HomeMy WebLinkAbout14924 (20)CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 851-3117
BUILDING PERMIT -APPLICATION
JOBSITE
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DESIGNER AJ
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 FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REOUIRESA PERMrTTO CONSTRUCT, ALTER, IMPROVE, DEMOLISH, CR REPAIR ANY 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 LI.
CENSE LAW (CHAPTER B (COMMENCING WITH SECTION 7000) OF DIVISION 3 O THE BUSINESS AND PRO.
FESSIONSCODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP.
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 (S500)J:
❑ I, AS OWNEROFTHE PROPERTY, OR MV EMPLOYEES WITH WAGESAS 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 IMPROVESTHEREON, AND WHO DOES SUCH WORK HIMSELFOR HERSELF OR
THROUGH HIS DR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTSARE NOT INTENDED OR
OFFERED FOR SALE. IF, HOWEVERTHE BUILDINGOR IMPPOVEMENTIS SOLD WITHIN ONEYEAR OFCOMPLE.
TION. THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE)•
C 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
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTORIS) LICENSED PURSUANTTOTHE CONTRA(_
TORS UCE14SE LAW.).
G I AM EXEMPT UNDER SEC. S. A P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
41HEIRIE YAFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER
NCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND
SE IS IN FULL FORCE AND EFFECT.
SE CLASS LIC. NO. '�1�_ CONTRALTO __ _
WORKERS' COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLI OWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 37000FTHE LABOR CODE, FOR THE PERFORMANCE 1
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
--I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED S" SECTION
37000FTHE 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
UNISSECDON NEED NOT BE OOMPUIT- DOFT.f'e PERMITISWP.CI-lEHUWDREDDCLLAV"100)CRi.ESS}
• I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I
SHALL
4
0
7 EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
RKERS' COMPENSATKIN LAWS OF CALIFORNIA, AND AGREE THAT IF I SHOULD BECOME
'SUBJECTTO THE WORKERS' COMPENSATION PROVISICNS OF SECTION 3110OFT'IE LABOR
�CO(O'E, 1 HAL �fRTHW H COMPLY WITH -SEP
VISE�DSHWARNINGFAILU
ETOSECUREWORKERS'COMPEIJSA COVALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (f1 40,00), IN ADDITION TO THE COSTOF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT M ISSUED (SEC.
LENDER'S NAME__ _
LENDER'SADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THEABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITH ALL CRY 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.
74
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DATE NUMBER _ / #
ISSUE�^y�ss 1 TYPE OCC
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ZONING SETBACKS
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PROPOSED USE
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NO. DWEL. NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREAI ALUATION
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ENERGY PERMIT
RETENTION FEE:
PRE -ALT FEE:
TOTAL FEES
COMMENTS
--FY--VAL—IDATION
I RECPT NO. _- I PAID BY
WHITE --Department Copy, YELLOW --Finance Copy, PINE—Assessor Copy, GOLDENROD—File Copy, GREEN—Applicants Copy
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