HomeMy WebLinkAbout10121I
CITY OF DIAMOND BAR
COMMUNITY DEVELOPMENT DEPARTMENT
21660 F- Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION ,
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OWNER 1ejZ
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ARCRIENG/
DESIGNER
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OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LF
CENSE LAW FOR THE FOLLOWING REASON (SEM 7W 1.5 BUSINESS AND PROFESSIONS CODE ANY CITY OR
COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT, ALTER, IMPROVE DEMOLISH, OR REPAIR ANYSTRUC.
TUBE, PRIOR TO ITS ISSUANCE ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FRE A SIGNED
STATEMENT THATHE OR SHE IS LICENSED PURSUANT TO THE PAOVISIONS OF THE CONTRACTORS L4
CENSE LAW IOU PTER I (COMMENCING WITH SECTOR 70001 OF DIVISION S OF THE BUSINESS AND PRO-
FESSKNS CODE) OR THATHE OR SHE 13 EXEMPT THEREFROM AND THE BASIS FOR THEALLEGED EXEMP-
TION. ANY VIOLATION OF SECTOR 7031.5 BYANYAPPLICAHT FOR APERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (5600) k
O L AS OW NER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEG 70". BUSI-
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IAPfOVESTHEREOK 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 OFCOIMPLE-
TON, THE OWNER BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
OVE FOR THE
YPRPURPOSE OF SALEL
O L AS OWNER OFTHE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEG 7044. BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LF
CENSE LAW DOZES NOTAPPLY TORN OWNER OF APROPERTY WHO BUILDS OR IMPROVES THEREON AND
WHO MNTRACTS FOR SUCH PROJECTS WITHA CONTRACTOR($) LICENSED PURSUANT TO THE CONTRAG
TORS LICENSE LAW S
O 1 AM EX UPTUNDER SEG 0. a P.C. FOR TMS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBYAFFIPM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
0 (COMMENCING MCENCNG WITH SECTION 7000)
DIVISIONOF DIVISION S OF THE BUSINESS AND PROFESSIONS CODE AND
W LICENSE IS N FOAL FORCE AND EFFECT.
LICENSE CLASS LIC. NO.
DATE CONTRACTOR
WORKERS' COMPENSATION DECLARATION
I HEREBYAFFIMC UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELFINSURE FOR WOWERT
COMPENSATION. AS PROVIDED BY SECTION 3700 OF THE LABOR CODE FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
1 HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY SECTION
57000E THE LABOR CODE FOR THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS
ISSUED. MY WORI COMPEC�SA NSU GUTRIER AND POLICY NUMBER ARE:
CARRIER li LL
POLICY NUMBER Iv3.1fPAH a
(THIS SECTION TfIDNOT BECOM LSEDOFTHE PEAMT IS FOR DHEFODFIEDOOLLARS(SIM OR LESS}
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FCR WHICH THIS PERMIT IS ISSUED. I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS' COM PENSATION LAWS OF CALIFORNIA AND AGREE THAT IF I SHOULD BECOME
SUILIECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 37000E THE LABOR
CODE II SHALL FORTHWITH COMPLY YATHTgs ROYISIONS,
DATE: 7 APFLICANT: L
WARMN@FAILURE TO SECURE WORKERSCOMPENSATO-N COVERAGE I 1MWFUL. AND SHALL BE
SUBJECTAN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (SI00.000L IN TO
TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN
SECTION 3701 OF THE LABOR CODE, INTEREST. AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
L HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE O A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC 3007. CM G).
LENDERS NAME
LENDERS ADDRESS
1 IFY CERTTHAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION 13 CORRECT.
1 AGREE TO COMPLY YAM ALL CRY AND COUNTY ORDNANCE$ AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSE&
PERMITTEE MW6 (PR n
SIGNATURE OF PERMITTEE DATE
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