HomeMy WebLinkAbout14906CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117+
PRESS
BUILDING PERMIT APPLICATION _ i4612z FIRMLY
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OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT i AM EXEMPT FROM THE CONTRACTORS LI.
CENSE LAW FOR THE FOLLOWING REASON (SEC. 701.5 BUSINESS AND PROFESSIONS CODE: ANYCITY OR
COUNTY WHICH REOUIRESA PERMIT TO CONSTRUCT, ALTER, IMPROVE, DEMOLISH, OR REPAIR ANY STRUC.
TURE. PRIOR TO ITS ISSUANCE. ALSO REGUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
.STATEMENT THAT HE OR SHE I6 LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS U.
-CENSE LAW (CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 O THE BUSINESS AND PRO.
. FESSIONS CODE) ORTHATHE ORSHE 16 EXEMPT THEREFROM AND THE BASIS FOR THEALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($500).):
D 1, AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION.
WILL
DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUST.
NESS AND 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 FORSALE IF.HOWEVER.THE BUILDING ORIMPROVEMENT IS SOLD WITHINONEYEAROFCOMPLE-
TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
01, AS OWNEROF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 70th, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS UI
CENSE LAW DOES NOTAPPLY TO AN OWNER OFAPROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS FORSUCH PROJECTS WITH ACONTRACTOR(S) LICENSED PURSUANT TO THECONTRAC-
TORS LICENSE LAW.).
❑ 1 AM EXEMPT LINDER SEC. D. a P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER
9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS IN. FULL FORCE AND EFFECT.
LICENSE CLASS 1�1 LIC. NO. I Z
DATE "'U"1� CONTRACTOR
WORKERS' COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
—__ I HAVE AND WILL MAINTAIN WORKES' COMPENSATION INSURANCE, AS REQUIRED BY SECTION
3700 OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER ___-
POLICY NUMBER
MRS SECTION NESDNOTBE00FPLETEDOFTHE PERMIT IS FORONEHUFAREDDOLLARS (3100)OR LESS)_
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
j. WORKERS COMPENSATION LAWS OF CALIFORNIA, AND REETHAT IF I SHOULD BECOME
SUBJECT TO THE WORKER! DM
PENSATI NPROV OF SECTION 3700 OF THE LABOR
CODE. SHALL FORTHWITH COMPLY WITH NS.
I i
I" DATE: f �. 'PUCANT: _
j
r _ WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE
IUBJECTAN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (51 D0,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
1. SECTION 3708 OF THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
IHEREBY AFFIRMUNDER PENALTY OF PERJURY THAT THERE IS ACONSUED(S LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC.
3097, CIV. C.).
- LENDEfl'S NAME
LENDER'S ADDRESS
CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
`- ABOVEMENTIONEO PROPERTY FOR INSPECTION PURPOSES. ,j
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NO. DWEL. NO. NO.
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