HomeMy WebLinkAbout15119F ,q
f� CITY OF DIAMOND BAR 0.
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION
JOBS
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OWNER
ADDRESS
CITY A IP TEL
PLI ANT TEL
CONTRACTOR G v'
ADDRESS
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DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION
I NEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS Lf-
CENSE
I.CENSE UW FORTHE FOLLOWPW REASON (SEG 7031.6 VA14ESSAND PROFESSIONS CODE ANY CITYOR
COUNTY WHIGS REDUIRESAPERMR TO CONSTRUCT,ALTER. IMPROVE. DEMOUSH,OR REPAIR ANYSTRUG
TURF. PRIOR TO ITS MWANCE
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 UW (CHAPTER 9 (COMMENCPq WITH SECTION 7000) OF DIVISION S OF THE "NESS AND PRO-
FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TXX ANY VIOLATION OF SECTION 7031.6 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS
DL AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORD AND THE STRUCTURE S NOT NTENOED OR OFFERED FOR SALE (SEG 70". BUSI-
NESS AND PROFESSIONS COOS THE CONTRACTORS LICENSE UW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHOBULDS OR IMPROVES THEREON. AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HS OR HER O'MN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT MENDED OR
OFFEREDFORSN.EIF,HOWEVER THE BUILDNOOR IMPROVEMENT 18SOLD WIRiNONEYEAROFOOMPLE-
TON, THE OWNER OULDER WALL HAVE THE BURDEN OF PROVNO THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE}
D LAS OWNER OF THE PROPEmv AM EXCLUSIVELY CONTRACTLNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 7014, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI-
CENSE
I.CENSE LAW DOES NOT APPLY TO AN OWNER OFAPROPERTY WHO BUILDS OR rANIOVES THEREOML AND
YMOCONYRAM FOR SUCH PROTECTS WITHA CONTRACTORS) LICENSED PURSUANT TO THE CONTRAC
TORS LICENSE LAW.),
O 1 UA EXEMPT UNDER SEG B. L 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
6 (COMMENCING WAR( SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE. AND
LiLICENSE S N FULL EFOR� AND EFFECT. I
LICENSE CUSS ��I�<j))���
DATE %' — �- — 1• r coNrRACTOR
WORKERS' COMPENSATION DECLARATION .
I HEREBY AFFIRM UNDER PENALTY OF PERJU1W ONE OF THE FOLLOYM40 DECLARATIONS: 1
—I HAVE AND WALL MAINTAIN A CERTIFICATE OF CONSENT TO SELFJNSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BY SECTION 5700 OF THE LABOR CODE. FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT S ISSUED.
__1 AV
HE AND WILL MAINTAINWOFKERS' COMPENSATION INSURANCE AS REOUIREO BY SECTION
'Too OF THE LABOR CODE FOR THE PERFORMANCE OF THE W M( FOR WHICH THIS PERMIT IS
SSVEA MYYWR4EF COM f- AT10VJbISURANCE CARRIEJ AND POLICY NUMBER ARE:
CARtlF:II % A �-
POLICY NUMBER n-
(n6aSMCNNMNOTeECCINU MOFRePEFMTSSIEFO�RONEH JNDRIEDCOtLA/aMIMORLEM
1 CERTI YTNAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS SSUED, I
--. SHALL NOT EMPLOY ANY PERSON N ANY MANNER 50 AS TO BECOME SUBJECT TO THE _--- -._
WORKERS COMPENSATION LAWS OF CALIFORNIA ANO AGREE THAT IF 1 SHOULD BECOME
SUBJECT TO THE WORKERS* COMPENSA KN PR ISKNS OF SECTION 6700LF .FUROR
CODE,ISHALLFORTHINITHCOMPLYWI TH40 119MONS.
.A_=16_40 APPLICANT. _ CJI ^[�
WAFUNMFALURETOSECUREYARKERS'COMP HSATION COVER*GEI UNLAWFTA. AND SHALLBE
1¢Id
SUBJECT AN EMPLOYER 10 CRIMINAL PENALTIES AND CML FINES ONE (KINDRED THOUSAND
DOLLARS ($100,000)• N ADDITION TO THE OOSTOF COMPENSATION, DAMAGES AS PROVIDED FOR IN
I BECTON 77060E THE LABOR CODE INTEREST. AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
i
1 HEREBYAFFIFIM UNDER PLNALTYOF PERAJRY THAT THERE S A WNSTRUC710N LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC 3097, CR. C.),
I
LENDERS NAME
LENDERrS ADDRESS
i(CERT" THAT I HAVE READ THIS APPLICATION AND STATE THATTHE ABOVE INFORMATION IS CORRECT
1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDNANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION. AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE.MENTIONED PROPERTY FOR INSPECTION PURPOSES.
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P�RMITT (PANT) -
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SIGNCUREOF PEAMIREE DATE
' PRESS\
FIRMLY
APPLICATION PERMIT
DATE NUMBER
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ❑
REAR ❑
SIDE/SIDE STREET RW ❑
11
SIDE ❑
PROPOSED USE OD B A
00 F.
NO. DWEL PA77 la NIC5. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF ADD. AREANALUATION
SFR/ADD/REM
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