HomeMy WebLinkAbout14944CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION
JOBSITE
ADDRESS --C C
ADDRE-�'
APN LOT TRACT
OWNER /L -N
ADDRESS—� S _ "
CITY ZIP TEL.
APPLICANT TEL.
CONTRACTOR
ADDRESS
CITY ZIP. TEL
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION .
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS U -
CENSE UW FOR THE FOLLOWING REASON (SEC 7071.5 BUSINESS ANO PROFESSIONS CDOE. ANY CITYOR
COUNTY WMCH REONRES A PERMIT TO CONSTRUCT. ALTER MPROVF, DEMOUSH, OR REPAIRANY STRUC-
TUBE. 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 U.
CENSE LAW ICHAPTER S (COMMENCING WITH SECTION 7000) OF DIVISION 0 OF THE BUSINESS AND PRO-
FESSIONS CODE) ORTHAT HEORSHE ISEXEMPTTHEREFROM ANDDTHE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7071.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CML PENALTY OFNOT MORE THAN FIVE HUNDRED DOLLARS (MI.):
CI L ASOWNER OFTHE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION.
WILL DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE ISEC. 7044, BUSI-
NESS AND PROFESSIONS CODE THE CONTRACTORS LICENSE UW DOES NOTAPPLY TO AN OWNER OF
PROPERTY WHO BUNDS OR IMPROVES THEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELF On
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE K HOWEVERTHE BUILDING OR IMPROVEMENT IS SOLDWITHIN ONE YEAR OFCOMPLE-
TION. THE OWNERBUIWER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
O L AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U -
CENSE LAW DOESNOTAPPLY TOAN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON. AND
W40 CONTRACTS FOR SUCH PROJECTS WITH AOONTRACTOR(S) LICENSED PURSUANT TO THF. CONTRAC-
TM LICENSE LAW.).
O IAM EXEMPT UNDER SEC a. I P.C. FOR THIS REASON
DATE - OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBYAFFU*A UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER
• (COMMENCING WITH SECTION 7000) OF DIVISION S OF THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS N FULL FORCE AND EFFECT.
LICENSE��� LIC. NO.1,
DATE --fi// 2,"o- � CONTRACTOR �f
WORKERS'COMPENSATION DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
_ I NAVE ANO WILMANTAN A CER'nFICATE OF OONSENTTO SCLF-INSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BY SECTION 37000FTHE LABOR CODE, FOR THE PERFORMANCE
OFTHE WORK FOR WHICINTHIS PERMIT IS ISSUED.
I
_I HAVE AND WILLMANTAN WORKERS -COMPENSATION INSURANCE, AS REQUIRED BY SECTION
5700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
iISSUED. LIYWO COIAPENSATOWINSUPANCE/GT4RRIER AND POLICY NUMBER ARE:
CARRIER �
POLICY N IMBER /
MW SECTION NEED NOT BE COM`U1EDOF THE PERM(6 FOR DNF. HI.TDRID DOLLARLS (5:07 0q LFSo'i
1
(CERTIFY THAT LA THE BE
OF THE WORK FOR WHICH THIS PERMIT IS LSSUED.1
1 SHALLNOTEMPLOYAMYPERSONNANYMR OAS TO BE COME L.L
SUBJECTTOTHE
j WORKERS' COMPENSATION LAWS OF CAUFANNEORNI AND AG E THATIF I SHOD BECOM.
SUDRECT TO THE WORKERS'COMPENSATION PR AS SECTION 7700 OF THE LABOR
CODE, SHALL FORTHWITH COMPLY WITH THOS PP
T OATEt � FN. GO APPLICANT
J
1 WARNING: FAILURE SECURE VARNERS'COMP .SATION COVERAGE IS UNLAWFUL. AND SHALL BE
SUBJECTAN EMPLOYER TO CRIMINAL PENALTIES D CIVIL FINES UP TOONE HUNDRED THOUSAND
DOLLARS (L100.000). N ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN
J
SECTION 3708 OF THE LABOR CODE, INTEREST. AND ATTORNEY'S FEES.
A CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY T THERE L A CONSTRUCTION LENDINGNCY THE PERFORMANCE OF THE WORK FOR WHICHICH C.). THIS PERMIT IS ISSUED (SEC. 5097. CIV. CJ.
3
— LENDER'S NAME
LENDERSADDRESS
.1 I CERTIFYTHAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
U LY WITH ALL CNTY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
ANO HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
D PROPERTY FOR INSPECTION PURPOSES.
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APPLI TI NPERMIT , �, '%
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DATE CONST. GROUP
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.PROPOSED USE
NO. DWEL. NO. NO.
UNITS STORIES BEDROOMS
-DESCRIPTION SO. FT.' FACTOR PSF ADJ. AREA/VALUATION
SFR/ADD/REM
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TOTAL FEES
COMMENTS
RECPT NO. PAID BY VALIDATION
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