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Home My WebLink About18441 (11)UI,I~III~UIIdRi JOBSITE1600GrandAve ADDRESS __ APNLOTTRACT -- __ OWNERCltofDiamondBar ADDRESS2125E. Copley clTVDiamondBarzIP9176~EL. 909396.566 APPLICANTDavidDoyleTEL. _ CONTRACTOR '- _ ~ C }°11/ Z' ADDRESSZlI - b ~ K..'S~S 'iD ~~~nEy~ CITY~~L.~vn~ ~~ ZIPt1Lr) TEL~~l- ~?-l~I~/i ARCH/ENG/ G UvZ.f3C~. ,`~ ZG Ct~!1i~ DESIGNER ADD~SS1~ia1, (-~t-t"'E:JSIi2 :~,;,i'E~--- CITY \[\[:~~.C.\\~C~~ (.,~ ZIP `"t~_V`~ TEL~I • ~ ~1f - (4 ~ OWNER-BUILDER DECLARATION 1HEREBYAFFIRMUNDERPENALTYOFPERJURYTHATIAMEXEMPTFROMTHECONTRACTORS LI- CENSELAWFORTHEFOLLOWINGREASON (SEC. 7031.5BUSINESSANDPROFESSIONSCODE: ANVCITYOR COUNTYWHICHREQUIRESAPERMITTOCONSTRUCT, ALTER, IMPROVE, DEMOLISH, CRREPAIRANV STRUC- TURE, PRIORTOITSISSUANCE. ALSOREQUIRESTHEAPPLICANT FORSUCHPERMITTOFILEASIGNED STATEMENTTHATHEORSHEISLICENSEDPURSUANTTOTHEPROVISIONSOFTHECONTRACTORS LI- CENSELAW (CHAPTER9 (COMMENCINGWITHSECTION7000) OFDIVISK)N3OFTHEBUSINESS ANDPRO- FESSIONSCODE) ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXEMP- TION. ANVVIOLATIONOFSECTION7031.5BYANYAPPLICANT FORAPERMITSUBJECi5 "fHEAPPLICANTTO ACIVILPENALTYOFNOTMORETHANFIVEHUNDREDDOLLARS (5500).): ' I. ASOWNEROFTHEPROPERTY, ORMVEMPLOYEESWiTHWAGESASTHEIRSOLECOMPENSATION, WILLDOTHEWORK, ANDTHESTRUCTUREISNOTINTENDEDOROFFEREDFOHSALE (SEC. 7044. BUSI~ NESSANDPROFESSIONS CODE: THECONTRACTORSLICENSELAWDOeSNO. APPLYTOANOWNEROF PROPERTYWHOBUILDSORIMPROVES THEREON, ANDWHODOESSUCHWORKHIMSELFORHERSELFOR THROUGHHISORHEROWNEMPLOYEES, PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTENDEDOR OFFEREDFORSALE. IF, HOWEVER, THEBUILDINGORIMPROVEMENTISSOLOWITHINONEYEAROFCOMPLE- TION, THEOWNER-BUILDERWILLHAVETHEBURDENOFPROVING 'HATHEORSHEDIDNOTBUILDOH IMPROVEFORTHEPURPOSEOFSALE). I. ASOWNEROFTHEPROPERTY AMEXCLUSIVELYCONTRACTINGWIiHLICENSEDCONTRACTORS TOCONSTRUCTTHEPROJECT (SEC. 7044, BUSINESSANDPROFESSIONSCODE: THECONTRACTORSLI- CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTYWHOdUII.DSORIMPROVESTHEREON, AND WHOCONTRACTSFORSUCHPROJECTSWITHACONTRACTOR(S) LICENSEDPURSUANTTOTHECONTRAC- TORSLICENSELAW ). C7IAMEXEMPTUNDERSEC, B. 8PC. FORTHISREASON DATEOWNER LICENSEDCONTRACTORSDECLARATION IHEREBYAFFIRMUNDERPENALTY OFPEPJURVTHATIAMLICENSEDUNDERPROVISIONSOFCHAPTER 9 (COMMENCINGWITHSECTION7000) OFDIVISION30FTHEBUSINESSANDPP.OFESSiONSCODE. AND MYLICENSEISINFULLFORCEANDEFFECT. yyy~ 7 _ LIC. NO. ~ LICEN~CL1A'S,S,~_ /' S p~ CONTRACTORL1l~X ~~ V '~T~I~~ DATE WORKERS' COMPENSATION DECLARATION IHEREBYAFFIRMUNDERPENALTYOFPERJURYONEOFTHEFOLLOWINGDECLARATIONS: IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' COMPENSATION, ASPROVIDED BVSECTION 37009ETHELABORCODE. FORTHEPERFORMANCE OFTHEWORKFORWHICHTHISPERMITISISSUED. INAVEANDWILLMAINTAINWORKERS' COMPENSATIONINSURANCE, ASREQUIREDBVSECTION 3700OFTHELABORCODE, FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS ISSUED. MVWORKERS COMPENSATION INSURANCE CARRIERANDPOLICYNUMBERARE: CARRIERS(AT ~. POLICYNUMBER ~(Li-I~el7 iN15SECTIONNEEDNOTBE ~MPLETEDOFTHEPERMRISFORCNEHUNDREDDOLARS (5100) ORLESS). 1CERTIFYTHATINTHEVERFORMANCEOFTHEWORKFORWHICHTHISPERMITISISSUED, I SHALLNOTEMPLOYANVPERSONINANVMANNER50ASTOBECOMESUBJECTTOTHE WORKERS' COMPENSATION LAWSOFCALIFORNIA, ANUAGREETHATIFISHOULDBECOME U J CTT H R COMPEN TIONPRV IS FSEON37 OFTHE ABOR KERS q 00 S B E OT EWO S L E, ISHALLFORTHWITHCOMPLYWIHTHOSPleIS COD nx 1 e ~ DATE` ` APPLICANT WARNING: FAILURETOSECUREWORKERS' COMPENATIONCOVERAGEISUNLAWFUL, ANDSHALLBE SUBJECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND DOLLARS (8100000), INADDITIONTOTHECOSTOFCOMPENSATION, DAMAGESASPROVIDEDFORIN SECTION3708OFTHELABORCODE. INTEREST, ANDATTORNEY'SFEES. CONSTRUCTION LENDINGAGENCY 1HEREBYAFFIRMUNDERPENALTY OFPERJURYTHATTHEREISACONSTHUCTIONLENDINGAGENCY FORTHEPERFORMANCE OFTHEWOFKFORWHICHTHISPERMITISISSUED (SEC. 3097, CIVC.). LENDER'SNAME LENDER'SADDRESS ICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETHATTHEABOVEINFORMATION ISCORRECT IAGREETOCOMPLYWITHALL (:ITVANDCOUNTYORDINANCESANDSTATELAWSRELATINGTOBUILDING CONSTRUCTION, ANDHEREBYAUTHORIZEREPRESENTATIVES OFTHISCOUNTYTOENTERUPONTHE ABOVE-MENTIONEDPROPERTYFORINSPECTIONPURPOSES il.~ h~ ~ ~ ILTAZI-1C~1~ PEIEENAM INT SIGIRE~~(IFPITTEEDATE CITYOFDIAMONDBAR DEPARTMENT OFCOIvIIvtUNI'fY & DEVELOPMENT SERVICES 21825E. CopleyDrive 909) 860-3195Fax (909) 861-3117 BUILDINGPERMITAPPLICATION PRESS FIRMLY WHITE-DepaAmentCopy, YELI-OW-FinanceCopy, PINK-AssessorCopy, GOLDENROD-FileCopy, GREEN-Applicant'sCopy