HomeMy WebLinkAbout15101N: CITY OF DIAMOND BAR
_�?aI DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION T
JOBSITE
ADDRESS
APN LOT TRACT
OWNER t-.— �" t
ADD S5 ,- i
CITY ZIP+ 1 TEL W' 3'4S-Ld,-
APPLICANT .ate _. .le'r-`� TEL.
CONTRACTOR
ADDRESS
CITY ZIP TEL.
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
-
OWNER -BUILDER DECLARATION
I HEREBY Arpw UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS U -
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.6 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
COUNTY WHICH REOUIRESAPERMrrTO CONSTRUCTALTER, IMPROVE, DEMOLISH, OR REPAIRANY STRUC-
TURE,
PRIOR T3 ITS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
'STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE LAW (CHAPTER 8 (COMMENCING WITH SECTION 7030) OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($500).):
1, ASOWNER OFTHE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSI-
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
0ROPERTY 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 FORSALF IF, HOWEVER, THE BUILDING OR IMPROVEMENT 15 SOLD WITHIN ONE YEAHOFCOMPLE-
TION, THE CWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
❑ 1, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS ODDS: THE CONTRACTORS U -
CENSE LAW DOES NOTAPPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS
FOR SUCH PROJECTS WITHACONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAG
TORS LICENSE LAW.).
CI 1 AM EXEMPT UNDER SEC. B. & P.C. FOR THIS REASON
DATE "'JH`-~ OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISION'S OFCHAPTER
,(COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE. AND
" MY LICENSE IS IN PULL FORCE AND EFFECT.
LICENSE CUSS _ LIC. NO.
DATE CONTRACTOR
WORKERS' COMPENSAT)ON DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
1 HAVE AND WILL MAINTAIN A CERTIFICATE OF CONS ENT TO SELFINSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BY SECTION 37M 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. MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER
POLICY NUMBER_,_
(PMS SECTION NEED NOT BE COMP ETEDOFTHE PERMIT IS FOR ONE HUNDRED OLYLARS ($1m) OR LESS}
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR'NHICH THIS PERMIT IS ISSUED,!.
i SHALLNOT EMPLOYANY PERSON INANY MANNERSOAS TO BECOME SUBJECTTOTHE
j WORKERS' COMPENSATION LAWS OF CALIFORNIA. AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE, I SHALL FORTHWITH COMPLY WfTH THOSE_ PROVISIONS.
1
t, DATE: - APPLICANT:
r
,WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE
SUBJECTAN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
(DOLLARS ($10 =), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
l SECTION 3709 OF THE LABOR CODE, INTEREST AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
1 HEREBYAFFIRM 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.).
I'„
LENDER'S NAME _
LENDER'SADDRESS
',.'_ CERTIFY THAT i HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
�' I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCESAND STATE LAWS RELATING TO BUILDING
ICONSTRUCTION, AND HEREaYAUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
yi ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
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PRESS
FIRMLY
APPLICATIONrj
PERMIT PIC
DATE
NUMBER
ISSUE
TYPE
DCC
DATE
CONST.
GROUP
ZONING SETBACKS
FRONT
RW
El
REAR
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SIDE/SIDE STREET
RW
SIDE
0
PROPOSED USE m, /' c`
NO. DWEL. _s,,gjjya NO.
NO.
UNITS g STORIES
BEDROOMS
DESCRIPTION SQ. FT.
FACTOR PSF
ADJ. AREA/VALUATION
SFRIADD/REM
'C/)
Garage/Carport
W
PatiO/DecX
LL
POCl/Spa
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Commercial
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Value &
ADJ.AREA
QUANTITY DESCRIPTION
FEE
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ISSUANCE
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RETENTION FEE:
PRE -ALT FEE:
TOTAL FEES
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COMMENTS
RECPT. NO. PAID BY� -
VALIDATION
d �" WHITE—Department Copy, YELLOW—Finance Copy, PINK --Assessor Copy, tiVLULNHULr--1-ue L:OPY, L.HttN—Appucanrs a opy