HomeMy WebLinkAbout14949 (20)CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909) 860.3195 Fax (909) 851-3117
BUILDING PERMIT APPLICATION
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OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LL
CENSE LAW FOR THE FOLLOWING REASON (SEC.7071.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
CMMff NOCHREQUIRESAPEmMrTTOCONSTRUCT,ALTERIMPROVE, DEMCLSRORREPAJRANY STRUC-
TURF PRIOR TO ITS ISSUANCE, ALSO RECUIRES 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 9 (COMMENCING WITH SECTION 7000) OF DIVISION S OF THE BUSINESS AND PRO-
FESSIONS OOMORTHATHEORSHE ISEXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TON. ANY VIOLATION OF SECTION IMI.A RY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (SSW).):
O L AS OWNER OF THE PROPERTY. OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044.BUSI-
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY VA40 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
OFFERED FOR SALE IF.HOAIEWFk THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAROF COMPLE-
TION. THE OWNERSUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALEL
O L AS OWNER OF THE PROPERTY. ALA EXCLUSIVELY CONTRACTING "INN LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEG 7044. BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U•
CENSE LAW DOES NOT APPLY TO AN OWNER OF APRDPERTY WHO BUILDS OR IMPROVES THEREON. AND
WHO CONTRACTS FOR SUCH PROJECTSMITH A CONTRACTORS) LICENSED PURSUANT 70THE CONTRAC-
TORS LICENSE LAW I,
�I AM EXEMPT UNDER SEG B. A P.C. FOR THIS REASON
DATE If — 1 -IC -OD OWNER V�
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM ANDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
B POWANM40 WITH SECTION 7000) OF DMSON 7 OF THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
LICENSE CLASS LIC. NO.
DATE CONTRACTOR
WORKERS' COMPENSATION DECLARATION,
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
l
�I HAVE AND WILL MAMAW A CERTIFICATE OF CONSENT TO BELF-INSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BY SECTION VW OF THE LABOR CODE. FOR THE PERFORMANCE
OF THE WORK FOR WHISH THIS PEPMITISISSUED.
_I HAVE MID WILL MAINTAIN WORKERS' CCMPENSATICN INSURANCE, AS REQUIRED BY SECTION
3700 OF THE LABOR CODE, FOR THE PERFOPoAANCE OF THE WORK FOR WH0/7HI5 PERMIT IS
ISSUED. MY WGRKERS'COMPENSATON INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER . . .. .
- POUC/NUMSER
(n6 SECTION NEED NOT BE COMFUTEDOFTE PEAR I5F DRONE HUNDRED ECULARS ($I00)ORLET5%
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 SUB7ECT TO THE
WORKERS COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF 1 SHOULD BECOME
SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 4700 0E THE LABOR
CODE, I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE: APPLICANT.
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 15 UNLAWFUL AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND
DOLLARS is 100.000). N ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF 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 ISEC. 3007. CIV. G).
LENDER'S NAME
LENOER'SADDRESS
I CERTIP7TNAT 1 HAVE RFXO THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE TOOOMPLY NRH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION, ANO HEREBY AUTHMZE REPRESENTATIVES OF INS COUNTY TO ENTER UPON THE
ABOVEMENTONED PROPERTY FOR INSPECTION PURPOSES.
kyo1�� P. SAW
PERMITTEE NAME (PWHT){Q� /
SIGNATURE OF PERMITTEE ! DATE
PRESS
FIRMLY
APPLICATION5-1_ PERMIT� 6 PIco DATE ��/ ` D � NUMBER � M 6
ISSUE TYPE OCC
DATE CONST, GROUP
ZONING SETBACKS
FRONT RW ❑
REAR ❑
SIDE(SIDE STREET RW ❑
SIDE ❑
PROPOSED USE TT�17i! 1 1
NO. DWEL. NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION O. FT. FA9TOR PSF ADJ. AREANALUATION
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ELECTRIC % •
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MECHANICAL -
INSPECTION FEE
ISSUANCE _
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ENERGY PIC _
ENERGY PERMIT
RETENTION FEE:
PRE -ALT FEE:
TOTAL FEES a
COMMENTS
RECPT. NO. PAID BY VALIDATION
WHITE—Department Copy. YELLOW—Frmnce Copy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—Applicants COW
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