HomeMy WebLinkAbout16773 (25) - CITY�F DIAMOND BAR �— �'/�J f
� ---��----- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117 PRESS
������ BUILDING PERMIT APPLICATION FIRMLY
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o ADDRESS DATE � 1 �^vINUMBER #
� ISSUE TYPE , OCC
APN LOT TRAC�`T� �..�� DATE CONST. GROUP
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o ADDRESS E• ZONING SETBACKS
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� APPLICANT �FL��I� TEL. REAR ❑
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p� OWNER-BUILDER DECLARATION SFR/ADD/REM
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p I HEREBY AFFIRM UNDER PENALTY OF PERIURY THAT I AA1 EXEMPT F{iOM THE CANTRACTORS LI� GefB(JB/C8fp0A �
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U COUNTVWHICHREOUIRESAPERMITTOCANSTRUCT.ALTER,IMPROVE,DEMOLISH,ORREPAIRANYS7RUC-
w TURE,PRIOR TO ITS ISSUANCE,ALSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w Patio/Deck
� STATEMENT THAT HE OR SHE IS LICENSED PURSUAN7 70 THE PROVISIONS OF THE CONTRACTORS LI- �
� CENSE UW(CHAPTEFi D(CAMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO� POOVSPa
� FESSIONSCODE)ORTHATHEORSHEISE%EMP7THEREFROMANDTHEBASISFORTHEALLEGEDE%EMP- (�
V TION.ANV VIOLATION OF SECTION 7031.5 BV ANV APPLICAN7 FOR A PERMIT SUBJECTS 7HE APPLICANT T0 Z Re-Roof
� A CIVIL PENALTV OF NOT MORE THAN FIVE HUNDRED DOLLARS(f5o0).J:
Z ❑I,ASOWNEROFTHEPfiOPER7V,ORMVEMPLOVEESWITHWA�E5A5THEIR50LECOMPENSATION, � COmmBfCifll -
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.701�,BUSI� J
N NE55 AND PROFESSIONS CADE:THE CANTRACTORS LICENSE lAW DOES NOT APPLV TO AN OWNER OF �
PROPERTV WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
Q THROUGH HIS OR HER ON7J EMPLOYEES,PROVIDED THAT SUCH IMPROVEMEN7S ARE NOT INTENDED OR m
Q OFFEREDFORSALEIF,HOWEVER,7HEBUILDINGORIMPROVEMENTISSOLDWITHINONEVEAROFCOMPLE-
Z TION,THE OWNER�BUILDEH WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR �
� IMPROVE FOR THE PURPOSE OF SALE).
❑I,AS ONRJER OF THE PROPERTV,AM EXCLUSIVELY CANTRACTING WITH LICENSED CANTFACTORS
� TO CONSTqUCT THE PRQIECT(SEC.70�4,BUSINESS AND PROFESSIONS CODE:THE CON7RACTORS LI- V81u8fion 5 ADJ.AREA
W CENSELAWDOESNOTAPPLVTOANOWNEROFAPROPERTYWHOBUILDSORIMPROVESTHEREON,AND
� WHOCONTRACTSFORSUCHFRQIECTSWITHACON7FiAC70R(5)LICENSEDPURSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FEE
Y 70R5 LICENSE LAW.).
' 0 ❑1 MI EXEMPT UNDER SEC. B.8 P.C.FOR THIS REASON Q
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DATE OWNER F'
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�¢ LICENSED CONTRACTORS DECLARATION w
2 I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER �
d D(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND Z �
X MY LICENSE IS IN FULL FORCE AND EFFECT.
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�� � WORKERS'COMPENSATIONDECLARATION ¢
NI HEREBY AFFIRM UNDER PENALTV OF PERIURV ONE OF 7HE FOLLOWING DECLARATIONS: Z
Z _I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS' a �
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¢ CAMPENSATION,AS PROVIDED BV SECTION 37000FTHE LABOR CODE,FOR THE PERFORMANCE U
Q / OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. �
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V I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BV SECTION �+���///
Q 3700 OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 7l / �
ISSUED.MV WORKERS'COMPENSATION INSURANCE CARRIER AN�POLICY NUMBER ARE: CONSTRUCTION ��i
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j c�aaiER /., PLAN REVIEW
Z POLICVNUMBER � Q"fI�O,IO9 �(/ ELECTRIC
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� (fHISSECiIONNE�NOT8E00f.1PLEfFDOFTHEPERMITISfOfiONEFNPDFiEDDOILARSR��)ORLESS� PLUMBING
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Z I CER7IFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
C.�J SHALL NOT EMPLOY ANY PERSON IN ANV MANNER 50 AS TO BECOME SUBJECT TO THE �T(`� �
vj WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECAME INSPECT�ON FEE I I
� SU&IECTTOTHEWORKERS'COMPENSATIONPROVISIONSOFSECTION3700OFTHELABOfi ' � �
CA E.I SH LL FORTHWITH COMPLV WITH THOSE PROVISIONS. ISSUANCE 11 1 I �✓
1p DATE:� v APPLICANT: �• • ��1y� - SMIP 4l�F 1 ���� I ��D
J WARNING:FAILURE TO SECUHE WOHKERS'COMPENSATION CAVERAGE IS UNUWFUL,AND SHALL BE ENERGY P/C
� SUBJECTANEMPLOVERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENEFGYPERMIT � f�
DOlLARS(5700.000�,IN ADDITION TO THE CO57 OF CAMPENSATION,DAMAGES AS PROVIDED FOR IN
� SECTION37080FTHELABORCODE,INTEREST,ANDATTOflNEV'SFEES. RETENTIONFEE: -"-------�--�-�-�--�`�
a CONSTFiUCTION LENDING AGENCY PRE-ALT FEE:
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� I HEREBV AFFIRM UNDER PENALTV OF PERIURV THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3087,CIV.C.).
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� LENDER'S NAME �_
F- LENDER'SADDRESS
� TOTAL FEES `�
� I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. � � / .��
w I AGHEE TO COMPLV WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS FELATING TO BUIL�ING l v' �
� CONSTRUCTION,AND HEREBV AUTHORIZE REPRESENTA71VE5 OF THIS COUN7V 70 ENTER UPON THE
� ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
Z COMMENTS
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SEPTIC TANK LANCSGAPE/IRRIG. � ' -
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FINAL ELECTRIC � � � � DEV. FEES PAID
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