HomeMy WebLinkAbout14961 (27)CITY OF DIAMOND SAE
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117 PRESS
BUILDING PE1 Mff APPLICATION FIRMLY
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® OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER ENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
U CENSELAWFORTHE FOLLOWM REASON(SEC.7031.5 BUSINESSAND PROFESSIONS OODE:AN'YCITYOR
(Z� COWTYWHICH REOUIRESA PE MITTOCONSTPUCr,ALTER,IMPROVE, DEMOLISH, OR REPAIRANY STRUC.
llJ TUBE, PRIOR TO ITS ISSUANCEI ALSO REQUIRES THEAPPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SNE LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
�, CENSE LAW
(CHAPTER . ICOM ENGMG WITH SECTION 7000)OFDIVISION 3OFTHE BUSINESSANDPRO-
FESSIONS CODE) OR THAT HE O SHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXEMP-
TION -ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
" A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (8500).):
❑ I. AS OWIEROFTHE PR PERTY.ORMY EMPLOYEES WITH WAGES As THEIR SOLE COMPENSATION,
Z =WILL DO THE WORK, AND THE TRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC -7044, BUS I-
NESS AND PflOFES510N5 CODE THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMP OVES THEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
IC THROUGH HIB OR HEROWN EM LOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
Il: DFFEREDFORSdLLE IF,HOWEVETHEBUILDINGORIMPROVEMENT ISSOLDWITHINONE YEAR OFCOMPLE-
LZ-Y 1
TION, THE ONMER-BUILDER WI HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE O SALE).
❑LASOWNEROFTHEPR PERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
YO CONSTRUCT THE PROJECT ;SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI -
LIS CENSE LAW DOES NOTAPPLY TVN OWNER OF A PROPERTY WHO BUILDS OR IM PROVES THEREON, AND
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S) LICENSED PU RSUANT TO THE CONTRA( -
TORS UCENSE LAW.).
®' ❑ 1 AM EXEMPT UNDER SEG.- D. 8 P.C. FOR THIS REASON
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DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALI�1' OF'IE-U,.Y THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
e (COMMENCINO WITH SECTION p000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS IN FULL FFORCE A D EFFECT.
LICENSE CLASS �^ ! LIC. N0.
C.~,DDATEill, NT. RACTO
COR
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WORil COMPENSATION DECLARATION -
IHEREB FFIRM UNDER PENAL OF PERJURY ONE OF THE FOLLOWING DECLARATION S:
® I VEAND WILL MAINT�ACERTIFICATEDF CONSENT TO SELF-INSIJRE FOR WORKERS'
¢L COMPENSATION, AS Pft VIDES BY SECYlON 37W OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
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i HAVE AND WILL MAIN T IN WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY SECTION
37o00FTHELABOR'ro It. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
J ISSUED, MY WORK FIV COMPENSATION INSURANCE CARRIER AND POLICY NUMi ARE:
a CARRIER /g✓ oit3 `�f�y '
POLICY NUMBER
(IH15 SECTION NEWRO7 NEtTED OFT}iE PERMIT IS FOR LXVE HUNDRED [XA1P.R5 ($100) OR LESS).
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Z I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THI5 PERMIT 15 ISSUED,I
C;J SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
gn WORKERS' COMPENSATI Il LAWS OF CALIFORNIA, AND AGREE THAT IF 1 SHOULD BECOME
SUPLIECT TO THE WORK RS'COMPENSATION PROVE IONS OF SECT N3]a00F 7HE LABOR
CODE,ISHAIJ. ORYHWI COMPLY WITH TH 10
DATE: ! '�" " APPLICANT:
J
J WARNING: FAILURE TO SECURE y�YYORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE
SURIECT'AN EMPLOYER TO CRIkIINAL PENALTIES AND CIVIL PINES UP TOONE HUNDRED THOUSAND
L'i
DOLLARS (S10o,on), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES.
4� CONSTRUCTION LENDING AGENCY
DC (HEREBY AFFIRM UNDER PENALjy OF PERJURY THAT THERE IS ACONSTRUCTION LEN DING AGENCY
®- FOR THE PERFORMANCE OFTH�e WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097, CIV. CJ.
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LENDERS NAME
I_ LENDERSADDRESS
1 CEIlin-P HAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
DONSTRUCTION,AND HEREBYAIITHOR[ZE REPRESENTATIVES OF THI5 COUNTYTO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
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NUMBER #
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TYPE OCC
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PROPOSED USE
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