HomeMy WebLinkAbout16136 (9) �` CITY OF DIAMOND BAR ,,��}.,.�
� DEPARTMENT OF C4MMUNITY&DEVELOPMENT SERVICES `�,
. : 2156�0 E.Caplay Drive Suite 19Q � ' `� ��
(904)860-3145 Fax(904)861-3117 PRESS
, ��M��� BUII.DING PERMIT APPLICATION FIRMLY
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� DESCRIPTIpN SQ.FT. FAGTOR PSF ADJ.AREANALUATION
a OWNER-9UILDER DECLARATlON f SFRtADD1AEM
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�] I NERE9Y AFflRM UNDER PENALTV OF PEKNRV THAT I AM EXEMPT FqOM THE CONTRACIORS L.I� Gdt8�8IC8(p0t2
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7URE.PRIOH TO ITS ISSUANCE.AISQ REOUIRES TNE APPUCMIT FOR SUCH PERMIT TO FlLE A S14NFA �
� STAEMENT TH)�T NE OR SHE IS UCENSED PURSUAN7 TO THE PpOVIBi6NS OF TtiE CONTRACTORS LI-
CENSE 6AW(GHAPTER Y(COMM8NCN0 WITN SECTION�oq0)OF bIVISION 3 OF THE 9USINE55 AND PRO- � Po0USp8
FESSlONS C4DE}OATHAT HE OR SHE IS EXEMPT TNEREFHOM AND THE$A515 fOR THEA6.4EGE�ExEMP-
T10N.ANYYKKATKMiOFS£:CTK7N7031.58YANYAPPI.ICMlTiONAPERMiTSUBJECTSTHEAPPUCAN7T0 Z F18^f�00f
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VALL DO iHE wORK,�t�10 7HE 5THUCNRE IS NOT INTENDED pR OFGERED FOR SALE(SEC.7oa.�,eUSI. J
HE55 AND PROFESSIONS CODE:THE CONTMCTORS LICENSE LAW DOES NO7 APPLY TO AN OWNEH OF
� PROFER7YHt+�9UkDSORiMAROVESTHEREON.AtlDVAt06DES5lJCNVx�RKN�AiSE�FORFERSE�FOA �
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UC t HEREBYlFfii9A U1�ER PE:NALTY t3F PENURY TiiAT i tAi ItCENSED UNDER PPOV151dN5 OF CHAPTER �
� Y(COMMENGINO WITH SECI'KKJ 7D00)G7F DIVISION 8 OF THF BLISWESS AND PPOFES610N5 CODE,AND Z „
LLj MY LICENSE IS IN NLL FOHCEAµD EFFECT r� m
� LICENSE CLASS__^�'! LIC.N0.,���__ `/ ._ �
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� DATE CC7NTRACTOR _�.,._ �-
� WORKERS'COMPENSATIQN DECLARATION J
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� 1 tfERE AFFlRM VN6E9 PENlJ..TY UF P6AJURY ONE OF TitF FOLt6WING DECLARATiONS: �
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� i!UN[AND NhLt MAWTANi A CERT1�tCATE OF ix}NS£iiT f O SEIFINSUftE FCNi WDRKEftS' _�
COMPENSI1�ION,ASPROVIDEDBYSECTION9'OOPFTHEUBOflCODE,FORTHEPERFOFMANCE 1U
OF TNE WORK FOR IMHICH THiS PERMiT IS ISSUEp. �
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� I HAVE ANO WILL MA�MAIN WtlRKER9'COMCENSATION INSUMNCE,AS REQUIREO 6Y SECl'ION
�d�, J7oo O�THE tt80fl CdDE,FOR TH£PERK}RAtANCE 4F ifiE WORK F6R VdFIICH THIS PERMIT IS
ISSUED.MY WORNENS'GOMPFYNSATN]N INSURANGE ApRIERAND�5POUCY Nl1M9ER nRE: CONSTRUCTICJN ,,,��J �-- _
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� I CEIiTIFV TMAT IN TFiE PERFORMANCE OF 7NE WORK FOR WHIGN THIS PERIAIT IS ISSUEO,I MECHANI AL _,,, � _ __�_
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(/� WC}fiKERS'COMPENSATKNI UWS OF CALIFCaFNiA,aND AGREE 7HAT IF i SitOUL066COME INSPECT) N FEE�� �
� SUB,IECTTC7THE W(IRKERS'p]AIVEN$ATION PiiOVISIONSOF SECTION 3]OOpFTHE LABOR ' �`''� �
CA�E,1 SHALL fORTHWITH COMPLY WI7H T41QSE PPOYtSKNi3 �SSUANC _,,,,,,,___,,, ,,,,,,,,_,,,,�_�-`^�+�",
rj DATE:�� APPUCANT: �_��..,�p4-- l�wu�- ._. L SMIP `�l� ..^„
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� WARNIN4:FAILURE 1'O SECURE WORKERS'CdMPEN9ATIQN CAVERAGE IS UNLpWFUL,AND 5HAL�BE """ —
� SUBJECTANEMPLOYEflTOI:RIMINALPEN41.T1E5ANDC1VILfINESUPTp�NEHVNDREQTHOUSpNp ENERC�YPERMIT
�OLUpS tS106.60aj,IN AC}pi'nON TO TifE COST OF COMPEMSATK}N.DAMAGEu AS PROViDED FOR IN - ����--�—
� SECTION 31tl6 oF THE 1A80R CODE,INTERESL AND ATTOPNEYS FEES. RETENTION FEE: _,,,, _.... .—_
p�,. CONSTRUCTION LENDING AGENCY PFiE-ALT FEE: _ ..� ...
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� i}tER£8Y AFFIftM UMDER PENAtTY 6F PE WURY TNAT TH6RE IS A CONSTRUCT�ON LENDIN6 A6ENCY
FOF THE PERFORMANCE OF THE RK FOR WH1CN 7HI5 PERMIT IS ISSUED(9&C.3991,CIV.C.),
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LENDER'S NAME____
h— LENDER'S AbDRE55_ . ...„ i ( j�
� ICERTIFYTMATiHAVEREAOTHISAPPtiCATItJNANDSTATETHATTkEA80VEMFORMATION�SCORRECT. TtJ1A� 1—E�� 1 "�„�SL.J
� I AGREE TO COMPLV wITH ALL dTV PNp COUNTv OqDINANCES AND STATE LAWS RELATIN070 BUILDING �,.,ai��{r
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
APN LOT i TFjQCT��ZZ�7
OWNER�!i/.13��IK-�-
ADDRESS U t��� �,I/7rL+�+l
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CITY���ZIp���GJZ TEL.
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APPLICANT,TEL.4
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CONTRACTOR_
ADDRESS
CITY ZIP TEL.
ARCH/ENG/
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DESIGNER-I--F-1 �-
ADDRESS�� �f I/��
CITY�T�ti P I TEL.-7/(1 ��G
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OWNER-BUILDER DECLARATION�
I HEREBY AFFRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLfNVING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REWIRES.A PERMRTO 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 70 THE PROVISIONS OF THE CONTRACTORS LI-
CENSE LAW(giAPTER D(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONSCODE)ORTHAT IiE ORSHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TgN.ANY VIOLATION OF SECTION 7031.5 BV ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CML PENALTY OF NOT ANDRE THAN FIVE HUNDRED DOLLARS(!5001.):
^ 1,AS OWNER OF THE PROPERTY,OR MV EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
MALL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 70a,8U51-
NESSAND PROFESSIONS CODE:THE CONTRACTORS LICENSE UW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUDDS OFI NAPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
TNROUCiH HIS OR HER ONTI EMPLOYEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF,HOMIEVER THE BUILDING OR IMPROVEMFM IS SOLD WITHIN ONE YEAR OF COMPLE-
TION,THE(INNER-BUILDEiI WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
^I,AS OWNER OF THE: PROPERTY,AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7041, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSELAW DOES NOT APPLY 70 AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUgi PROJECTS WITH A CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAP
TORS DCENSE LAW.j.
^ I AM EXEMPT UNDEfI SEC. B. 8 P.C. FOR THi5 REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PF:NALN OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
D(COIAMENCINO WITH SECI'K3N 7000)OF DIVISKNJ 3 OF THE BUSINESS AND PROFESSIONS CODE.AND
MY LICENSE IS IN FULL FORCE D EFFECT.
�j
LICENSE CLASS_-,
LIC. N0._
I
DATE CONTRACTOR
s-
WORKERS'COMPENSATION DECLARATION
1 HERE AFFIRM UNDER PE NALN OF PERJURY ONE OF THE FOLLOWING DECLARATK)NS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATKKJ,AS PROVIDED BY SECTION 3700 OF THE LIBOR 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 PERMIT IS
ISSUED. MY WORKERS'COMPENSATION INSURANCE ARRIER AND POLICY NUMBER ARE:
CARRIER.�� � ����
POLICY NUMBER��� !L s"��I�/pS--7
Tf
(iVDS SECTION NEED N07 BE�A4T-ETEU OF THE PERMIT IS FOR ONE FRINDRED DOI lARS(Si 00)OR LESSL
I CERTIFY THAT IN TFiE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I
SHALL NOT EMPLOY ANV PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATKKJ LAWS OF CALIWRNIA AND AGREE THAT IF 1 SHOULD BECOME
SUBJECT TO THE WCIRKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE. 1 SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
L'
//mar-a ��
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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 HUNDRED THOUSAND
DOLLARS(1100,000),IN ADDITION TO THE COST OF COMPENSATKN, DAMAGES AS PROVIDED FOR IN
SECTON 3708 Of THE LABOFI CODE,INTEREST AND ATTORNEYS FEES.
CONSTRUCTlON LENDING AGENCY
1 HEREBY AFFIRM UNDER PEIJALN OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE RK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3087,CIV.C.),
LENDER'S NAME��[
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY ANO COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORI E REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTI
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SIGNAT PERMITTEE� DATE
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy