HomeMy WebLinkAbout18767 �� CITY OF DIAMOND BAR
� DEPARTME'VT OF COMMi 1NI"I'Y&DEVELOPMENT SERVICES
� � 21825 E.Copley Drive
(909)860-3195 Fa�c(909)861-3117 PAE$S
BUILDING PERMIT APPLICATION FIRMLY
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� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
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� FESSIONSCAOEJORTHATHEORSHEISE%EMPTTHEREFROMANDTMEBASISfORTMEALLEGEDEXEMP- �
� TION.ANYVIOLATIONOFSECTION7037.SBYANVAPP'�IGAN�FORFPEFMITSU9JEG�5"MFAPPLiGANTTO Z Re-Roof
� A CIVIL PENALTV OF NOT MORE THAN FIVE NUNDRED DOLURS(SSoO�.)'. '
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� Z WiLL DO THE WORK,nND THE STRUCTURE IS NOT INTEN�ED ON OFFEFED FOH SALE(SEC.7040.BU�.I� J
NESS PNO PHOFESSIONS CODI=:THE CANTRACTORS LICENSE LAW OOFS NO�APPL�TO AN OWNER OF
� PROPERTVWHOBUILDSORIMPROVESTHEREON,ANOWHODOESSUCHWORNN'�MSELFOFHERSELFOR �
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Z IMPROYEFOflTHEPURPOSEOFSALE�. /
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p. 9(COMMENGNG WI7H SECTIOIJ l000)Of DIVISION 3 DF THE 9USINESSAND PPOfE55iON5 CODE.AND Z
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� WOFKERS'GOMPENSATION�ECLARATION �
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� I HEREBY AFFlRM UNDER PENALTV OF PERJURV ONE OFTHE FO'_LOWING DEC�ARATIONS: Z
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O IHAVEANDWILLMAIN'-AINACERTIFICATEOFCANSENTTOSELF-INSUREFORWORKERS' _
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¢ OF THE WORK FOR WFIICH THIS PERMIT IS ISSUEO. �
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Q 9]DOOFTHELABORCODE,FORTHEPERFORMANCEOFTMEWOqK ORWHICHTHISPERMITIS � 3O
0 ISSUE7.MV WORKERS'COM ENS TION I UPA4C CARRIER Af OLICY NUMBER ARE�. CONSTRUGTION _ _
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Z I CER1IFVTHAT iNTHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I —
L} SHAL�NOT fMPLOV AIJY GERSON IN ANY MANNER 50 AS TO BECOME SUBJECT'O THE
� WORKERS'COMPENSATION LAWS OF CALIFORNIA.AND AGREE THAT IF I SHOULD BECOME INS:�ECTION FEE _
SUBJECTTOTHEWOPKERS'COI.IGENSATIONP VISIONSOFSEC710NJ]OaOF�HELA60R �l
� CO�E.1 N FORTH�NITH COMPLY WITH TH PR VISI01 . I ISSUANCE _ � V�U
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—� WARNING:FAI�URE TO SECURE VJORKERS'COMPENSATION COVERAGE IS UNLAWFUL A ALLBE —
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� SVBJECTANEMPLOVERTOCRIMINAL7ENALTIESANDCIVIt,FWESUPTOONEHUNDFED USAN� ENERGYPERMIT
DOLLAFS(ftao.oOD),IN ADDRION TO THE COST OF COMPENSAT✓JN,DAMAGES AS VROVIDE�FOR IN X—
J SEGTIDN 3]Oe Of THE LABOR��ODE,INTEREST,ANDATTORNEV'S FEES. RETENTION FEE: • �U
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� CONSTRUCTION LENDING AGENCY PRE-ALT FEE: _
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� I HEREBV AFFIRI.1 UN�EF PEN4lTV OF PERJURV THATTHERE IS ACONSTFUI:TION I.EN�ING AGFNCY
� FOR THE PER-OFMANCE DF THE WORK FOR WHICH THIS CERMIT IS ISSUED(SEC.3D9],CIJ C.).
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S LENDEN'S NAME __
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F- LENDER'SADDFE55
� I CERTIFV THAT I NAVE REA�THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION I$COFRECT TOTAL FEES , �� •
W I ACREE TO COMPLV WITH ALl CITV ANO COUNTV ORpiNANCES AND STATE LAWS RELATINC TG Plllt[]ING
� CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATNES OFTHIS COUNTV TO ENTER UPUN THE ^
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� SIGN OFPERMITTEE DAit
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ADDRESS
CITY ZIP TEL.
APPLICANT TEL.
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ADDRESS�
CITY��ZIP TEL. �'
ARCH/ENG/3�,�
DESIGNER_
ADDRESS
CITY ZIP_TEL._
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI�
CENSE LAW FOR THE FOLLOW IMG REASON (SEC. 7031 5 BUSINESS AND PROFESSIONS CODE: ANV CITY OR
COUNTY WHICH REOUIRESAPERMIT TO CONSTRUCT,ALTER,IMPROVE,DEMOLISH,OR REPAIR ANV STRUC�
TORE, 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 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONSCODE)ORTHAT HE ORSHE IS E%EMPTTHEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANV VIOLATION OF SECTION 7037.5 BV ANV APPLICAN� FOR A PERMIT.SUBJEC tS'(HEAPPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLURS(5500).): '
^ I,AS OWN ER OF THE PPoDPERTY.OR MY EMPLOYEES WITH WAGES AS 1 HEIR SOLE COMPENSATION.
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OH OFFERED FOR SALE(SEC. 7044, BUSI�
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES N0.APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORN HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE. IF,HOWEVER,THE BUILDING OR IMPROVEMENT IS SOLO WITHIN ONE V EAR OF COMPLE-
TION,THE OWNER�BUILDER WILL HAVE THE BURDEN OF PROVING'HA7 HE OR SHE DID NOT BUILD OH
IMPROVE FOR THE PURPOSE OF SALE).
^ I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7064, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI�
CENSE LAW DOES N07 APPLY 1'0 AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS W ITH A CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
C I AM EXEMPT UNDER SE:C. B. 8 P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH BECTIOIJ 7000)OF DIVISION 30F THE BUSINESS AND PP.OFESSiONS CODE,AND
MV LICENSE IS IN FULL FORCE AND EFFECT.
LICENSE CLASS_LIC. N0.
DATE'-�L CONTRACTOR-
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENO�LN OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAIN"-AIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BV SECTION 37000E THE LABOR C00 E,FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
1 HAVE AND WILL MAIN'rplN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION
37000E THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK OR WHICH THIS PERMIT IS
ISSUED. MV WORKERS'COM ENS TION I URANC CARRIER A OLICV NUMBER ARE:
CARRIER
POLICY NUMBER
(THIS SECTION NEED NO t RE ODMP(.ETED OF THE PERMR IS FOR ONE HUNDRED DOLLARS(5100)OFi LESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY AIJV PERSON IN ANV MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WOP KERS'COMPENSATION P VISIONS OF SECTION 3700 OF THE LABOR
CODE.I H FORTHWITH COMPLY WITH TH PR VISIO
DATE: ��APPLICANT
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,A ALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED USAND
DOLLARS(5100,000),IN ADDITI�DN TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 Of THE LABOR CODE.INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY AFFIRM UNDER PEN 4LN OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY
FOR THE PE RFOfIMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097,CI'J.C.).
LENDER'S NAME
LENDER'S ADDRESS
� 1 CERTIFY THAT I NAVE 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
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OFfHIS COUNTY TO ENTER UPON THE
ABOVE�ME ZONED PROPERTY FOR INSPECTION PURPOSES.
� PENAE(PRINT
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�SIGN OF PERMITTEE DATE
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CITY OF DIAMOND BAR
DEPARTME'�IT OF CONIIvIUNIl'Y&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
PRESS
FIRMLY
WHITE-Department Copy,YELL-OW-Finance Copy,PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy