HomeMy WebLinkAbout15513 _�� CITY OF DIAMOND BAR EXP�RED
DEPARTMENT OF COMMUNITY�DEVELOPMENT SERVICES Mqy O 9 2003
21660 E.Copley Drive Suite 190
w (909)860-3195 Fax(909)861-3117 PR ESS
''�' BUILDING PERMIT APPLICATION FIRMLY
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� I HEREBY AFFliW UNDER PENALTV OF PERNRY THAT I AM EXEMPT FROM THE CONTRACTORS LI� GdfB JB/COfpOR
W CENSEUWFOi1THEFOLLOWMIGHEASON(SEC.7o31.5BUSINESSArDPROFESSIONSCADE:ANVCI7YOR (n
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Z 7URE.PRIDN TO ITS�SSUANCE,ALSO REW IRES TME APVLICANT FOR SUCH PERMIT TO FILE A SIGNED w Patio/Deck
� ST�TEMEM 7HAT NE OR SME IS IICENSED PUiiSUANT TO THE PROVISIONS OF THE CONiMCTORS LL
� CENSE LAW(p/APTER 9(COMMENCINO NMTH SECTION�000�OF DIVISION 9 OF THE BUSINESSANO PRO- � POOUSPe
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� A CIVII PENALTI OF NOT MOqE TMAN FIYE HUNORED DOLURS(iSooJ.):
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N NESS AND PAOFESSIONS COOE:THE CONTMCTORS LICENSE UW DOES NOT MPLY 7o AN oWNEF oF � �
PROPERTY MAIOBUILDSOR IMPROVES hIEREON.AND WHO DOES SUCH WORK HIMSELF oR HERSELF oq
� THROUl3HHI50RHEROWNEMPLOVEES,VROVIDE�THATSUp11MPiiOVEMENTSARENOTINTENDE00R m
O OFFEiiEDiOR5ALEIF,HDWEVERTMEBUILDINQORIMPROVEMFNfI550LDWITHINONEVEAROFCOMPLE
Z TqN,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING TH�i NE OR SHE DID NOT BUILD OR
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� I HEREBY AFFIRM UNOER PENALTY OF PERIURV THAT I AM LICENSED UNDER PROVISIO4S OF CHAPTEH �
� 9(COMMENCINO WITH SECTION 7000)OF OIVISION 3 OF THE BUSINESSAND PROFESSIONS COOE,AND Z
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U DATE v ��I'T�G�� CONTRACTOFkd�<_(��Q d
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� WORKERS'COMPENSATION DECLARATION �
� I HEREBV AFFIpY UNDER PENALTY OF PERIURV ONE OF THE FOLLOWING DECLA T � f t�
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� _IHAVEANDWILLMAINTNNACERTIFICATEOFCONSENiTOSEIFINSU .FOR E ' /
� COMPENSATION,ASPROVDEDBYSECTION37000FiHEUBORCOOE FORT PEHFOFMANCE
OF THE WORK FOR WHICH THIS VERMIT IS ISSUED.
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Qw _I HAVE AND WILL MAINTNN WORKERS'COMiENS�TION INSURANCE,AS REQIIIRED BY SELTION ��
]7ooOF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK W R WHICH TMIS PERMIT 15 ��""' � � � ;-�*
� ISSUED.MY/NNN���/QR�(ERS' ENSATKKJ INSURANCE CARRIER AND POLICV NUMBEfl ARE: CDNSTRUCTION 7' l
� CARRIER �-�'/ /� � � P/�N�EVIEW.
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Z I CEflTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUE, NICAL ��j���
C,'} SHALL NOT EMPLOV pNV PERSON N ANV MANNER SO AS TO BECOME SUBJECT TO THE --����. ..�
(n N/ORKERS'COMPENSATION UWS OF CALIFOpNIA.AND AGREE TMAT!F 1 SHIX1L�9ECOME I SPECTION FEE
� $U&IECT TO THE WORKEFS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR i'��l"
� DE, SHpL.FOFlTHWITHCOMPLVWI7HTFpSEPROVI510N5. ISSUANCE �€a��-t (/'ll
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Ip DATE: � APPLICANT:���_F��-� SMIP �Rv� � ''�,'. r t a �2 � ,./'
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J WARNINfi:FAILURE TO SECURE WORKERS'COMPENSATION CAVERACaE IS UNLAWFUL,ANO SHALI BE ENERGY P/C T g�',;�� _i i.���1S`��
�y SU&IECT AN EMPLOYER TO CRIMINAL PENALTIES ANO CIVII FINES UP TD ONE HUNDRED THOUSAND ENERGY PERMIT �^�� , � � � ����_.j A.
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OOLLARS(f100.000).IN ADDITION TO THE CAST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN '
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0[ RETENTION FEE: €i� t�.,i)x�'�-" � -
OGONSTRUCTION LENDING AGENCY PRE�AL7J fE .
� I HEREBY AFFIRM UNDER PENALTV OF PERJUfiV THAT THERE IS A CONSTRUCTION LENDING AGENCV /��`.
FOR THE PERFORMANCE OFTHE WORK FOR WHICN THIS PERMIT IS ISSUED(SEC.30B],CIV.C.).
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� LENDER'S NAME _ -
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W ICERTIFYTHATIHAVEREADTHISAPPUCATIONANDSTATETHATTHEABOVEINFORMATIONISCORRECT TOTAL FEES _ � � /� , /.�yJ��
p. I AGREE TO CAMPLV WITH ALL CITY AND COUNTV ORDINANCES AND STATE LAW$REL4TING TO BUILDMG � � l4 `
� CONSTR�CTION,ANO HEREBV AUTViORIZE REPHESENTATIVES OF 7HI5 CAUNTV TO ENTER UPON TNE �
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UI,IIIIIJU 6,111 I
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
JOBSITE���
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ADDRESS
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APN LOT TRACT
OWNER""
ADDRESS
CITY IP TE.�Q97Srf'Is���
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APPLICANT TEL.
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CITY ZIP OTE.
ARCH/ENG/
DESIGNER 1�V(s S%�N .�1�- �SSOG�C'�j'�
S'
ADDRESS�''�"�
CITY�NI�/�r/A,-ZIP TEL./s
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OWNER-BUILDER DECLARATION
I HEREBY AFFRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE UW FOii THE FOLLOWNJG REASON(SEC. 7031.5 BUSINESS AND PROFESSKNS CODE:ANY CI7V OR
COUNTY WHICFI REWIRESA PERMRTO CONSTRUCT,ALTER IMPROVE,DEMOLISH,OR REPAIR ANV STRUC-
TURE, PRXM TO ITS ISSUANCE,ALSO REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT 70 THE PROVISIONS OF THE CONTRACTORS LI-
CENSE UW(CHAPTER B(COMMENCING WITH SECTION 7000)OF DIVISK)N 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPTTHEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TK)N.ANV VIOLATKMI OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLURS(1500).):
^ I,AS OWNER OF THE PROPERTY OR MY EMPLOYEES WITH WAGES AS THEIq SOLE COMPENSATK)N
MALL DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 70u, BUSI-
NESS AND PROFESSKNS CODE:THE CONTRACTORS LICENSE UW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE N07 INTENDED OR
OFFERED FOR SALE IF HOWEVER,THE BUILDING OR IMPROVEMEM IS SOLD WITHIN ONE YEAR OF COMPLE-
TK)rl,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
^ 1,AS OWNER OF THE PROPERTY,AM EXCLUSNELY CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 70th,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE UW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE UW.).
^ 1 AM EXEMPT UNDER SEC. B. 8 P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERIURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCMKi WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSONS CODE,AND
MY LICENSE IS IN FULL FORC D EFFECT.
99
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Q LIC. N0.
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DATE J
�CONTRACTO
WORKERS'COMPENSATION DECLARATION
///���
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECD T
I HAVE AND WILL MAINTIUN A CERTIFICATE OF CONSENT TOSELF-INSU .FOR E'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE LIBOR CODE FOR 7 PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTNN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
37000E THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MV NyRI(ERS' ENSATKKJ INSURANCE CARRIER AND POLICY NUMBER ARE:
/
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CARRIER{
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f
POLICY NUM
E
B
R
(iF�SECfICN NEEG NOT BE CIJMPLETlDOF THE PERMtT IS FOR ONEFiIN-DRED DCLIARS 00)OFiL),
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUE,
SHALL NOT EMPLOY ANV PERSON IN ANV MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION UWS OF CALIFORNIA,AND AGREE THAT IF 1 SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTKNJ 3700 OF THE LABOR
DE,SHALL FORTHWITH COMPLY WITH THOSE PR
0
V
IONS.
I'S
�
J\
�
DATE:APPLICANT: �� ����
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNUWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLURS(5100,000),IN ADDITION TO THE COST OF COMPENSATK)N, DAMAGES AS PROVIDED FOR IN
SECTK)N 3708 OF THE LIBOR 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. 3087,CIV G).
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATKKJ IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE UWS REUTING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTK)N PURPOSES.
PITTEENAME()� �_^ ! ��
S
S ATURE OF PER I7TEE DATE
WHITE-Department Copy,YELLOW�inence Copy, PIN
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FIRMLY
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COyfNJENTS �
RECPT. N0. PAID BY VALIDATION