HomeMy WebLinkAbout15956 �� CITY OF DIAMOND BAR
DEPARTMENT dF COMMUNITY&DEVELOPMEN'T'SERVICES i �r '
���� 21bfi0 E.Copley Drive Suite 190 � C
(969}$60-3195 Fax(9Q4)861-311? "` �� PRESS
����^� BUILDING PERMTT APPLICATION ��-- ;r,� ��„� � � FIRMLY
JOBSITE / S APPLICATION .% �`"� PERMIT ` (,.4/� _ P/C �
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o ADDRESS��t./ _ �_,..,—,. DATE � � �� '�`-✓ NUMBER-j�`� # `✓ J`�.�� 1
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0 1 HERE9Y AfFIlYI tNIDEH�ENALTY CsF PEflJURY THAT 1 AM EXEMPT FROM THE C�JNTRACTOqS LI- � C,a�age/Carport C �,()' � �" � � �-�
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U CpJNTYWHICHpEWWE:SAPERMfTTOCONSTRUCT,ALTER,IMPROVE,DEMOUSH,ORRWFlAIRANYSTRUC- W PalIO/DBCk
Z TURE,PFiIOH TO ITS FSSUANGE.AlSO Fi€(XIVRES THE AFPIICANT fOR SUCH PEFlMIT TO FILE A SIGNED �
STATEMENT THAT HE OFI SHE IS LICENSED PURSUANT TO THE PRbVISIOMS OF THE CdNTRAGTORS U-
� CENSE UW(CHAPTEp B(COMMENCINO WI'fH SECTION 7000)OF DIVISION 3 OF THE eU31NE5S ANO PRO- �" POOUSP&
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TIpN.lWVVIOLATIONOFSEGTION703�.SBVANVAPPLICANTGQRAPEPMITSU&IECTSTHEAPPLICAN770 � Re-Rqot
� AGVlI PENAITY OE NOT MOflE THAN FIVE HUNORED Df.1L.UR5(f5W)):
� Q4�.SOWNEROFI}iEPflOPER'fV,ORAiYEMPIOV�ESWiTHWAGESAS.^.IEIRS6�ECAMPENSATION, � �pmRiBtCiel
MIILL DO 7HE WOill(,ANJ TNE STRUCTURE IS N07 IN7ENDED OR qFFER�D FOR SALE(SEC.70<a,6U51- J
FiESS ANO FflOFE5516M5 COUE TttE CON'lflACfORS LIGENSE tAW pOE9 NOT APPLY Tq pN OWNER oF
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= IMpROYEFURTHEPURPOSEOFSAIEJ.
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� �X�� WQRKERS'COMPENSATION DECLARATION � ` � �!
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COMPENSATICIN,AS PROVIUED @Y SEGTION J]COOF THE IABOR CADE,FOR THE PEFFORMANCE IU �� '�
#TME WOftK FOR WHICN THIS PEFIMIT IS tS5UE0. �
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W �1 MAVEANDFNIl MANJTAl1J WORKERS'f:OMCENSATIQN INSURANuE,AS REDUIflEU 6Y SEGTIGN '
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Z" I CERTIfY THAT IN THE PERFORMANGE OF TI IE N'OqK FOR WHICM THIS pFRMIT IS ISSIJED.I —._,.
' t� SMti�NOT E�kPIOY ANY PEflSQN IN ANY MANNEft 50 AS TO BECAME SUeJECT TO TNE
�/y WOFiKEAS'G"�MVENSATiqN UWS Of GALtF04iN�A,ANDAGIiEE TrypT ff i SHOiII�fl€CAME INSPECTICYN FEE _ 1�h
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OOIURS(t100,o00),IN POpITION TO TME C057 Of COMPENSAT�ON,6AMAGES AS PRQVI�E6 FOR�N �
� $ECTqN 37oB OF'fHE IABOR GOL7E,MTEREST,AND ATfORNEY'S LEES, RETENTION FEE: �
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� I HEREBV AFFIpN UA�DER PENALTY Of P�NllpYTHA�THEF2E IS A CONSTRUCTION lEtJ01NG AGENCY � ,
FOR TNE PEpiORMp,NCE pF THE WORK FOF W,H�-IC�H THIS PERMIT IS ISSUEO�SEC.9oB7,CIV C.). , � ���—
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� LENDEq'S NAME.__'r�� � �`�'
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� ICEi1TIfYTHAT(HAVEREAATHISAPPI.ICATKM4ANOSTATETHAT7HEA86VEiNi'-0flMATiaNiSL�RRECT TOTAL FEES � � �����`�• ����y���
� I A6REE TO CAMPLI'WITN ALl C17V ANLI COUNTY OHUINANCES AND STATE LAWS RE4ATING 70 BUIIDING s`� �. �i
� CbNISTRUCTi('IN,ANDHEREBYAUTFK:RIZEftEPRESEKTATiV£SOFTMISCOUNTYTOENTERVPONTNE
ABOVE�MEN710NE0 GROPERTV FOR IN$PECT N PUR70SES. CQMMENTS_. ,,,_
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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�'�4�I�-�
PRESS
FIRMLY
JOBSITE I 0 5
ADDRESS�I !�"
APN LOT TACT,S2-2fo I
OWNER P�11-i"r w
ADDRESS t8,�o
CITY �LV 1 A.�ZIP q2�-f 2-TEL.q� 797"yea
APPLICANT�I�'VF.TEL 5 Aw�Fi
CONTRACTOR- U
ADDRESS 143LI=b I/'0
CITY V w/': ZIPqu r z TEL.�r! �7�TS�G
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DESIGNER/
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ADDRES
CITY�L�.(i/,I/,E ZIPg26/2 TEL.�JS� 797 S�S��D
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE UW fOR THE FOLLOW WG REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REWIRES A PERMIT TO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY STAUC-
TURE. PRIOR TO ITS ISSUANCE,ALSO REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OFI SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE UW(CHAPTER 9(COMMENCING WITH SECTKN 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CCIDE)OR THNT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CMI PENALTY OF NOT MORE THAN FIVE HUNDRED DOLURS(f500).):
^I,AS OWNER OF 1'HE PROPERTY,OR MV EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK ANO THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE ISEC. 70dd, BUSI-
NESS AND PROFESSIONS CWE:THE CONTRACTORS LICENSE UW 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,HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE-
TION,THE OWNER-BUIL'�ER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
1,AS OWNER OF THE PROPERTY,AM EXCLUSiVELV CONTMCTING WITH LICENSED CONTRACTORS
PTO CONSTRUCT THE PRO.IECT(SEC. 7041,BUSINESS AND PROFESSIONS LADE:THE CONTRACTORS LI-
CENSE UW DOES NOLIPPLV 70 AN OWNER OF A PROPERTY WHO BUILDS OH IMPROVES THEREON,AND
WNO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE UW.).
^ 1 AM EXEMPT UNDER SEC. ,__B. 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
0 (GOMMENCWG WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
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DATE�7C•�G%/_CONTRACTOR_�!�� �(�I1 N.
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COMPENSATION DECLARATI
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T WORKERS
t HEREBY AFFIRM LINO ER PENALTY OF PERJURY ONE CF THE FOLLOWING DECORATIONS:
I HAVE AND WILL MAINTAINACERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATKN, P.S PROVIDED BV SECTION 37000E THE LIBOR CODE,FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS HEOUIREU BV SECTION
3700 Of THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
IER A
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MBER ARE
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I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANY PERSON IN ANV MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'GJMPENSATKNJ UWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO'IHE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LIBOR
E PROVISIONS.
ORTHWITH COMPLY WITH THOS
CODE. I SHALL F
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APPLICAN
1 DATE:
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I WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNUWFUL,AND SHALL BE
1
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DCILURS(1100,000),IN ADDITION TO THE COST Of COMPENSATION, DAMAGES AS PROVIDED FOR IN
I SECTON 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
I CONSTRUCTION LENDING AGENCY
i
I HEREBY AFFIRM UNDER PENALTY OF PERDU RV THAT THERE IS A CONSTRUCTKNJ LENDING AGENCY
RMIT IS ISSUED(SEC. 3087,
C
IV. C.).
F THE WORK FOR WHICH THIS
PE
FOR THE PERFORMANCE
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LENDER'S NAME� � '•'�� � �L' �� /Lrn �Cad',�
LENDER'S ADDRESS
�I CERTIFY THAT I HA'/E READ THIS APPLICATK)N AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 AGREE TO COMPLI'WITH ALL CITY AND COUNTY ORDINANCES AND STATE UWS REUTING TO BUILDING
5 CONSTRUCTlON,AND HEREBY AUTHORIZE REPRESENTATIVES OFfHIS COUNTY TO ENTER UPON THE
ONED PROPERTY FOR INSPECT CMI PURPOSES.
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