HomeMy WebLinkAbout12783 (14)11I,1H(INU 11,111
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
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DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI.
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
COUNTY WHICH REQUIRESA PERMrTTO CONSTRUCT, ALTER; IMPROVE, DEMOLISH, OR REPAIR ANYSTRUC.
TURE, PRKOR TO 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 U.
CENSE LAW (CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS OODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THEBASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7031.9 BYANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($500).):
01, AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO 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 HIMSELF OR HERSELFOR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTSARE NOT INTENDED OR
OFFERED FORSALE, IR HOWEVERTHE BUILDING OR IMPROVEMENTIS SOLD WITHIN 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).
0 I, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC, 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI-
CENSE LAW DOES NOTAPPLY TO AN CWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS FOR SUCH PROJECTSWITHAOONTRACTOR(S) LICENSED PURSUANTTOTHF. CONTRAC.
TORS LICENSE LAW.).
0 IAM EXEMPT UNDER SEC. B. & P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSEO UNDER PROVISIONS OF CHAPTER
9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS IN FULL FORCE AND EFFECT. / o
LICENSE CLASS __) LIC. NO.C]� /
DATEIZ-'�"f, O=�'T� CONTRACTOR
WORKERS' COMPENSATION DECLARATION
HEREBYAFFIRM 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 37000E THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
_I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS nEOUIRED 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
(THIS SECTIM NEED NOT BEOOMPLETED OF71 E PERMIT IS FOR ONE HUNDRED DOLLARS ($100)ORLESS).
1 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
SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE, I SHALL FORTHWITH COMPLY WITH THOSE P OVISIONS
DATE: _.�Q=� APPLICANT:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 37080E THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3087, CIV. C.).
LENDER'S NAME
LENDER'S ADDRESS
1 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 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 PURPOSES-
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PERMITTEE NAME (PRINT)
SIGNATURE OF PERMiTTEE GATE
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PERMIT
DATE ` UMBERRII #
ISSUE TYPE OCC
DATE CONST, GROUP
ZONING SETBACKS
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PROPOSED USE
NO. DWEL, NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREANALUATION
SFR/ADD/REM
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COMMENTS
RECPT. NO. PAID BY ..VALIDATION
VYHI I E --Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD --File Copy, GREEN—Applicant's Copy
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