HomeMy WebLinkAbout18629 �� CITY OF DIAMOND BAR
- DEPARTMENT OF COMMUNI"I�Y&DEVELOPMENT SERVICES
�. 21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117 PRESS
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- �`� DEPARTME?�'T OF CONIIvIUNITY&DEVELOPIv�NT SERVICES
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BUILDING PERMIT APPLICATION
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OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQUIRES 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
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^ I,ASOWNEROFfHE PROPERTY,OR MY EMPLOYEES WITH WAGESAS THEIR SOLE COMPENSATION,
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044,BUSK
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
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THROUGH HIS OR HER OWN EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
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^ I AM EXEMPT UNDER SEC. B. &PC. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
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WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN 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 WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 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
(THIS SECTION NEED NO" BE COMPLETED OF THE PERMIT IS FOR ONE HUNDRED DOLLARS($100)OR LESS)
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
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J SECTION 3708 OF THE LABOR CODE.INTEREST,AND ATTORNEY'S FEES
CONSTRUCTlON 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 IS ISSUED(SEC 3097, DIV C,).
LENDER'S NAME
LENDER'S ADDRESS
CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT
1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
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OWNER-BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSELAW FOR THE FOLLOWING REASON(SEC. 703i_5 BUSINESS AND PROFESSIONS CODE: ANV CITY OR
COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,CR REPAIR ANV STRUC-
TURE,PRK)R TO ITS ISSUANCE.ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
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^ I,AS OWN ER OF THE PROPERTY,OR MV EMPLOYEES W iTH WAGES AS 1 HE IR SOLE COMPENSATION,
WILL DO THE WORK,AND THE STRUCTURE I5 NOT INTENDED OR OFFERED FOH SALE(SEC. 70x6, BUSI-
NESSAND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW D0�e5 NOT APPLY TO AN OWNER Of
PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
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TKNI,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING'HAT HE OR SHE DIO NOT BUILD OR
IMPROVE FOR THE PURPOSE 01= SALE).
C I,AS OWNER OF THE PROPERTY,AM E%CLUSIVELV CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 70aa,BUSINESS AND PROFESSIUNS CODE:THE CONTRACTORS LI�
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO dUII.DS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PFIOJECTS W ITH A CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
^ I AM EXEMPT UNDER SEC. B. H PC. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISION 30F THE BUSINESS AND PPOFESSiONS CODE.AND
MV LICENSE IS IN FULL FORC AND EFFECT. �^ �/!
LICENSE CLASS�_LIC. NO �J(/'�/'_
DATE
� ��� CONTRACTOR-
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENA LN OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION.AS PFOVIDED BV SECTION 3700 OF THE LABOR CODE. FOR THE PERFORMANCE
OF THE WORK FOP WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION
37000E THE LABOR CODE. FOR THE PERFORMANCE OF TH[WORK FOR WHICH THIS PERMIT IS
ISSUED. MV WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER
POLICY NUMBER
(THIS SECTION NEED NO'. BE COMPLETED OF THE PERMN IS FOR ONE HUNDRED DDLIARS(E700)OR LESSI.
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY AIJV PERSON IN ANV MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF 1 SHOULD BECOME
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DOLLARS(f 100,000). IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
I:ONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF IHE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV C.I.
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ--HIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITH ALL GIN AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION,AND HEREB'/AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE�MENTIgI�'OIWOPERI'V FOR INSPECTION PURPOSES.
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COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT.ALTER,IMPROVE, DEMOLISH,CR REPAIR ANY STRUC-
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FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
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A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500)):
^ I,AS OWNER OF THE PROPER TY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
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IMPROVE FOR THE PURPOSE OF SALE).
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WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(SI LICENSED PURSUANTTOTHE CONTRAC-
TORS LICENSE LAW)
^ I AM EXEMPT UNDER SEC. B. &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
9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PPOFESSIONS CODE,AND
MY LICENSE IS IN FULL F RCE AND EFFECT
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WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAIN"'AIN 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 WHICH THIS PERMIT IS ISSUED
I HAVE AND WILL MAIN'rAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE LABOR CODE, FOR THE PERF MANGE OF THEW RK FOR WHICH THIS PERMIT IS
ISSUED MY WORKERS'COMPENSATIO RAN CARRIE D POLICY MBER ARE:
CARRIER J/A-1
POLICY NUMBER?If V
(THIS SECTION NEED NOT BE COMPLETED OF THE PERMIT IS FOR ONE HUNDRED DOLLARS($100)OR LESS)
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY Ally PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATIO ROVISIONS OF S TI N 3700 OF THE LABOR
0 E.SH LL F RTHCOMPLY WIT S PROVISIONS WITH
DATE.APPLICANT,
WARNING: FAILURE TO SECUFE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS($100000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF"-HE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC 3097,CIV C.)
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT
AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTR TION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-NTIONED PROPERTY FOR I E I
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PAMITTEE NAME
I SIGNATURE OF PE ITTE DATE
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
PRESS
FIRMLY
L41 02
APPLICATION PERMIT P/C
073
S
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DATE NUMBER
5
ISSUE (7 TYPE OCC
DATE ! CONST. GROUP
ZONING SETBACKS
FRONT RW^
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DESCRIPTION S0. FT. FACTOR PSF ADJ.AREANALUATION
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LU Patio/Deck
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QUANTITY DESCRIPTION FEE
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ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES
COMMENTS
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RECPT N0. PAID BY VALIDATION
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy