HomeMy WebLinkAbout15053 (17)1►11�III�ll BAh i
CITY OF DIAMOND BATS
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
BUILDINGPERMITAPPLICATION
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APPLICANT�.�.
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DESIGNER
ADDRESS
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OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FORTHE FOLLOWING REASON (SEC.7031.5 BUSINESSAND PROFESSIONS CODE: ANY CITYOR
COUNTY WHICH REOUIRESA PERMrTTO CONSTRUCT, ALTER, IMPROVE, DEMOUSH, OR REPAIR ANYSTRUC-
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 U -
CENSE LAW (CHAPTER 9 (COMMENCING WITH SECTION 7000) 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 BYANY APPLICANT FOR A PERMIT SUB.IECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (S500).):
❑ 1, AS OWNEROFTHE 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 HERSE_F OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FORSALE IF, HOWEVER,THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE 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).
L AS OWNER OF THE PROPERTY AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THEPROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI-
CENSE LAW DOES NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON. AND
WFIOCONTRACTSFOR SUCH PROJECTS WITHACONTRACTOR(S) LICENSED PURSUANTTOTHE CONTPAC-
ToRS LICENSE LAW.).
D I AM EXEMPT UNDER SEC. B. A P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM LINGER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTE R
B (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESSAND PROFESSIONS CODE, AND
MY LICENSE IS IN FULL FORCE AND EFFECT. /,, c., Z
LICENSE CLASS 4 4' ✓� LIC. NO. �!
.-_7�.:' d G7
DATE _ _ CONTRACTOR A- On __. �'
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIrMA 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 THF_ PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
_ I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE; AS REQUIRED BY SECTION
37000FTHE LABOR CODE, FORTHE PERFORMANCE OF THE WORK FOR WHICHTHIS PERMITIS
ISSUED. MV WO FRS' COMPENSATION INSU�NCE CARRIER AND POLICY NUMBER ARE:
CARRIER r` `�n
POLICY NUMBER L� �/ 'co
(THIS SECTION NEEONOT BE COMPLETED OF THE PERMIT 15 FOR ONE HUNDRED DOLLARS ($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
SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE, I SHALL FORTHWITH COMPLY WITH
,, ^THOSE
_TPROVISION�
DATE: _ APPLICANT: /_Nv'
WARNING: FAILURE TO SECURE WORKERSCOMPENSATION COVERAGE IS UNLAWFUL. AND SHALL BE
SUBJECTAN 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 3709 OF 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. n097' CIV C.),
I
LENDER'S NAME
LENDER'SADDRESS -- —.--
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORD'NANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COI FYTO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
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FIRMLY
APPLICATION T10i
PERMIT ( _ (�
DATE
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ISSUE
TYPE
OCC
DATE
CONST.
GROUP
ZONING SETBACKS
FRONT
RW
❑
REAR
❑
SIDEISIDE STRE T
RW
❑
_ SIDE
❑
PROPOSED USE
V
NO. DWEL. NO.
NO.
UNITS STORIES
BEDROOMS
DESCRIPTION SQ. FT.
FACTOR PSF
ADJ. AREAIVALUATION
SFR/ADD/REM
Garage/Carpon
W
Patio/Deck
LL-
POOVSpa
0
Z
Re -Roof
Commercial
--
5
m
Valuation
ADTAREA
DESCRIPTION
FEE
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rQUANTITY
U
U
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w
0
U
121
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CONSTRUCTION
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ELECTRIC
PLUMBING
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MECHANICAL
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INSPECTION FEE —
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ISSUANCE
DA TV%
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
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PRE -ALT FEE:
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TOTAL FEES
COMMENTS
RECPT NO. � PAID BY VALIDATION "
WHITE—Department Copy, YELLOW—Finanoe Copy, PINK—Assessor Copy, GOLDENROD --File Copy, GREEN—Applicant's Copy