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HomeMy WebLinkAbout15081C +� 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 lil .1 y is O 8 o� Z Lcc G ll. W O Cn fn CD Z0 C C _5 0 LU z S2 Rn S O O J w O [L d } LU 0- 2 Ca Ca Ca Q Co Cn r JOBSITE / ADDRESS �rJ- aI �1QMo/1 Y. APN LOT TRACT OWNER E ADDRESS ' CITY 12"Cl rmeAd&-xrZIP TEL. APPLICANT TEL CONTRACTOR U pAP.-Ir ADDRESS / e% !/C — CITY +"10 ZIP7174 I TEL VI�' `�7 ARCRENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS Ll- CENSE SCENSE LAW FOR THE FOLLOWNG REASON (SEC.7001.5 BUSNESSAND PROFESSIONS COOS ANY CITYOR COUNTYWHICH REOUIHESA PERMRTO CONSTRUCT,ALTER IMPROVE. DEMOUSH.OR REPAIRANY STRUC- 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 LF CENSE LAW (CHAPTER 0 (COMMENCING WITH SECTION 7000) OF DIVISION 0 OF THE BUSINESS AND PRO. FESSIONS WOE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION. ANY VIOLATION OF SECTION 7031.5 BYANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS 15500),). 0 LAS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WILL Do THE WORD(. AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 70". B USI• NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON. AND LN10 DOES SUCH WORK HIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FORME. F. HOWEYERTHE BUILDING OR IMPROVEMENT LS SOLD WITHIN ONE YEAR OFCOMPLE- TION• THE OWNER-84'" RDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE D5) NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). O LAS OWNER OF THE PROPERTY.AM EXCLUSNELYCONTRACTTNG WTI LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 70M, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS U - CENSE LAW DOES NOTAPPLYTO AN OWNER OF APROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITHA CONTRACTORS) LICENSED PURSUANT TO THE OONTRArS TORS LICENSE LAW). 01 AM EXEMPT UNDER SEC. B. 5 PC. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM ANDER PENALTY OF PERJURY THAT IMI LICENSED UNDER PROVISIONS OF CHAPTER 0 tOOMMENCNO WITH SECTION 7000) OF DIVISION 5 OF THE BUSINESS AND PROFESSIONS CODE. AND W LICENSE IS N FULL FORCE ANO EFFECT. - • ! ` . LICENSE CUSS FA..`�� LIC. NO. DATE 3d O CONTRACTOR— VL 1-44.-W17 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 SELFANSURE FOR WORKERS' COMPFINSATON, AS PROVIDED BY SECTION 3M OF THE LABOR CODE. FOR THE PERPORMAN'CE ,. OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE. AS REOUIRED BY SECTION 5700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WOF/W�ERS' COMPENSA;, INSURANCE CAR/RIE.A AND POLIO% NUMOER ARE: CARRIER— I�ICGIG1lQ/O Z N�.N�1'C•►�: POLICY NUMBER - 0 71C OI L 4 000 g 7 1 (1106 SECTION NEED NOT BE 03NU-T©OF THE PERMIT B FOR ONE M UNDRED DOL ARS (SID))OR LESS} I CERTIFYTHAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON N ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKERS' COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS COMPENSATION PROVISIONS OF SECTION 5700 OF THE LABOR CODE, I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. DATE: APPLICANT; WARNING,- FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SUE IECT AN EMPLOYER TO CRIMINAL PENALTIES MID CML FINES UP TO ONE MXNORED THOUSAND DOL ARS ($IOD.000), N ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN IO SECTN 0708 OF THE LABOR CODE. INTEREST, MIO ATTORNEYS FEES. CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR ME PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 5097, CN. C.) LENDERS NAME LENDERSADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. I AGREE TO COMPLY WITH ALL CRY AND COUNTY ORDINANCES AND STATE LAWS RELATING M BUILDING CONSTRUCTIONAND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. /- _S_ a .F i