HomeMy WebLinkAbout12157 (11)CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICE
> 21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117 PRESS
BUHMING PERMIT APPLICATION FIRMLY
JOBSITE
ADDRESS rte- 0 &_rZ-A/
APN LOT TRACT
OWNER AAALIr
ADDRESS
CITY ZIP f -+f- TEL
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CONTRACTOR A
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CITY 01 A M _012 Keit ZIP q#12jkC:-_ TEL20Y161715-0
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS 114
CENSE LAW FOR THE FOLLOWING REASON (SEC 70.71.5 BUSINESS AND PROFESSIONS CODE ANY CTTYOR
COUiTYNRYW REQLARESA PERMITTO CONSTR=.ALTEK IMPROVE. DEMOUSK OR REPARANY STRJC-
TURE PRIOR TO ITSISSUANCE MIT ALSO REQUIRES THE APPLICANT FOR SUCH PERTO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE TO
U-
CENSE LAW (CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 O THE BUSINESS AND PRO.
FESSIONS OWE) OR TINT 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 PERW T SUBJECTS THE APPLICANT TO
ACML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (5500).).
OLASOWNEROFTHE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION.
WILL DO THE WORK AND THE STRICTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC 7044. SUSI.
NESS AND PROFESSIONS OOOE THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPENTY 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
OFFEREDFOR SALE F. HOWEVER THE BLURDNO OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OFCOMPLE-
TION. THE OWMERBIISDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE 00 HOT BUILD OR
BIPHWE FOR THE PURPOSE OF SALE}
O L AS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEG 7044, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI-
CENSE LAW DOES NGTAPPLY TO AN OWNER OF A PROPERTY WHO BOLDS OR IMPROVES THEREON. MIO
INHO CONTRACTS FOR SUCH PROJECTS WITHACONTRACTOR(S) LICENSED PURSUANT 70THE CONTRAC-
TORS
ONTRACTORS LICENSE LAW}
O 1 AM EXEMPT UNDER SEC B. S P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
a (COMMENCNO WITH SECTION TODD) OF DIVISION! 3 O THE BUSINESS AND PROFESSIONS COOS AND
MY LICENSE IS N FULL FORCE AND EFFECT. (�
LICENSE CLASS E_ LIC. NO. Q 7 y
CONTRACTOR_ 0444"Jpa
WO COMPENSATION DECLARATION
1 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'
COMPENSATKA 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 WORKERS COMPENSATION INSURANCE AS REQUIRED BY SECTION
97000E THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WQRKERS COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE
CARWER �IJA-Te— GUAM
POLICY NUMBER L1.40 t4 3,
PHIS SECTION WED MDT BEOOJARFTmCFTHE PERMIT a FOR ONE"CAEDDOUARS rI o1 ORLESS?
1 CERTIFY THAT N THE PERFORMANCE OF THE WOW( FOR WHICH THIS PERMIT IS ISSUED, I
SMALL 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 3700 OF THE LABOR
COO�{I�SLH-'A(�N�F0R7MVITH COMPLY WITH 71M0 PRDYISI 445.
DATE: -•� ` / $PPLKAJJT` —C
WARNING: FAILURE TO SECURE WORKERS COMPENSATION VERAGE IS UNLAWFUL. AND SHALL BE
SUB.IECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FNES UP TO ONE HUNDRED THOUSAND
DOLLARS ISI00.000J. NDITI
ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR N
SECTION 37050E THE LABOR CODE INTEREST. AND ATTORNEYS FEES,
CONSTRUCTION LENDING AGENCY
I HEREBY 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
LElNDEASADDRESS
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 TO BRIDING
CONSTRUCTION. AND HEREBY AUTHMZE REPRESENTATIVES OF THISL
TO ENTERUPON THE
ABOVE.MENTMED PROPERTY FOR INSPECTION PURPOSES
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PERMITTEE E (PINT) \
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SIGFIA DATE
APPLICATION4 PERMIT 5 /C
DATE aT NUMBEIi� S
ISSUE TYPE OCC
DATE CONST. GROUP
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