HomeMy WebLinkAbout12002CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVIC
21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117 PRESS
BU"ING PERMIT APPLICATION ` FIRMLY
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ADDRESS
APNT T ACT _
OWNER
ADDRESS
CITY -P TE
APPLICANT _ TEL.
CONTRACT
ADDRES
CITY ZIP f TEL.
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DESIGNER , •z 4 l.®
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OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI.
CENSE LAW FORTHE FOLLOWING REASON (SEC. 7031.5 SUSINESSAND PROFESSIONS CODE' ANY CITYOR
COUNTY WHICH REQLARES A PERMITTO CONSTRUCT, ALTER, IMPROVE, DEMOLISH, OR REPAIR ANYSTRUC-
TURF, 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.
CENSE LAW (CHAPTER B (COMMENCING WITH SECTION TODD) OF DIVISION 3 O THE BUSINESS AND PRO.
FESSIONS CODE) OR KaTHAT 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 SUBJECT S THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS
CI 1, AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES ASTHFIR SOLE COMPENSATION,
WILL DO THE WORT( AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044. BUSI-
NESS
USKNESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON, AND W140 DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED PORSALE.IF. HOWEVER,THE BUILDING OR IMPROVEMENT 15 SOLD WITHIN ONE YEAR OF COM PILE.
TION, THE OWNER'BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OP
IMPROVE FOR THE PURPOSE OF SALEI.
[11, AS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI.
CENSE LAW DOES NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHOOONTRACTS FOR SUCH PROJECTS W ITHACONTRACTOR(S) LICENSED PURSUANTTO THE CONTRAC
TOPS LICENSE LAW.).
r) I AN EXEMPT UNDER SEC. ------ S. & P.C. FOR THIS REASON
DATE — OWNER__,
LICENSED CONTRACTORS DECLARATION
HEREBYAFFIRM UNDER PENALTYCF PERJURY THAT IAN LICENSED UNDER PROVISIONS OF CHAPTER
9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS N FULL FORCE AND EFFECT. ✓�
LICENSE CLASS_ LIC. NO.
DATE CONTRACTOR �!li
WORKERS' COMPENSATION DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARA IONS:
1 HAVE AND WILL MAINTAIN ACERTIFICATE 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 WORKEr,S' 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 A
CARRIER
POLICY NUMBER
(THIS BECTON NEED NOT BE ODWLETEDOFTHE PERMITIS FORS ONE HUFDRED j (SICO)DRLESS}
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SOAS TO BECOME SUBJECT TOTHE
WORNEHS' COMPENSATION LAWS OF PATION
EE THAT IF 1 SHOULD BECOME
SUBJECT TO THE WORKERS'COMPF,NNSO��Yj SECTION 37000F7HELABOR
CO ISH
FORTHWITH COMPLY WISI S.
DATE: ,__ APPLICANT:7UNLAWFUL,
WARNING: FAILURE TO SECURE WORKERS' COVERAGAND SHALL BE
SUBJECT AN EMPLOYERTO CRIMINAL PENALTIES UP TD THOUSAND
DOLLARS ($1 00,0W), IN TO
TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
IN REBY 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'SIDDRESS _.,_-______.,
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STAT E THATTHE ABOVE INFORMATION IS CORRECT
I 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
ABOVE-MENTIONED PROPERTY F SPECTION PURPOSES.
PERMITTEE NAME (PRINT RM
SIGNATURE OF FEI E DATE
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DATECATION
NERMIT'
ISSUE
TYPE
OCC
DATE
CONST.
GROUP
ZONING SETBACKS
FRONT
RW
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REAR
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SIDE/SIDE STREET RW
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SIDE
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NO. DWEL.
NO.
NO.
UNITS
STORIES
BEDROOMS
DESCRIPTION
SO. FT. FACTOR PSF
ADJ. AREAIVALUATION
SFR/ADDIREM
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Garage/Carport
LLIwPatio/Deck
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ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE -ALT FEE:
TOTAL FEES
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COMMENTS__
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RECPT. NO. _67PAID
BY
VALIDATION
WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD --File Copy, GREEN—Applicant's Copy