HomeMy WebLinkAbout15953 CITY OF DIAMONI7 BAR ���
---�1"�``� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �./�
21660 E.Copley Arive Surte 140 n �"J
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY dr DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190 I� Mld
(909)860-3195 Fax(909)861-3117�� ��
BUILDING PERMIT APPLICATION �
ADDRESSi
�t-'TRACT� �
APN L T
OWNER S" � +
ADDRESS('�
CITY.�//.vy�e ZIP TE. i
APPLICANT�-.TEL Gam..'-k...'�
CONTRACTOR��
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CITY�/�ZI I--��y TE�/� '[
ARCH/ENG/r
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DESIGNER�
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CITY ZIP'
OWNER-BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LI-
CENSELAW FOR THE FOLLOWING REASON(SEC. 7W 1.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REWIRESAPERMITTO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIRANV 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 PP.OYISIONS OF THE CONTRACTORS LI-
CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISK)N 3 OF THE BUSINESS AND PRO-
FESSpNSCODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANY VKX-ATION OF SECTION 7031.5 BY ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT 70
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(5500).):
^ I,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK ANb THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7041,BUSI-
NESS AND PROFESSION! 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,HOWEVER THE BUILDING OR IMPROVEMENT I$SOLD W(THIN ONE V EAR OF COMPLE-
TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR 111E PURPOSE OF SALE).
^ I,AS OWNER DF'fHE PROPERTY,AM EXCLUSIVELY(ANTRACTING WITN LICENSC-D CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7041, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI"
CENSE LAW DOES NOT APPLY 70 AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,ANO
WMO CONTRACTS FOR SUCH PRO.IECTS WITH ACONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAG
TORS DCENSE LAW.).
^ I AM EXEMPT UNDER SEC. B. 8 P.C. FOR THIS REASON
DATE OWNER �
LICENSED CONTRACTORS DECLARATION
1
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER
P(COMMENCING WITH SECTION 7000)OF DIVISION 30F THE BUSINESS AND PROFESSIONS CODE,AND
MV LICENSE IS IN FULL�=ORCE AND EFFECT.
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DATE�"'•pI_CONTRACTOR V L'fL CDEID�
WORKERS'COMPENSATION DECL.ARATIUN
I HEREB AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WIf.L MAINTAIN A CERTIFICATE OF CONSENT 70 SELF-INSURE FOR WORKERS'
COMPENSATION.AS PROVIDED BY SECTION 3700 OF TI lE LABOR CODE, FOR THE PERFORMANCE
F T11E WORK FOR WHICH THIS PERMIT IS ISSUED.
A
I HAVE AND WILL MAINTAIN WORKEPS'COMPENSATION INSURANCE,AS REQU{RED BV SECTION
3700 OF THE LIBOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ORI<ER$'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE.-.
ISSUED. MY W
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CARRIER i I:,L� �i C, � m�� ��-,�
POUCV NUMBI_R W�R I'. .,�'�,�-_,
i (fYUS$ECilUN NEED NOT BE OJMPL.LZED OF THE PERMIT6FOR ONE HUFDHED OOIlARS(5100)OR LESS}
I
I CERT:FV THAT IN 1-HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EAAPLOY ANV PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
�WORKERS'CCMIPENSAT KNI LAWS OF CALIFORNIA.AND AGREE THAT IF I SHOULD BECOME
SUBJECT TG 1NE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF TIRE LABOR
HWITH COMPLY WITH TH E PR
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1 GATE: �� ��� APPLICANT: �I �J��1�'e,-' �
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j 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(5700,000),IN ADDITION TO 1 HE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
1 SECTION 3708 OF THf: IABOR CODE,INTEREST.AND ATTORNEYS FEES.
1 CONSTRUCTION LENDING AGENCY
i
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
(SEC. 3097,CIV.C.),
S PERMIT IS I
UE
OF THE WORK FO
R WHICN TH
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LENDER'S NAME�Q•I �� ' �• �1 � �C��C I I. �+
LENDER'S ADDRESS-
� 1 CERTIFY THAT I HAVE READ TNIS APPLICATK)N AND STATE THAT THE ABOVE INFORMATpN IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
3 CONSTRUCTlON,AND HEREBY AUTHORIZE RE ESENTATIVES OF THIS COUNTY TO ENTER UPON THE
PROPERTY FOR INSPEC ON PURPOSES.
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