HomeMy WebLinkAbout12973 (13)1. CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Scute 190
(909) 860-3195 Fax (909) 861-3117 PRESS
BUILDING PERMIT APPLICATION FIRMLY
JOBSITE -
ADDRESS Z. Z 7 O
APN LOT TRACT
OWNER Pe I /
ADDRESS
CITY ro IP TEL Flkc--5113
APPLICANT TELQ09 6Z/�/�/
CONTRACTOR I Too- /nom
ADDRESS Y -1-4 a vP
CITY Mo'w" ZIP />C> TEL j eZ-1- /6/
ARCKENG/
DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LF
CENSE LAW FOR THE FOLLOWING REASON (SEG 7031.6 BUSINESS AND PROFESSIONS CODE ANY CITYGR
COUNTY WHICH REQUIRES CONSTRUCT. ALTER. IMPROVE DEMOLISH, OR REPAJRANY STRUG
TUBE• 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 LL
CENSE LAW (CHAPTER I (COMMENCM WITH SECTION TODD) OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSJOKS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TON. ANY VIOLATION OF SECTON 7031.5 BYANYAPPUC&NT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OFNOT MORE THAN FIVE HUNDRED DOLLARS (SSW).): L - -
OLASOWNEROFTHE PROPERTY. OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION.
WILL DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE ISEC:. 7044• BUSH
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES HOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON. AND V440 DOES SUCH WORK HIMSELF OR MERSEY OR
TI ROUIH HS OR HER OWN EMPLOYEES- PROVIDED THAT SUCH IMPROVEMENTS ARE NOT MENDED OR
OFFERED FOR SALE IF. HOWEVER, THE BUILDING OR IMPROVEMENT S SOLD WITWNONE YEAR OFC7MPLE-
TION. THE OVJNER&1IDER WILL HAVE THE BURDEN OF MOVING THAT HE OR SHE DO NOT BUILD OR
"PROVE FOR THE PURPOSE OF SALE} -
O L AS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROTECT (SEC 70A4, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS L4
CENSE LAW DOES NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON. AND
WHO CONTRACTS FOR SUCH PROJECTS WITHACONTRACTQy5) LICENSED PURSUANT TOTHE CONTRAC-
TORS LICENSE LAW.}
O I AM EXEMPT UNDER SEG B. a P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBYAFFIPL UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
s (COMMENCING WITH SECTION 7000) OF DIVISION 3 O THE BUSINESS AND PROFESSIONS CODE -AND
S N
MY LICENSE IFULL FORCE AID EFFECT. a
LICENSE CLASS 9 - LIC. NO. ��2 6 > p
LATE —3— 99 CONTRACTOR YS -Oe'-Vqfl
WORKERS' COMPENSATION DECLARATION Its O 1
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
_ I HAVE AND WILL MAINTAIN ACERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS'
COMPENSATON.AS PROVIDED BYSECTON 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
3700 OF THE LABOR CODE FOR THE PERFORMANCE OF THE WOW( FOR WHICH THIS PERMIT IS
. BEEF MY WOB/IeA� COMPS �� N RANCE CARRIER AND POLICY NUMBER ARE:
POUCYNWBEERR /d �-
(r,MSECMNN£®N3TBEp01iiEm FTWPBWSFOROWNIERED (SIDO)ORLE55)
1 CERTIFY THAT 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
&A"CT TO THE WORKERS' COMPENSATKN IONS OF SECTION 7T OF THE LABOR
GOOF, I SHALL FORTHWITH COMPLY WITH
DATE: 7-3— 99 APPLOANT:'It
gz
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL BE
SUBJECT AN EMPLOYER TO CRUINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (s10o.oWl, N ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3700 OF THE LABOR OOOE 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 (SEG 3097, GV. C).
LENDERS NAME
LENDERSADORESS
1 CERTIFY THAT 1 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
CONSTRUCTICK AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TD ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
PERMITTEE NAME (PINT)
510NATURE OF PERMITTEE DATE
APPLICATION
PERMIT
P/C
DATE
NUMBER_
ISSUE
TYPE
OCC
DATE
CONST.
GROUP
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WHITE—Department Copy. YELLOW—FirLB = Copy, PINK—A"assor Copy. GOLDENROD—File Copy, GREEN—,Applicant's Copy
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