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Home My WebLink About19275ADDRESS ~~ ~ • ~ ~"~ ~ ~" V APNL.OTTRACT OWNER ADDRESS CITYIL. APPLICAN TEL. CONTRACTOR~I / ~r- C.4~. ADDRESS CITY ~_ TEL.~~c~ / ARCH/ G/ DESIGNER ADDRESS CITYZIPTEL. OWNER-BUILDER DECLARATION IHEREBYAFFIRMUNDERPENALTYOFPERJURYTHATIAMEXEMPTFROMTHECONTRACTORSLI~ CENSEUWFORTHEFOLLOWINGREASON (SEC. 7031.5BUSINESSANDPROFESSIONSCODE: ANYCITYOR COUNTYWHICHREWIRESAPERMIT TOCONSTRUCT,ALTER, IMPROVE, DEMOLISH, ORREPAIRANV STRUC- TURE. PRIORTOITSISSUAVCE, ALSOREQUIRESTHEAPPLICANT FORSUCHPERMITTOFILEASIGNED STATEMENTTHATHEORSHEISLICENSEDPURSUANTTOTHEPROVISIONSOFTHECONTRACTORSLI~ CENSELAW (CHAPTERB (p~MMENCINGWITHSECTION7000) OFDIVISK)N3OFTHEBUSINESS ANDPRO- FESSIONSCODE) ORTHATFIEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXEMP- TION. ANVVIOLATIONOFSECTION7031.5BVANVAPPLICANT FORAPERMITSUBJECTSTHEAPPLICANTTO ACIVILPENALTYOFNOTMORETHANFIVEHUNDREDDOLLARS (f500).): C71, ASOWNEROFTHEPROPERTY, ORMVEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, WILL00THEWORK, ANDTHESTRUCTUREISNOTINTENDEDOROFFERED FORSALE (SEC. 7064, BUSI- NESSANDPROFESSIONS OODE: THECONTRACTORSLICENSE LAWGOESNOTAPPLYTOANOWNEROF PROPERTYWHOBUILDSORIMPROVES THEREON, ANDWHODOESSUCHWORKHIMSELFORHERSELFOR THROUGHHISORHEROWNEMPLOYEES, PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTENDEDOR OFFEREDFORSALEIF, HOWEVER, THEBUILDINGORIMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE- TION, THEOWNER-BUILDERWILLHAVETHEBURDEN OFPROVINGTHATHEORSHEDIDNOTBUILDOR IMPROVEFORTHEPURPOSEOFSALE). I, ASOWNEROFTHEPROPERTY, AMEXCLUSIVELYCONTRACTINGWITHLICENSEDCONTRACTORS TOCONSTRUCTTHEPROJECT (SEC. 7066, BUSINESSANDPROFESSIONSCODE: THECONTRACTORSLI- CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUILDSORIMPROVESTHEREON AND WHOCONTRACTSFORSUCHPROJECTSWITHACONTRACTOR(S) LICENSEDPURSUANT TOTHECONTRAF TORSLICENSELAW.). 1AMEXEMPTUNDEFISEC. 8. 8P.C. FORTHISREASON DATEOWNER LICENSEDCONTRACTORSDECLARATION IHEREBYAFFIRMUNDER PENALTYOFPERJURYTHATIAMLICENSEDUNDER PROVISIONSOFCHAPTER e (COMMENCINGWITHSECTK>N7000) OFDIVISION3OFTHEBUSINESSANDPROFESSIONS CODE, AND MYLICENSEISINFULLFORCEANDEFF ECT. 2 LICENSECLASS ~ ~ ~ / LIC. NO. DATE ____ CONTRACTOR O .- LGO~ WORKERS' C AR OMPENSATIONDEL ATI IHEREBYAFFIRMUNDERPENALTVOFPERJURY ONEOFTHEFOLLOWINGDECLARATIONS: IHAVEANDWILLMAINTAINACERTIFICATE OFCONSENTTOSELF-INSUREFORWORKERS' COMPENSATK)N, ASPROVIDEDBVSECTION3700OFTHELABORCODE, FORTHEPERFORMANCE OFTHEWORKFORWHICHTHISPERMITISISSVED. IHAVEANDWILLMAINTAINWORKERS' COMPENSATIONINSURANCE. ASREQUIREDBYSECTION 3700OFTHELABORCODE, FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS ISSUED. MYWORKEJ3ZCOt.IPENS A RRIERDPOLICYNUMBERARE: 2 / W1~.' / ~J/-J~ CARRIER -_ POL.ICVNUMBER __ ~ ~~~_ THISSECTIONNEEDMOTBEOONIRETEDOFTHEPERL.iiISFORONEHUPOREDDOLUIRS (f1OD) ORLESS 1CERTIFYTHATINTHEPERFORMANCE OFTHEWORKFORWHICHTHISPERMITISISSUED, I SHALLNOTEMPLOYANVPERSONINANYMANNERSOASTOBECOMESUBJECTTOTHE WORKERS' COMPENSATK)NLAWSOFCALIFORNIA, ANDAGREETHATIF1SHOULDBECOME SUBJECTTOTHEWORKERS' COMPENSATION POVISIONSOFSECTION3700OFTHELABOR CODE, ISHALLFORTHWITHCOMPROVISKNS. DATE: __ APPLICANT 3-03 WARNING: FAILURETOSECUREWORKERS' COMPENSATIONCOVERAGE ISUNLAWFUL, ANDSHALLBE SUBJECTANEMPLOYERTOCRIMINALPENALTIESANOCIVILFINESUPTOONEHUNDREDTHOUSAND DOLLARS (f100,000), INADDITIONTOTHECOSTOFCOMPENSATION, DAMAGESASPROVIDEDFORIN SECTION3708OFTHELABORCODE, INTEREST, ANDATTORNEY'SFEES. CONSTRUCTION LENDINGAGENCY IHEREBYAFFIRMUNDERPENALTY OFPERJURYTHATTHEREISACONSTRUCTION LENDINGAGENCY FORTHEPERFORMANCE OFTHEWORNFORWHICHTERMITI SI SSUED (SE C. 308IV. C.). S~ I LENDER'SNAME ~._~~~,I~ID/VJ~ LENDER'SADDRESS 1CERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETHATTHEABOVEINFORMATK)NISCORRECT. IAGREETOCOMPLYWITHALLCITYANDCOUNTYORDINANCESANDSTATELAWSRELATINGTOBUILDING CONSTRUCTION, ANDHEREBYAUTHORIZEREPRESENTATIVES OFTHISCOUNTYTOENTERUPONTHE ABOV - TIONEPROPEFITVFORINSPECTION PURPOSES. EE (PT) SIGFPRMITE 0 0 ao 12 O w z 0 a z O Ir O 0 W U Z W U F-- 0 Z 0 W Z O 2 n~ X W O U Z Q C\] W Q J Z Q D W Z C7 UJ O J J lL Q W d O 2 d Z F- W CL C3 Z J Ln Q, 2 F CITYOFDIAMONDBAR DEPARTMENT OFCOMMUNTI'Y & DEVELOPMENTSERVICES 21825E. CopleyDrive 909) 860-3195Fax (909) 861-3117 BUILDINGPERMITAPPLICATION PRESS FIRMLY WHITE-Department Copy, YELLOW-FinanceCopy, PIN i