HomeMy WebLinkAbout15097 (17)_1� _ CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
w (909) 860.3195 Fax (909) 861-3117 PRESS
�„�� BUILDING PERMIT APPLICATION FIRMLY
JOBSITE
ADDRESS
APN LOT TRACT _
OWNER , A_;e=t.—
ADDRESS
CITY ZIP TEL.
APPLICANT TEL.
CONTRACTOR
.ADDR
CITY ZIP TEL
ARC G/
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 REQUIRESAPERMI CONSTRUCT, ALTER, IMPROVE, DEMOLISH, OR REPAIRANY STRUC-
TURE, PRIOR 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 LI.
CENSE LAW (CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 O THE BUSINESS AND PRO-
FESSIONS CODE) ORTHATHE OR SHE IS EXEMPTTHEREFROM AND THE BASIS FOR THEALLEGED EXEMP-
TION, ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS
❑ i, AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIRSOLE COMPENSATION,
WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 70", 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 HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THATSUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FORSALE. IF, HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHINONE YEAR OF COMPLE-
TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
❑ 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 NOT APPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHOCONTRACTS FOR SUCH PRO.IECTS WITH ACONTRACTORIS) LICENSED PURSUANTTO THE CONTRAC-
TORS LICENSE LAW.).
❑ I EMPT UNDER GEC. _tea -8, P.C. FOR THIS REASON
oil.-/'' _ V __
OWNER_
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE ISM FULL FORCE AND EFFECT.
LICENSE CLASS _____._____..__ LIC. N0..__-___.__. _
DATE CONTRACTOR—
WORKERSCOMPENSATION DECLARATION
I HEREBY AFFIRM 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 3700 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
(THIS SECTION NEED NOTBE CCIVIP ETED OFTHE PERMIT IS FOR ONE HUNDRED DOLLARS ($100)OR LESS,
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I
LSHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
l RKERS'COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME
1( SUEUECT70THE WORKERS'COMPENSATION PROVISICNSOFSECTION 37000FTHE LABOR
F CODE, i SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
✓DATE _ APPLICANT: -
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE
SUBJECT AN EMPLOY ERTO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (51 00,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED ISEC. 3D , CIV. C.J.
LENDER'S NAME _
LENDERSADORESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
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.
PERMITFEE N E (PRINT)
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PERMITTEE DATE
APPLICATIO
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DATE
NU BER
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ISSUE
TYPE
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DATE
CONST.
GROUP
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PROPOSED USE
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UNITS
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BEDROOMS
DESCRIPTION
SO. FT. FACTOR PSF
ADJ. AREA/VALUATION
SFR/ADWREM
Garage/Carport
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Patio/Deck
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Pool/Spa
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Valuation
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VALIDATION
WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—Applicant's Copy
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