HomeMy WebLinkAbout14934 (30)M-111111,191111
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
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ADDRESS
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ADDRESS
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OWNER
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DESIGNER
ADDRESS
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OWNER -BUILDER DECLARATION
I MCREBY AFFIRM UYOER PENALTY CF PER "TRY THAT I AM-cX!�MP- FROM THE CO\TRAC-0a5 LI- i
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7M:.53L'S. VESSAND PROFESSONS CODE ANY CITY OR
CDUNTYWH!CHREWIRE,SAPERMrrTOCONSTRUC:'.ALTER.WPROVE. DEMCLSr.OR CE?A:RAN,';TFUC• I
TURF. PRIOR TO ITS ISSUANCE, K -SO REGU'RES THE APPLICANT FOR SCC`I PERMIT. TO FILO A 5%1X.
STATEMENT T!'.AT HE OR SHE IS LICENSED PURSUAN" TO -NF. ?gOV15!CN+S C= -HF. CJ\T,RA,;'OHS Li•
H 7ION7 C'Or'•'V!SION 50F THE EUEiNOSS AND PRG•
CE7:SE LAW (CHAPTERS {..bMMENC :4R WT -4 SEC OC
FESSICNS CCOE) OR THAT tiC OR SnE 15 EX -MP' TIT: REFR.OM AND THE W-16 AOF THC ALLEGED EXE.'AP•
TION. ANY VK7LA- ON
OF SCCTION 7031.5 DY ANY APPLICANT FOR A PERMIT S',;;T,IEC'S'- IE APP_(;ANT-O
A CML PENALTY OP NOT MORE TPAN F.VE HUNDRED DOLLARS ;SSOC;* 1
_ I.ASOWNEAOFTn5 PROPERTY, ORMYEMPLOYEES W!'H WAGES AS TIIEIR SOLE OOMPCNS:J.CN.
WILL DO THe WORK. ANO T'E STRi:CTURE !S NOT INTENDED Ga OFZ.REO FOR SALE;SEC. 703x. EUSI-
NESS AND P,IOFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOfy NOTAP=-Y -C AN dWNER OF
PROPERTY VAIO aU:LDS OR IMPROVES THEREON. AND WHO DOES SUCH %ORK H.Mi'_F OR-ERSEL=,^R
THROUGH HIS OR HER OWN EMPLO"EES. PROVIDED -HA' SUCH IMPROVEMLN'N ARE tib" IFTENDr;D OR
OFFERED FOR SALE In HOWEVER THE 9UILDING OR IMPROVEMENT. IS SOL' W-
L NTHIN CNE YEAROFCOMPLE
TION• THE OWNER-HUZOER WILL TF -.E BURDEN OF PROVING THAT H= OP. S -'E DID tibT BUILD Ory
IMPROVE FOR
HE
PURPOSc OF SALE(.
I, Ay OWNER O+' THE PPDP=PT,; AM FXCI.US"dELY CONTRAGTING WIT(, _ICENT:ED CONTRALTO RS
TO CONSTRUCT THE PROJECT (SEL 7"A, BUSiNCSS AND PPOFRSG'•ONS CODE. T.'E coN-FACTORS LI-
SkNSELAW DOES NOTAPPLY-DAN OWNER OFAPRCPEnTY WHO BU' -DSO R -MPRCVES THERSCN. AND
VM CONTRACTS FOR SUG+PHDJEc-S WITH A CONTRACTORS) _ICENSED P;:RSUAriT TO THE CON'RaC-
TORS LICENSE LAW.).
.C: I AM EXEMFT UNDER SEG _ .._—.. R. 3 RC =0R 7.15 REASON
DATE,
LICENSED CONTRACTORS DECLARATION;
I HEREBYAFFIRM UNDER PFNALIV OF PCRJUR-T'HATIMJ L-CENSED TINDER PROVI3l0%S OF CIIA- ER
Y(COMMENCING WITH SECTION 70001DIV'GK)N Y Or TR.'. 3:!S!YESSA4.) F;C=CS:i"NS GO^i:.AND
MY LICENSE=S IN FUUF RCCANDEFFECT.
LICENSE C q S LIC. NO.
-TA .
C.:N'?.nCTOR _f+!_L.•-A..rYL•: =1
WORKERS' CON.PENSAT:ON DECLARATION
I H,.REDYAFPIRM LNDER PcNALT'YOF PERJURY 04E C=T -17 FOLLOW.NG ,EC_ARAT:Cj.
I HAVE AND VCLL MAINTI.;NACCRT:F'CATE or CONSENT -O3F:F- NOURE rCR WCR•CER:P
COMPENSATD.%. AS PFTOVIDCD D'+ SECTION 37Ya Or TSE LABOR CODE, FOR 'HE PERTORMALNCT
OF THE WORK 1O1i WHICH THIS PER'A:T IS ISSUED
I H0.VF ANO Iii MAIN rA:N WCiKCR'i' CGMPENSAT':.N I.NSURANr.E, FS F.EC_'RED S" -IS
700
;f 700 OP 1NF LABOR CODE, FOR THE PEP.FCRMANCE OFTrI WCRKFO-1W:i,'•17HI.;P' VI -IE
ISSUED M`.' WORRFRu���OIr'PrNSA'ION IN
CARRIER �_..S PANCC CA9i .' AND PC_ _YNUMECRA.-.'c'
..,�5�.S�Jj�+�
POLICYNUM9CR._..r,�-Aj/P.'.
(TILS sCCRON NEE.O NOTL•C ODP+Oy REC OTT( �E PFiiWT B. v1 CNE-:r�}iE0 D%IARe 15•x.cf: LCS;i:•.
!CERTIFY THAT w r< PERFORMANCE OF THE WORK FOP, WHICH THI5 FEF.MI- a-SE'JEC.
SPALL NOT EMPLOY ANY PE.RSCn.:.N ANY MANNER SOAR 70 BECCM-a ":'.:EJECT TO •E
'A'ORKER!T COMPENSA7104 LAW, CF CALIFORNIA ,:ND AC.REE'HATSFIC..-O i(COMy
SU JFCT 70 THE WORNC-RS' COMP -k; AT 0 ' PAOVi SiONS Or SEC7I0'. $7.^.J OF THE LA9p('
L:ODE i SHALL O= COMP"' WI -H E P?.1_2!A.P:j
j r
OAYE.�I EF-_ APPLICANT._./. - .._...
WARNING:FA:LL:RE TO SECLIILWORKEP.S' GCMPENSAT;O% U.NLAW'FL'_. AND SHALL BC
SU9JEC r A4 EMPLOYER TD CR'MINAL P-cNALTIFS AND CN:L r'NE5 UP TO?N.: I IVNDRED-1 %%3
DOLLARS:SIOC.DODI.:HADD.TOh;TOTHECC_'C'('.OMPENSP:ION.UAMACESASPROV:DEO FOP. %
SEC -ION 37CC OF T.iC LAyOR OCCE, INTEREST, AND A-TORNErS FEES
CONSTRUCTION LENDING AGENCY
IHr-1L;,WAFFIRML!NDER PENALTYUF-ERj:R.YT-ATTIIERE SACONSTR„G-:CNLENDINCAGrNCY
FOR THE PEERFOiMANCE DF TH: •A'ORK FOR W -ICH -HTS PERMIT.SIZS!:ED 15EC. SO:I7 C:V. G.;.
:ENDERS .NAME,._.
LENDER'SADDRESS �_. ...."._�—.._
i CERTIFY THAT I HAVE READ Th";ADPL-CA'IONAND STA ETHAT T•IEAGOVE INFCNMATiON IE CORRECT
I ASREL TO COMP1Y V/.1 H 1 L C.—AND CCUFI-' ORO'NAMCES ANC 5-01EL O'S RCLAMNG TO S_r DING
COVSTR::C7 dN. ANC HCRCBY AUT.CR7r-nFPRESEN.ATIvr.!; OF -HI-a CO -NT's -O ENTER 1!PON --C
AWVE.MENTIONCO PROP_RIY FOR INSPECT." .N PLH-OSES.
HANE z' R!
Copy.
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APPLICATPERMIT / 9r P 1 0
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ISSUE` 9 Y TYPE OCC
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DESCRIPTION
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TOTAL FEES`
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COMMENTS _ `
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RECPT, NO. _L___, PAID By `•-, VALIDATION
PINK—Assessor Copy, GOLDENROD—File Copy. GREEN—Applicant's Copy
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