HomeMy WebLinkAbout18366 (11) �":z?`�•._ CITY nF DIAMOND BAR �,,. �. � i ,�
� DEPARTME'NT OF CQh9V[IINITY&DEVELOFMENT SERVICES � �`, �� �` t• t
21825 E.Copley I7rive
(409)860-3195 Faac(909)861-3117 PRESS
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� i HAVE AND WILL MAINTAIN WOPKERS'COMPENSATfON IN5UqpNCE,PS R£QUIREO BY SECTION
Q 3�0o OF THE LABdR CObE,FOR iHE PERFOflMANCE OF THE WORK FOR WHICH THIS PERMI IS
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(„3' SHALL NOT EMPLOV 4NV PER5f7N IN ANY MANNER$O AS TO BECOME SUBJECT TO7HE
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,ISHALLFdRTHW17HCOMPLVWITdTHOSE �/ISIONS.
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w ENERGY P!G
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� SUBJEGTAN EMPLOVERiO CRIMINAL PENALTIES AND CIVII FINES UP TQONE NUNDRED TNClUSAND ENERGY PERMIT �
� DOLLAfIS{fi0Q,00�),IN ADOII'ION TOTHE COST OF COMPEN5ATION,DAMAGES AS PftCJYiDED FOR 1N --���- --"'
J SECTiON 3JC8 Of TNE LABOFt CAGE,iNTEREST,AND AT70RNEV'S fEES. fIETENTION FEE: ��,,,
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a GONSTRUCTION IENDING AGENCY PRE-ALT FEE: ,._. .._
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� I HERE6Y AFFIRM UNQEft PEllALTY OF pFR.fUAY THAT THE0.E�S A CONSTRUCT40N LE4DlNC AGENCY
a- FOR THE oERFORMRNCE OF 7NF WnRK FOR WHICH TH�S PERFEiT IS I5SUE0 j5[C.309],CiV C.}. —"" "—-
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� ICEAi�FYTMATt1iAVEREADTHISAPPLICATI�NANbSTAiETHPTTNEA90vEINFORMATIONISCOflRECT. TOTAL FEES
� i AGREE TO COMPLV WITN AF i_CITY ANb CAUNTY ORDtNANCES ANO STATE�WS RELATINQ TO 8UIL6�NG
� CONSTRUCTION,ANf1NEREBVAUTHORIZEREPRESENTATNE50FTHI5COVNTVTOENTERUPONTHE
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OWNER�!i
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CITY-'t'-A'°�'-�-°4� ZIP�-��,�TEL. ��I �(c�InS
APPLICANT TEL.
CONTRACTOR- .�IOsH F'F��,DA�s�Trl N
ADDRESS�Z�i,'�__��, FCrA��Q�-p•
CITY�,�Ir ZIP�i23GK TEL. �_C�
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSELAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANV CITY OR
COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT,ALTER,IMPROVE,DEMOLISH,OR REPAIR ANV STRUC-
TURE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSELAW(CHAPTER 9(GOMMENCING WITH SECTION 700x)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONSCODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANV VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(5500).):
0 I,AS OWNER OF THE PROPERTY,OR M V EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK,AND 7HE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7004, BUSI-
NESSAND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS 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,HOW EVER,THE BUILDING OR IMPROVEMENT IS SOLD W ITHIN ONE YEAR OF COMPLE-
TION,THE OWNER-BUILDEF'.WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
0 I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTlNG W ITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE LAW DOES NOT APPI_V TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS W ITN A CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAG
TORS LICENSE LAW.).
^ 1 AM EXEMPT UNDER SEC. B. 8 P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PE NALN OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISION 30F THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE
AN
EFFECT.
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LICENSE CLASS�� LIC. N0.
DATE���-��CONTRACTOR
WORKERS'COMPENSATION DECLARATION
I HER AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
1 HAVE AND WILL MAINTAIN ACERTIFICATE OF CONSENT TOSELF-INSURE FOR WORKERS'
MPENSATION,AS PROVIDED BV SECTION 3700 OF THE LAROR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMI IS
ISSUED. MV WO ERS'MPENSATION INSURANCE CARRIES ND POLICY NUMBE�g.ARE:
CARRIER���CJ�M
POLICY NUMBER
(Di1S SECTION NEm NOT BE COMRETED OF THE PERFAR IS FOR ONE HUNDF3ED OOL.IARS(5100)OR LESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY 4NV PERSON IN ANV MANNER 50 AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WGRKERS'COMPENSATION PROVISI N�ECTlON 3700 OF THE LABOR
CODE,I SHALL F
ORTHWITH COMPLY WITy THOSE ISIONS.
/nJ
0
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DATE:
Ii APPLICANT:
WARNING: FAILURE TO SECURE WORKERS'COMPENSAT ON COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(5100,000),IN ADDI110N TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
I HERERV 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.CIV.C.).
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ 7HIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITH ALI_CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZEREPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTI
PR
ON PURPO
ON
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OPER N FORINSPECT�I
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PERMITTEE N ME(PRINT
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SIGNATUR P RMI1T E DATE
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
1
PRESS
FIRMLY
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WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy
