HomeMy WebLinkAbout10300 (5)CITY OF DIAMOND BAR
COMMUNITY DEVELOPMENT DEPARTMENT
21660 E. Copley Drive Suite 190
(909) 860.3195 Fax (909) 861.3117
BUILDING PERMIT APPLICATION
JOBSITE
ADESS MI X (fEXCH1 u-4JtV 4/1)
APN LOT TRACT1('.3
OWNER 91AWlc ' 4-/¢ T
ADDRES , Rt- _caX 4C' a
CITY ZIP_ TEL.W'iI327
APPLICANT TEL.
CONTRACTOR 'n-y"'WC n
ADDRESS
CITY ZIP TEL.
ARCRENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER -EI VILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC.7031.6 BUSINESS AND PROFESSIONS CODE: ANY GTY OR
COUNTY MMICH RE WIRES A PERMIT TOCONSTRUCT, ALTER. IMPROVE, OEMOUSH, OR REPMRANV STRUC-
TURE PRIOR TO ITS ISSUANCE. ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THATHE OR SHE 6 LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS U.
CENSE LAW (CHAPTER 9 (COMMENCING WITH SECTION TWO] OF DIVISION 3 OF THE BUSINESS AND PTIO-
FESSIDNS COOEI OR THAT HE OR SHE 15 EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7031.6 BY ANYAPPUCANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (1500).):
0 L AS OWNER 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 (SEC. 7044, BUST.
NESS AND PROFESSIONS CODE: THE COMPACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BULLAS OR 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 IMPROVEMEMIS SOUR WITHIN ONE YEAR OF COMPILE.
TIN, THE OWNER43UILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DO NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
O LAS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT
(SEC. 7044, BUSINESS AND PROFESSIONS CODE: ME CONTRACTORS LI-
CENSE LAW DOESNOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON. AND
WM1O CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR($) LICENSED PURSUANT TOTHE CONTRAC-
TORS
LICENSE LAW.),
O 1 AM EXEMPT UNDER SEC. B. a P.C. FOR THIS REASON
DATE OWNERI
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED ANDER PROVISIONS OF CHAPTER
I (COMMENCING WITH SECTION 7000) OF DIVISION 3 O THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS N FULL FORCE AND EFFECT.
UCENSE CUSS LIC. NO.
DATE CONTRACTOR
WORKERS' COMPENSATION DECLARATION
1 HEREBYAFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECIARATIONS-
_I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS'
COMPENSATION. AS PROVIDED BY SECTION 7700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
_I HAVE AND WILLMANTAN WORKERS' COMPENSATION INSURANCE, AS REWIRED BY SECTION
5700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER
POLICY NUMBER
m65 SECTION NEED NOT BE QAFIJ:TmOFTHE PERMIT IS FORONE HLwREDDDUARS alBm CRLESS
1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I
SHALL NOT EMPLOY ANY PERSON N ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS' COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF 1 SHOULD BECOME
SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 37000E THE LABOR
CODE.1 SHALL FORTHYATH COMPLY WITH THOSE PROVISIONS.
DATE: APPLICANT:
WARNINGS FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL BE
SUBJECT
AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (1100,000)• N ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN
SECTION 3706 OF THE LABOR CODE. INTEREST, AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE 15 A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097, OA. C).
LENDERS NAME
LENDERSADDRESS
1 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 AGREE TO COMPLY WITH ALL CITY 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 PURPOSES.
A?e,a
PERWTTEE NAME (PRIM
VIRE OF P TrEE / ' DATE
PRESS
FIRMLY
APPLICATION
PERMIT I
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DATE
NUMBER
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ISSUE
TYPE
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DATE
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TOTAL FEES
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COMMENTS
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WHITE—Depan meet Copy. YELLOW --Finance Copy. PINK—Alu suor Copy. GOLDENROD—File Copy, GREEN—Appllcant's Copy
CITY OF DIAMIOND,GAR `
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