HomeMy WebLinkAbout13799 (17)PERMIT APP CATION-
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7 DESIGNER
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OWNER -BUILDER DECLARATION
- - I HMESV AFFAM LEDER PENILLW OF PMULMY THAT i AM OMMPT FROM THE CONTRACTORS LF
CENSE UAW FOR THEFOLLOWNO REASON (SEG7US.6 BUSNESSAND PROFESSIONS CODE MYCITY OR
GOWN V*MW REQWMAPERMITTO WNS:WIGT.ALTER VPROYE.OFdFWSKC RREPANAWSnWC,
TUBE. MOOR 70 ITB WRIM CE. ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR 06 E UCS PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LF � -
CBNIE LAIN (.TAP TERM (COMMENCING WITH SECTION nW) OF DIVISION 3OFTHE BUSINESS AND PRO.
FES.410NBOODE)ORTHATHE OR SFE 13EXBWRTHEREEROM NO THE SASIS FOR THEALLEGEDEXEMP- .
TIORANY VIOLATIONOFSECTIDM 7W 8 BY ANY APPLICANT FOR APERMIFMA,ECTSTHE APPLICANT TO -
ACAILPENALTY OFNOTMORE THAN RVE HUNDRED DOLLARS( WLO
0 LASOMNEROFTHE PROPERTY. OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION.
WILL DO THE WORK, AND THE STRUCTURE IS MDT NT6DE6 OR OFFERED FOR SALE (SEG 70M, BUSL
NEW NO PROFESSIONS CODE THE CONTRACTORS LICENSE LAM DOES NOTAPPLY TO AN OWNER OF
-PROPERTY WHO M UDSOR M/PROVESTEAWK A D WHODOES S"W011KHMSEL.FORNEASEIFOR
THROU(kNNISORHMOIMIEWUOVEMPROVOWIH Tg"*APROVEMENTBAFEKDTNTEIOEDOR
OFFUMFORS"F.HOWEVER,TEEBU DPOORAWROVHA6(TRSOLDWRMRONEYEMOFOOMRE
' TON. THE OWNf R WILL NAVE THE SUNDER OF P1IDVNG TLAY HE OR SHE DID NFT WILD OR
r) NP 0 LAS OWNER
TFE OF THE PROPERTY.
ROPERTY ... - O
LT oLAs orAiEILOFTHE PROPERm,AM ExCLusrvEcrCgrtRAGTNO wrnI LICENSEDODNTRAcroRs
l27 TO CONSTRUCT THE PROJECT (SES TOM, BUSINESS NO PROFESSIONS CODE THE CCMRACTORS LF
CEN$E LAW DOES NOTAPPLY TO AN OWNER OFAPROPERTY WHO BUILDS OR IMPROVES THEREOK AND
C WFOOOHTRACTSFOR SUCHPROJECTSWTHACCNTRACRORS)ucE sm PURSUAMTOTECONTMG.
TORE LICENSE LAN.}-
OIAM EXE MPTLNDO SEG 8. S P.G FORTHRS REASON '
in - -:
DATE .... ...--, OWNER
_ LICENSED CONTRACTORS DECLARATION
1 HIEREBYAFR MI UNDER PENALTY OF PERAXTY THATI AM LICENSED UNDER PROVISIONS OF CHAPTER
• (001YIHiCJND W17H SELTION 7000) OF DIVISION 3OFTHE BUSINESS AND PROFESSDNS CODE.AND
4 RALE EAND EFFECT _ L715
Y� - f - LIC._ NO. -
wtE — CONTRACTOR _.
WORICEW COMPENSATION DEC N e/
n INEREBVAFFMIYLBOERPENALTYOFPEMAP/OPEOFTHEFDULDVNWDEgJ1R1T10N9:U'3D
—I NAVEA D WLLMANTANACERTIFICATE OF CMSENTTO8H"MM FM WOR KEW
OOMMEMBATDN.AS PROVDED BY SECTION 3YW OFTHELABOR CODE. FOR THE PERFORMANCE
OFTW WORK FOR YM04 THIS PERMIT IS ISSUED. -
L - N
�I HMIEARO WLLYAMAN WORKERS' COMPENSATION MISURAIICE, AS REWIRED BY BECTON
Q 370DOF THELABOR CODE F'ORTHE PERFORMANCE OF THE WORK FOR WHICHTMS PERMIT IS
SSUMMY WOAI{EFB'-OOMPEN. SATK3V ISN iSURMIC GRIFR AND POLICY MAIBE TARE ... i
CARR" TF Fes+ { P
r-
POLIO'/MAABER
^ _ PMSBEf3 MNeWNOTBECOLfSMOFTHEPBWOMACWM MMLAFIS(FIOAIORLEB%
Z I CERTFYTHAT LATHE PERFORMANCE OF THE WORK FORWHICHL THIS PERMIT S ISSUED,1
L� SHALLNOT EMPLOY ANY PERSON MANY MANNER BOAS TO BECOME SUBJECT TO
� WOFtlKERB'COIAPENSATI011Ud75OF CI=A::QAgT EISIIDIADSUSJECTm TIE WORKERS=TION PROVI 3700 LABOR
CODE I SHALL_ LQM WRRH COMPLY WITH TFIOS
p DATE S-ql�� APPLICANT .
WMNPAi: FAILURE TO SECURE WORKERS (OMPENSAT (XWEIIAOES ANO SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES LAID ILFINES UP TOOPE TH/Du3AID
DOLLARS 01 00,000), N ADOMON TO THE CAST OF COMPENSATION. DAMAGES A6 PFRWED FOR N
SECTION 373BOF THE LABOR CODE, NTEREST.ANDATTO NEY'S FEES.
Lu CONSTRUCTION LENDING AGENCY
IHEREBYAFFFM HOER PENALTYOF PEFWRYTWUTTHEW S ACONBTRICTIONUEDBOAGENCY
Z PORTHE PERFORMANCE OF THE WORK FOR WHICH MS PERMIT S ISSUED(SEG 3W- CIV. G).
W
LE DEWS NAME
F-- L.ENDERSAWAESS
I CERTIFY TWAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IM:ORMA IDM S CORRECT.
IAGREE M COMPLY WIN ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
-!
CONSTRUCTION. AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO BRIER UPON THE
SLS AB K46NTIOMEO PROPERTY FOR INSPECTION PURPOSES.
D
KM mTTEENAME VANT) L
Co SIGNATURE OF PERITTEE DATE
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES (909) 860-3195Fax (909) 861-3117
BUILDING
APPLICATION
DATE �-�Sl NUMBER r PERMIT P/ -"'
ISSUE ..- -. TYPE OCC
DATE CONST. GROUP �^
ZONING SETBACKS
FRONT RW ❑
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SIDEISIDE STREET RW ❑
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PROPOSED USE
SCI wF
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DESCRIPTION SO. FT. FACTOR PSF ADJ. AREAIVALUATION
SFRIADWREM
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RETENTION FEE: • CJ O
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TOTAL FEES �+ - 055(p.
COMMENTS
RECPT. NO. PAID BY VAUDATID1
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APPLICATION
DATE �-�Sl NUMBER r PERMIT P/ -"'
ISSUE ..- -. TYPE OCC
DATE CONST. GROUP �^
ZONING SETBACKS
FRONT RW ❑
REAR ❑
SIDEISIDE STREET RW ❑
SIDE ❑
PROPOSED USE
SCI wF
NO. DWEL NO. ` NO.
UNITS STORIES f BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF ADJ. AREAIVALUATION
SFRIADWREM
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RETENTION FEE: • CJ O
PRE- T FEE �
TOTAL FEES �+ - 055(p.
COMMENTS
RECPT. NO. PAID BY VAUDATID1
WHITE-4DBPBRmBnt Can YEU.OVW-FYwm Copy. PINT—Asmsw vow. wjum— —+7
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