HomeMy WebLinkAbout15531 (22) _��R� CITYOFDIAMONDBAbt EXPIRED ,,��- -...,
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
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(909)860.3195 Fax(909)861-3117 J U N 17 2002
�-'A�^ BUILDING PERMIT APPLICATION FIRMLY
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�n DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
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I HEREBY AFFlRM UNDER PENALTV OF PERNRY THAT I MI EXEMPT FROM THE CONTMCTORS LI• G8f89B/C0ry0R
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� TURE,PRIDR TO 1T9 ISSUANCE,ALSO RE�UIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W
5TATEMEM THAT HE OR SHE IS LICENSED VURSUANT TO 7HE PROVISIONS OF 7HE CONTMCTORS LI-
� CENSE UW(CHAP7ER Y(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF 7HE BUSINESS AND PRO- � POOVSp2
FESSpNS ODDE)OR hiAT HE OR SHE IS EXEMPTTHEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- C7
TION.AHYVIOLATIONOFSECTIOH70.71.5BVANYMPLICANTFORAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Roof
� A qVIL PENALTY OF NOT MORE 7HAN FIVE HUNDRED DOLLARS(l500).�:
� ❑I,ASOWNEROFTHEPROPERT/,ORMVEMPLOYEESWITHWAGESASTHEIRSOLECOM7ENSATION, 0 COR1ff18fCi81 �
WILL DO THE WOHI(,AND THE STRUCTURE IS NOT IHTENDED OR OFFERED FOR SALE(SEC.70H,BUSI� J
� NESS AND VROFESSIONS CODE:7HE COMRACTORS LICENSE UW DOES NOT APPLV TO AN OWNER OF �
PROPEHTY WFIO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
� T11FqUGH HIS OR HER OMM EMPLOYEES,PROVIDED THAT SUCH IMVROVEMENTS ARE NOT INTENDED OR m
Q ,OFFEAEDPDRSALEIF,HOWEVERIF�EBUILDINGORIMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE•
Z 'TION,TNE OMMER-BUILDER WILL HAVE THE BURDEN OF VROVINO THAT HE OR SHE DID NOT BUILD OR
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w ❑I,AS OVMER OF THE PROPEHTY,AM El(CLUSNELV CONTMCTINO WI7H LICENSED CONTRACTORS .
Q TO CONSTRUCT 7HE PR0.IECT(SEC.70a�,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- V01Uat1011 ADJ.AREA
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� O I AM El(EMPT UNDER SEC. B.8 P.C.FOR THIS REASON U
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� LICENSED CONTRACTORS DECLARATION W
� I MEREBY AFFIRM UNDER PENALTY OF PERIUHY THAT 1 AM IICENSED UNDER PROVISIONS OF CHAPTER �
d Y(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND Z
AIY UCENSE IS IN FULL FORCE ANO EFFECT. � �
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� WORKERS'COMPENSATION DECLARATIO ��/� ' ,1 Y-y nn
� I HEREBV AFFIRM UNDER PENALTV OF PE0.IURY ONE OF THE WLLOWIN EC�Nq� � �l..r a �
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� COMPENSATION,ASIPROVID DEBV'SEC710N37aoOFETM705 LF-IN�SUE,FORTMEPRKERS' E �x� ����F ll1H1viT c A�.�/
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Q OF THE WORK FOR YMICH THIS PERMIT IS ISSUED. W ,y_� y�T T'If( T�u ��L"�
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w _I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE.AS REQUIRED BY SECTION ��J ��1�
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� ISSUED.MY WORKERS' INSURAN RIER LICY NUMBER A . CONST UCTION ��
jc�RwER I L�I R�VIEW
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Z I CERTIFY THAT IN THE PEHFORMANCE OF THE M/0RK FOR WHICH 7}115 P MIT IS ISSUED,I ECHANICAL
(,'J SHALL NOT EMPIOY ANV PERSON IN ANY MANNER SOAS TO BECAME SU 70 THE [�
� WOHKERS'COMPENSATIONUWSOFCQIFOHNIA,ANDAGREETHATIfISHOUL INSPECTIONFEE . S?Si'a. inR�n\\
SUBJECT TO THE WORKERS'COMPENSATION P ISIONS OF SECTI N 370o OF THE LABOR i �V`� Y'�
CO ISHALLFORTHWIT/COMPLYWI7HTH E OVISIONS. e ISSUANCE 1�� � � �
p �ATE:�� APPLICANT: .----, '�vC.� . SMIP ��1 .-.:AR 0��.�!G� G .
J WARNING:FAILURE TO SECURE WORKERS'CAMPENSA710N COVERAGE IS UNUWFUL,AND SMALL BE ENERGY P/C �'�`, � � / � ��Y �
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� SU&IECT AN EMPLOYER TO CRIMINAL PENAL7IES AND CIVIL FINES UP 700NE HUNDRED THOUSAND ENERGY PERMIT -- � U �R� +'� �
DOLLARS(S1ao.o00).IN/�DDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
JSEC710N 97oB OF THE UBOR CODE,INTEREST,AND ATTORNEY'S FEES. � �bv
� RETENTION FEE: r �f1G D��'_�. C l��''Fr
a CONSTRUCTION LENDING AGENCY PRE-ALT FEE: �..�p � (`� py L v-
� I HEHEBV AFFIRM UNDER PENALTV OF PERIURY THA7 THERE IS A CONSTRUCTION LENOINC,AGENCY D�J
FOR THE PEHFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.C.). .
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� LENDER'S NAME
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� ICERTIFYTHATIHAVEREADTHISAPPLICATIqJANDSTATETHATTHEA80VEINFORMATIONISCARRECT. TOTAL FEES ' � '�
w I AGREE TO CAMPLV N7TH ALL CfTV AND COUNTY ORDINANCES ANO STATE UWS REU7ING TO BUILDING
� CONSTRUCTION,AND HEREBV AUTHORIZE REPHESENTATIVES OF THIS COUNTY TO EMER UPON THE �
ZABOVE�MENTIONED PROP RTV FOR INSPECTION PURPOSES COMMENTS '
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� SIONA7URE OF PERMITTEE DATE
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~ WHITE-0epartment Copy,YELLOW—Finance Copy,PINK—Assessor Copy, O ENROD--File Copy,GREEN—Applicant's Copy
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