HomeMy WebLinkAbout15566 _1�_ CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
PRESS
FIRMLY
JOBSITE
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ADDRESS�Ltoti3
APN8'164' ^L-OT 14'1 TRACT 3320s�
OWNER For�vr..� �h
ADDRESS�I � � 3 2o)c
CITY���'ZIP CJk TEL.09 3q(o'241�
APPLICANT FQ-I"vti..�.Ch.a�'-TEL.
CONTRACTOR
ADDRESS
CITY ZIP TEL-
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFRM UNDER PENALTY OF PEiLA1RY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REOUIRESA PERMR TO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY STRUC-
TURE. PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR 5HE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISK)N 3 OF THE BUSINESS AND PRO.
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TK7N.ANY VKXATION OF SECTION 7037.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CML�ALN OF NOT MORE THAN FNE HUNDRED DOLLARS(5500).):
Qfl AS OWMER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATKNJ,
MALL DO THE WORK,AND'fHE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7011, BUSI-
NESS AND PROFESSKNIS CODE:THE CONTRACTORS LICENSE IAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS 09 IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
TNROUfL/HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF HOWEVER THE BUILDING OR IMPROVEMEN715 SOLD WITHIN ONE YEAR OF COMPLE-
TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SME DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
0 1,AS OVMER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PFIO.IECT(SEC. 7011, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY 70 AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONiRACTOR(S) LICENSED PURSUANT TO THE CONTRAC-
TORS UC NSE LAWJ.
I AM EXEMPT UNDER EC. �0 B. P.C. FORT REASON
L
DATE- (5�'�OWNER��IE[I}IEY�I,
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERIURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
D(COMMENCING WITH SECTION 7000)OF DIVISK)N 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
LICENSE CUSS LIC. N0._
DATE CONTRACTOR_
NIORKERS'COMPENSATION DECLARATION
1 HEREBY AFFIRM UNDER?ENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE ANO WILL MAINTAIN A CERTIFICATE OF CONSENT TOSELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BV 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
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MV WORKERS'COMPENSATKX�INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER
POLN:Y NUMBER
(TIi15 BECKON NE6J ND78E CCNRETm OFTHE PEPANT S fOR ONE HUI,ORED fXX1AfiS(E100)OR LESS
1 CERTIFY THAT Ih THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANV PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION IAWS OF CALIFORNIA,AND AGREE THAT IF 1 SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATK)N PROVISIONS OF SECTION 3700 OF THE LABOR
CODE, 1 SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE:APPLICANT.
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER 1'0 CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(5100,000),IN ADDITION TO THE COST OF COMPENSATK)N, DAMAGES AS PROVIDED FOR IN
I SECTK)N 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
I CONSTRUCTION LENDING AGENCY
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CANSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV.C.).
I
LENDER'S NAME
LENDER'S ADDRESS
I I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITIi ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
�CONSTRUCTlON,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTK)N PURPOSES.
Foa-�uN,E�'9'tE-J
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0 SIGNATU EU�PERMITTL"E DATE
WHITE-Department Copy,YELLOW-Finance Copy,PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Gopy
..�a�.