HomeMy WebLinkAbout15151CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
w (909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION
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DESIGNER
ADDRESS
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OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FORTHE FOLLOWING REASON (SEC 7027.5 BUSINESSAND PROFESSIONS CODE: ANY CITY OR
COUNTY WHICH REQUIRES A PERMrTTO CONSTRUCT, ALTER, IMPROVE, DEMOLISH, OR REPAIR ANY STRUC-
TURF, PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS UCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE
FCENSE LAW (CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 O THE BUSINESS AND PRO-
FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP.
KNJ
T.ANY VKX.ATION OF SECTION 70,77.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS
❑ i, AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
, NESA 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
PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO DOES SUCH WORK HIMSELFOR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED:FORSA.E IF, HOWEVER, THE BUILDING ORIMPROVEMENT IS SOLD WITHINONE YEAR OF COMPLE.
TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
j IMPROVE FOR THE PURPOSE OF SALE)-
❑ I, AS OWNER OF THE PROPERTY, AM EXCLUSIVELYCONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI
DENSE LAW. DOES NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS FOR SUCH PROJECTS WITH CONTRACTOR[S) LICENSED PURSUANT TO THE CONTRAC-
TORE LICENSE LAW.). -
71 AM EXEMPT UNDER SEC. B. & P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
'.1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
"9(COMMENCOJG WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS IIJ FULL FORCE AND EFFECT.
LICENSE CLASS
CLAyS�S, ✓ "-° LIC. NO.
;DATE'' `��' CONTRACTOR -"'
WORKERS' COMPENSATION DECLARATION
I HEREBYAFFIRM UNDER PENALTY OF PERJURY ONE OFTHE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BY SECTION 37W OF THE LABOR CODE, FOR THE PERFORMANCE
CF THE= FOR WHICH THIS PERMIT IS ISSUED.
e1 HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH PHIS PERMIT IS
ISSUED. MY WORI(ERS' ENSAJION INSE CARRIER AND POLICY NUMBER ARE:
CARRIER 7-i}Pym\ F"
POUCYNUMBER " - -
(IHISSFGipNN€ED NOTBE COMPLEfEDOFTF.'Ec PERMIT IS FOR ONE HUNDHEUDOLIARS ($100)OR LESS]
I CERTIFY THAT IN 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' COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME
SUBJECTTO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE, i SHALL FORTHWIIH COMPLYHOSE PROVI510N5.
"
DATE ;2 APPLICANT
�I.WARNING: FAILURE TO SECURE WORKERS'COMPENSATION CO ERAGE IS UNLAWFUL, AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (5900,0(10), IN ADDMN TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 Or THE LABOR CODE. INTEREST. AND ATTORNEY'S FEES.
CONSTRUCTION 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. 3097, CIV. C_).
LENDER'S NAME
LENCER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATICN 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 AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOOSAE1S.
PERMITTE E (POINT) - -
-�-
SIGNATUFIE ERMI EE DATE
1 PRESS
FIRMLY
APPLICATION�
PERMIT P/C
DATE
NUMBER
#
ISSUE
TYPE
OCC
DATE
CONST.
GROUP
ZONING SETBACKS
FRONT RW
❑
REAR
0-
SIDE/SIDE STREET
SIDE/SIDESTREET RW
❑
SIDE
❑
PROPOSED USE
NO. DWEL.
NO.
NO.
UNITS
STORIES
BEDROOMS
DESCRIPTION
SO. FT. FACTOR PSF
ADJ. AREA/VALUATION
SFR/ADD/REM
U)
Garage/Carport
W
Patio/Deck
V-'
Paol/Spa
Z
Re -Roof
®
Commercial
-
Valuation
ADJ.AREA
QUANTITY
DESCRIPTION
FEE
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F
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W
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Z
4111
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2
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CONSTRUCTION
PLAN REVIEW
PLUMBING
MECHANICAL
0 J
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INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
II +�Iv, s �� Le)'UU
j PRE -ALT FEE:
R 0
TOTAL FEES
COMMENTS '
RECPT. NO.
PAID BY VALIDATION
WRITE—Depanment Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—Applicant's Copy
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