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Home My WebLink About10286CITY OF DIAMOND BAR . COMMUNITY DEVELOPMENT DEPARTMENT 21660 E. Copley Drive Suite 190 (909) 860-3195 Fax (909) 861-3117 BUILDING PERMIT APPLICATION JOBSITE AD RESs_22f •yt?-6T0'el L APN LOT TRACT OWNER t144C A ADDRESS 00 CITY ZIP _tel TEL APPLICANT TEL CONTRACTORra�'x"Ch ADDRESS CITY ZIP TEL ARCHIENG/ DESIGNER ADDRESS CITY ZIP TEL OWNER -BUILDER DECLARATION 1 HEREBY AFF RM UNDER PENALLY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LI- CENSE LAW FOR THE FOLLOWING REASON (SEG 7031.5 BUSINESS AND PROFESSIONS CODE: ANYCITYOR COUNTY WHICH REWIRES A PERMITTO CONSTRICT, ALTER IMPROVE. DEMOUSH.OR REPAIRANY STRUOG TUBE, PRIOR TO RS 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 LI- CENSE FCENSE LAW (CHAPTER I (COMMENCING WITH SECTION 70001 OF DIVISION S OF THE BUSINESS AND PRO. FESSIONS CODE) OR THAT HE OR SHE 15 EXEMPTTHEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION. ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (1500).k O L AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WILL DO THE WON( AND ?D44.THE STRUCTURE 15 NOT INTENDED OR OFFERED FOR SALE (SEC 7D• BUSI- NESS AND PROFESSIONS COOS THE CONTRACTORS LICENSE LAW DOES NOTAPPLY TO AN OWNER OF PROPERTY WHO BURGS 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. HOWEVER THE BUILDING OR IMPROVEMENT 13 SOD WITHIN ONE YEAR OFCOUPLE- TION. THE OWNERBUILDER WDLL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OFSALEI, O L AS OWNER OF THE PROPERTY. AM EXCLUSNELYCONTRACrING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7D4I. BUSINESS AND PROFESSIONS CODE THE CONTRACTORS U - CENSE LAW DOES NOTAPPLY TO AN OWNER OF A PROPERTY WHO BULDS OR IMPROVES THEREON. AND WHOCONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S) LICENSED PURSUANTTO THE CONTRAG- TORS LICENSE LAW.} O 1 AM EXEMPT UNDER SEC A E P.C- FOR THIS REASON DATE 1 OWNER f Rif LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER / (COMMENCNG WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE. AND MY LICENSE W N 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: _I HAVE AND WILL MAINTAIN A CER7IFICATE OF CONSENTTO SELF -INSURE FOR WORKERS COMPENSATION.A5 PROVIDED BY SECTION 37DO 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 REWIRED BY SECTION 3700 OF THE LABOR CODE FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, MY WORKERS' COMPENSATION INSURANCE CARAZA AND POLICY NUMBERARE: CARRIER POLICY NUMBER (THIS SECTION NEED NOT BE OOMIXWOFTFE PERVITIS FOROJEH NDRED DOLLARS $100) OR LESS) I CERTIFY THAT INTHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY ANY PERSON IN ANY MANNER 50 AS TO BECOME SUBJECT TO THE WORKERS'COMPENSATION LAWS OF CALIFORNIA. AND AGREE THAT IF 1 SHOULD BECOME SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR CODE.I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. DATE APPLICANP. WARNING: FAILURE TO SECURE WORKERS* COMPENSATION COVERAGE 13 UNLAWFUL. AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (S100.000), IN ADDITION TO THE COSTOF COMPENSATION. DAMAGES AS PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE INTEREST. ANO 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 PENAIT IS ISSUED (SEC. 3007. CIV. C). LENDERS NAME LENDERS ADDRESS I CERTIFY THAT I 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 WILDING CONSTRUCTION. AND HEREBY AUTFgNZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ASOva4AENTIONED PROPERTY FOR INSPECTION PURPOSES. AeP G.gj-/ .4c(3e^ T PEAWTTEE NAME (PRINT) c�� r SIGNATURE OF PERMI E GATE - PRESS FIRMLY APPLICATION DATE ISSUE DATE PERMIT �n ti NUMBER (/ TYPE CONST. 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