HomeMy WebLinkAbout17617 (10) �� CITY OF DIAMOND BAR ������ , ,, r (,I;:
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES `� �
21660 E.Copley Drive Suitc 190 �
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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 PER.I�IIT APPLICATION
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ADDRESS
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ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER-BUILDER DECLARATION
1 HEREBY AFFRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LI-
CENSE IAW FOR THE FOLLtriYING REASON (SEC. 7031.5 BUSINESSAND PROFESSKNS CODE: ANV CI7V OR
COUNTY WHICH RECAIIRES A PERMIT TO 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 SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE LAW(CHAPTER B (COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THEALLEGED EXEMP-
TION.ANY VKXJ�TION OF SECTION 7031.5 BV ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
ACML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (f500).):
^I,AS OWNER OF THE: PROPERTY,OR MV EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION
WILL 00 THE WORK,AND 11iE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044, BUSI-
NESS AND PROFESSIONS(X3DE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OH IMPROVES THEREON,AND WHO DOES 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-BU4DER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
^ I,AS OWNER OF THE PROPERTY AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PRCU ECT(SEC. 7041, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE LAW DOES NOi APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,ANO
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAG
TORS LICENSE UW).
0 I AM EXEMPT UNDER SEC. B.f P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
0 (COMMENCING WITH SECTION 7000)OF DIVISK)N 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FOFC
EA
ND EFFECT.
2
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LICENSE CLASS� �� LIC. N0. � �� �s
DATE
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CONTRACTOR� D�
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TOSELF-INSURE FOR WORKERS'
COMPENSATION,A:i PROVIDED BV SECTION 3700 OF THE LABOR CODE,FOR THE PERFORMANCE
/OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
/
/
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION
3700 OF THE LABOfI CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS'C
OMP
ENSATION INS
U
RANCE CARRIER AND POLICY NUMBER ARE:
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CARRIER_LG r
POLICY NUMBER � � �
(fl-115 SC-CigN NC-fR)NOT 9E COMPLE7(DOF THE PERMR 6 FOR ONE TAN-DRED DOLLARS(E100)OR LESS).
I CERTIFY THAT IN 1HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1
SHALL NOT EMPLO�/ANY PERSON IN ANV MANNER 50 AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATKXJ PROVISKNS OF SECTKJN 3700 OF THE IABOR
CODE,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
i-12-��
��7�
DATE:
�APPLICANT:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATKN 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 AOCiTION TO THE COST OF COMPENSATON, DAMAGES AS PROVIDED FOR IN
SECTK)N 3708 OF THE LABOR CODE. INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
1 HEREBY AFFIRM UNDER PIFNALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK fOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV. C.I.
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY TNAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATKNJ IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES ANO STATE LAWS RELATING TO BUILDING
CONSTRUCTION,AND HERF.BV AUTHORIZE REPRESENTATIVES OFfHIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED P
ROP
ERTY F
OR IN
SPECTION PURPOSES.
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PERM TTEE F. (PRINT)
SIGN 7U EO PERMITTEE DATE
WHITE-Department Copy,YELLOW--Finance Copy,PIN
PRESS
FIRMLY