS OR IMPROVES THEREON.AND VMOOOES SI/CH WOfiK HIMSEL F oR NERSELF OR
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� L.ICENSED CONTRACTORS DECLARATION W
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I HEFE9YAFFIRM UNDER PENALTV GF�ER.IURV THAT I AM LICENSED UNOEF PROVISIONS OF CHAOTER �,
� Y�(T�MMENCIN(3 WITH SECTKKJ 70o%OF�IYISION 30F THE BUSINE55 AND r'pOFESSION5 CO�E,ANO Z
��� MV UCENSE i5 IN FULL FO�PND EFFECT. m
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U DATE �^-'����I CONTRACTOR_�✓I C _ d
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� WOHK�RS'COMPENSATION DEGLARATION Q
� I HEREBY AFFIRM 11N�F.R PENALTY OF PF0.1L'RV ONE OF THE FOLLOWING DECUFATIONS: Z
� I NAVE AND WILL NIAMTAIIV A CERTIFICATE 0i GONSENT TO SELFMSUR'e FOR WOflKERS' ¢
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COMPENSATION,1,5 PqOVI�k:D 9V SECTION 3]0o OF THE LABOR CODE,FOR 7HE PERFORMANCF U'
Q OF THE WORK FOfi WHIGH THiS GEflMI'i IS ISSUE�. �
� _ I HAVE�HD WILL NIAIMAIN WORKERS'WMPENSATION INSURANCE,AS REQUIREU BY SECTION
Q5]0a QF THE LABOR CODE,FOR 7HE PERFORMANGE OF TME WORK Fpq WHICH THIS PEPMIT IS
ISSUEO.MV NERS'i�MVENSATI0NIN5URANCECARRIERANDPOLICYNUMBERARe: CONSTRUCTION
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Z PaicV NUMdER_ �f N l�� U I .�'�. ELECTRIC
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Z �CEFIIFV TMAT IN THE PEFiFORMANGE OF THE WOFUC FOR bYHICH THIS PERMIT IS ISSUED,I MEGHANICAL
(J' SMALL NOT EMPLOY ANY PEHSON IN AN'I MANNER SOAS TO BECOME SUBJECT TO THE �
� WORKERS'COMPE:NSA'ION UWS OF CALIFOPNIA,AND AGREE THAT IF I SHOUL�BECOME INSPECTION FEE
r- SU&IECTTOTHE�NORKERS'COMPENSATpNPflOVi510N5OFSECTION9]DOOFTHEUBOR
� CODE,I SHALL FOqiVIWITH COMPLV WITHTHOSE PROVISIONS. ISSUANCE �, .,V J
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p DATE:�—�r._C� APPLICANT: _I V�tZ. ' "-- C�+I SMiP
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J WAflNINO�FAILURE TO SECURE WORNERS'COMPENSATION COVERAGE�S UNL4WFUL.AND SHALL BE ENERGY P/C �� � _
�y SU&IECTANEMPLOVERTOCRIMINALPENALTIESANDCIVILFWESUPTOONEHUNDREDTHOl15AND ENERGYPERMIT
DOLLARS(f t00.D0U).IN RDDITION TO THE COST Of C�MPENSATION,DAMAGES AS PqOVIDED FOR IN
� SECTION3�oBOFTNEIABORCODE,INTER[ST,ANDAT70RNEY'SFEES. RETENTIONFEE: �
OCONSTRUGTION LENDING AGENGY PRE-ALT FEE�
� I HEREBV AFFIHM UNOER PENALTY OF PERJUFV THATTHEqE IS A CONSTRUCTION LENDING AGENCV
FOfi THE VERF-0RMANCE OF THE WORK FON WHICN THIS PERMIT IS ISSUED(SEC.3a97.CIV C.)_
� LENDER'SNAME���l�� � �- __... .
F LENDER'SADDRESS �
W I CERTIFY THAT I HAVE RE11D THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORqECT. TOTAL F EES �� '�� �.�
� I AGREE TO CAMPLY WITH ALL CITV AND COUNTY ORDINANCES AND S7ATE LAWS RELATING TO Bl11LDING
� CANSTRUCiION,ANDHEREBYAUTHORIZEREPRESENTATNF50FTHISCOUNTVTOENTERUPONTHE
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� RECPL NO. ____ PAID BY VALIDATION '
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Faz(909)861-3117
BUILDING PERMIT APPLICATION
JOBSITE L� �/ 1
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ADDRESS
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APN LOT
-��TRACT SZZJL)7
OWNER�
ADDRESS��L IY-n,.Il
CITY�_ZIP�TEL.�j
APPLICANT tflp TEL. +'-1
CONTRACTOR(y
ADDRESS
CITY)rv� n ZIP TEL L'
ARCH/ENG/�/tt'I�K
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S�SS
DESIGNER,
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ADDRESS�SI-�1�v tPl
CITY��ZIP 9'?7gs'TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSELAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANV CITY Oq
COUNTY WHICH REWIRE:I A PERMIT70 CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY STRUC-
TURE,PRIOR TO ITS ISSUANCE.ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR BHE IS LICENSED PURSUANT TO THE PROVISIgJS OF THE CONTRACTORS LI-
CENSE LAW(CHAPTER B (C(NAMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSgNSCODE)OR LHA7 HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7037.5 BV ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
ACML PENALTY OF NOT MORE THAN FNE HUNDRED DOLLARS (f500).):
^ I,AS 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 FOP SALE(SEC. 7016, BUSI-
NESS AND PROFESSK)NS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BLINDS OR IMPROVES THERE-ON,AND WHO ODES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF,HOWEVER,THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE-
TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NUT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
^ I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS
70 CONSTRUCT THE PROTECT(SEC. 7011, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SU�71 PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TC THE CONTRAC-
TORS LICENSE LAW.).
^ I AM EXEMPT UNDER SEC. - B. 8 P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PER.IURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
P(COMMENCING WITH SECTKKJ 7000)OF DIVISION 30F THE BUSINESS AND FROFESSION5 CODE,AND
MV LICENSE i5 IN FULL FURyjE AND EFFECT.
LICENSE CUSS--. LTC. N0.
-i
�
DATE�^-' � ���I CONTRACTOR_�/I C
WORKERS'COMPENSATION DECLARATION
I HERERY AFFIRM UNDER PENALTY OF PF RJURY ONE OF THE FOLLOWING DECORATIONS:
I HAVE AND WILL NIAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSUR�e FOR WORKERS'
COMPENSATKNJ,I.S PROVIDED BV SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHIGH THIS PERMI'i IS ISSUED.
I HAVE ANO WILL NIAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIREU BY SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MV KERS'COMPENSATION INSURANCE CARRIER AND POLICY NU
M
B
ER
ARE:
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CARRIER_.L-t�� �/I�I � � �� �(�'
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POLK:YNUMBER- �t� rL!V
(THIS SECTION NFHINOT BE IX.Hd'LE-fED OF THE PER.KT IS FOR CNJE HINGRED OCIIAF� (f100)OR LESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR bYHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPE:NSATK]N UWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE\VORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LIBOR
CODE,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
t
� ��
�+/
DATE: �-� r C�APPLICANT:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE iS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(f 100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
SECTION 37oe OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV C.).
LENDER'S NAME����I �� �p�-
LENDER'S ADDRESS
I CERTIFY THAT I HAVE REVD THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPiERN FOR INSPECTION PURPOSES.
PERMITTEE NAME(PRINT)
SIGNATURE OF PERMITTEL' DATE
WHITE-Department Copy,YELLOW-Finance Copy, PIN
U mss c c.s Pt><� 3/a
PRESS
FIRMLY