HomeMy WebLinkAbout10702CITY OF DIAMOND BAR
COMMUNITY DEVELOPMENT DEPARTMENT
21660 E. Copley Drive Suite 190,
(909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION
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APN LOT TRACT
OWNER
ADDRESS
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APPLICANT
CONTRACTOR
ADDRESS
CITY ZIP TEL.
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DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM EXEMPT FROM THE CONTRACTORS U.
CENSE LAW FOR THE FOLLOWING REASON (SEC 7031.6 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
COUNTY WHCH REOIARESA PERMIT TO CONSTRUCT,ALTER, IMPROVE, DEMOUSH,OR REPMRANY STRUC.
TURE. PRIOR TO RS ISSUANCE. ALSO REWIRES THE APPLICANT FOR SUCH PERMIT TO RLE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS 1J_
CENSE LAW (CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DMSIN 3 OF THE BUSINESS AND PRO-
FESSIONSCDDE) ORTHAT HE OR SHE IS EXEMPTTHEREFROM AND THE BASIS FOR THEALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7031.5 BYANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (SSW).):
O 4AS OWNEROF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS LE THEIR SOCOMPENSATION,
WILL DO THE WORK, THE
THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC 7044, BUST•
NESS AND PROFESSKNS COO E: 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
THROUGN HIS OR HER OWN EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTSARE NOT INTENDED OR
OFFERED FOR SALE IF, MOWEVERTIIE BUILDING OR IMPROVEMENTIS SOLD WRHN ONE YEAROFCOMPLE-
TION, THE OWNER BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
O L AS OWNER OF THE PROPERTY,AM EXCLUSNELYCONTRACTNG WITH LICENSED CONTRACTORS
TO CONSTRUCT ME PROJECT (SEC 7041, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U.
CENSE LAW DOESNOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON. AND
WHO CONTRACTS FOR SUCH PROJECTS WITHA CONTRACTOR(S) LICENSED PURSUANT TO THE CONT
TORS UCENSE LAW I.
O IAM EXEMPT UN ER SEG. B. f P.0 FORTH EASON
DATE OWNE
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER
a (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS COOE,ANO
MY LICENSE IS IN FULL FORCE AND EFFECT.
UCENSE CUSS 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 CERTIFICATE OF CONSENT TO SELF•INSURE FOR WORKERS'
COMPENSATION. AS PROVIDED BY 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 REWIRED BY SECTION
3700 OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER
POLICY NUMBER
(THS SIECTON NEED NOT BE COMFUTED OFTI-E PERM IS RORONE H PORED DOU" (S1OD)OR LES%
I CER7IFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS' COMIPENSATION LAWS OF CALIFORNIA AND AGREE THAT F 1 SHOULD BECOME
SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE, I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE: APPLICANT:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (5100,000). 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
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC 3097, CIV, C.).
LENDERSNAME
LENDER'SADORESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION 15 CORRECT.
I AGREE TO COMPLY WITH ALL CRY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION. AND HEREBY AUTHORIZE REPRESENTATIVES OF TH UNTY
TOE ER UPON THE
ABOVE -MENTION PROPERTVFORINSPECTgN PUR SES,
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COMMENTS
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CITY OF -DIAMOKID LAR
INSPECTION RECORD.:,".,,
SET -BACK
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