HomeMy WebLinkAbout10012 (5)CITY OF DIAMOND BAR
COMMUNITY DEVELOPMENT DEPARTMENT
21660 E. Copley Drive Suite 190
(909) 860.3195 Fax (909) 661.3117
BUILDING PERMITAPPLICATION
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ADDRESS
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OWNER—K-11"i
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CITY ZIP 117cr TEL
APPLIC NT _�� TEL
CONTRACTOR A
ADDRESS
CITY AICK6b ZIP TEL * 736 /5' 1
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DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION
1 HERESY AFFIFM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS U
CENSE LAW FOR THE FOLLOWNO REASON (SEG 7WIS BUSINESS AND PROFESSIONS CCOE ANYCITY OR
COUNTY WHICH REOtIRE3APERMITT000NSTRUCTALTE0.IMPROVE, DEMOLISH ORREPAIRANY STRUG'
TUBE, PRIOR 70 ITS ISSUANCE, ALSO REQUIRES THE APPLICAM FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LL
CENSE LAW (CHAPTER f (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO.
FESSIONS OBOE) OR PUTHE OR SHE IS EXEMPT THEREFROM AND THE SASIS FOR THE ALLEGED EXEMP.
TION. ANY VOLATON OF SECTION 70!1.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLMJUR To
A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (3500}}
O L AS OWNER OFTHE PROPERTY, CHI MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORT( AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEG 7D44, BUS}
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE UAW DOES NOT APPLY TO AN OWNER OF
RT
PROPEY WHO BULBS OR IMPROVES THEREON. AND VA -10 DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH NIS OR HER ORM EMPLOYEES, PROVIDED THAT SLICH IMPROVEMENTS ARE NOT INTENDED OR
OFFFREO PDR SALE 1RHOWEVERTHE BUI DINOOR IMPROVEMENT IS SOLD WITHNONE YEAR OFOOMME•
TCN, THE OWNEREUILDER WILL HAVE THE BURDEN OF PROVPXI THAT HE OR SHE DO NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE}
O L AS OWNER OF THE PROPERTY AM EXCLUSNELYCOHTRACTNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LL
CENSE LAW DOESNOTAPPLY TO AN OWNER OFA PROPERTY WHO SULDS OR IMPROVES THEREON, AND
WAHOCONMCTS FOR SUCH PROJECTS WITHACONTRACTORS) LICENSED PURSUANT TOTHE CONTRAC.
TORS LICENSE LAW).
03151 EXEMPT UNDER SEC, B. A PC. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AITI M UNDER PENALTY OF PERJURY TUT IMI LICENSED UNDER PROVISIONS -CHAPTER
e (WANI WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS MA PROFESSIONS CODE, AND
MY LICENSE IS N FULL FORCE AND EFFECT.
LICENSE CUSS LLJ LIC. NO.
DATE —ZS - °I % CONrRACTOR K
WORKERS' COMPENSATION DECLARATION
114EREDYAFFMA UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
_I HAVE AND WILL MAYAN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS'
COMPENSATION. AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WMdI THIS PERMIT O ISSUED.
_I HAVE AND WILL MAINTAINWORKERT COMPENSATION INSURANCE, AS RECURRED BY SECTION
3700 OF THE LABOR CAGE, FOR THE PERFORMANCE OF THE WOW FOR YM04 THIS PERMIT IS
15SUM MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE
CARRIER
POLICYNUMBER
(THS SECTIONNEEDNDTBEam-, ETEDOFTE PERMIT IS FOR ONE IHIHIiEDDOLLARS (31GgORLESS}
1 CERTIFY THAT N THE PERFORMANCE OF THE WORIC FOR WHICH THIS PERMIT IS ISSUED, I
SHALL NOTEMPLOY ANY PERSON N ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS' COMPENSATION LAWS OF CALWORMA, AND AGREE THAT IF 1 SFHOLLD BECOME
SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
COOE,t FORTNA7H COMPLY WRIIEPROVISION
3/
DATE: � _ 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 NUNN" THOUSAND
DOLLARS (S100,00oL N ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR N
SECTION 3701 OF THE LABOR CODE, INTEREST, AND AT7OPO4EYS FEES,
CONSTRUCTION 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 15 ISSUED (SEG 3097, CFV. CL
LENDERS NAME
LENOERYADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECTT,
I AGREE Tb COMPLY WFTH ALL CRY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONST MID NE RESP AUTHORIZE REPRESENTATIVES OF TOS COUNTY TO ENTER UPON THE
NTONEO PROPER eNSPECTION PVRPOSEA
SKNATURE OF PE DATE
PRESS
FIRMLY
APPLICATION
PERMIT
DATE
NUMBER �#PIC
N
ISSUE
TYPE
OCC
DATE__j
CONST.
GROUP
ZONING SETBACKS
FRONT
RW
❑
REAR
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SIDEISIDE STREET
RW
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SIDE
❑
PROPOSED USE
IQ
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NO. DWEL NO.
NO.
UNITS STORIES
BEDROOMS
DESCRIPTION SO. FT.
FACTOR PSF
ADJ. AREANALUATION
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Gaapo/Carpon
WPatWDeck
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QUANTITY DESCRIPTION
FEE
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ENERGY PERMIT
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TOTAL FEES
COMMENTS
RECPT. NO. AID BY
VALIDATION
WHITE—D"itment Copy, YELLOW Finance Copy, PINK—ASSBaw Copy, GOLDENROD—fUB Copy. GREEN—Applft#rs Copy
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