HomeMy WebLinkAbout18944 �� _ CTTY OF DIAMOND BAR ��
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21825 E.Copiey Drive PRESS
(909)860-3195 Fax(909)861-3117
•�'""'.: BUILDIIVG PERMIT APPLICATION FIRMLY
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� ADDRESS��2 �'�1deII PIHdOS DATE
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CT!'Y OF DIAMOND BAR
DEPARTMENT OF COMMUNITY 8t DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
JOBSITE
ADDRESS 416 Golden Prados
APN L()j_
OWNER BOb
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ADDRESS-fie
CITY ZIP TEL. �F37.17$I.
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OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNN WHICH REW IRESA PERMIT TO CONSTRUCT,ALTER,IMPROVE,DEMOLISH,OR REPAIRANY STRUC-
TURE. PRIOR TO ITS ISSUANCE,AL50 REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SFIE IS LICENSED PURSUANT 70 THE PROVISIONS OF THE CONTRACTORS LI-
CENSE LAW(CHAPTER B(COMMENCING WITH SECTION 7000)OF DIVISK)N 3 OF THE BUSINESS AND PRO-
FESSIONSCODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031.5 BY ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(f5oo).):
^ I,AS OWNER OF THE PROPERTY,OR MV EMPLOYEES W ITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK,AND NiE STRUCTURE IS N07 INTENDED OR OFFERED FOR SALE(SEC. 7oM, BUSI-
NESS AND PROFESSIONS g7DE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO 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,HOW EVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE VEpR OF COMPLE-
TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
^ I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCTTHE PROJE:C7(SEC. 70sa,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE LAW DOES NOT APPI.V 70 AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITHACONTMCT9R(S)LICENSED PURSUANT�OTH CONTRAC
TORS LICENSE LAW.).
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U 1 AM EXEMPT UNDEFI SEC.Z�Q�(��� �"���g RC. FOR THIS REASON
DATE !��OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS Of CHAPTER
B(COMMENCING WITH SECTION 7000)OF DIVISK)N 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MV LICENSE IS IN FULL FORCE AND EFFECT.
LICENSE CLASS LIC. N0.
DATE CONTRACTOR
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATK)NS:
I HAVE AND WILL MAINTAIN ACERTIFICATE OFCONSENT TOSELF-INSURE FOR WORKERS'
COMPENSATION,A;i PROVIDED BV SECTION 37000E THE LABOR CODE,FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
1 HAVE ANO WILL M,4INTAIN 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'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER
POLICY NUMBER_
(EHIS SECTION NEOO NOT BE OOMPLEfEDOF THE PERMR IS FOR CNE HUNDRED OOLLAR.S(f100)OR LESS}
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I
SHALL NOT EMPLOY ANY PERSON IN ANV MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPE NSATK)N LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT 70 THE WORKERS'COMPENSATKKJ PROVISIONS OF SECTK)N 3700 OF THE LABOR
CODE,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE: APPLICANT:
WARNING FAILURE TO SEI;URE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(f 100,000),IN ADDITION TO THE COST OF COMPENSATON,DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE. INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON 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(SEC. 3087,CIV C.).
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATK)N AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORI2E REPRESENTATIVES OFfHIS COUNTY TO ENTER UPON THE
ABOVE-MENTKNIED PROPERTY FOR INSPECTION PURPOSES.
PERMITT AME(PRI 1
SIG 7 RE OF PERMITTE:E� DATE/
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy
PRESS
FIRMLY