HomeMy WebLinkAbout17855 CITY OF DIAMOND BAR
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21825 E.Copley Drive �X r I n E�
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'`'-�w��� BUILDING PERMIT APPLICATION J U N 18 2002 FI RM LY
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cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
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I HEREBY AFFIRM UNDER PENAL7V OF PERIURY THAT I AM EXEMPT FROM THE CONTRACTORS LI� G8f8(JBICBIpOR
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w TURE,PRIOR TO ITS ISSUANCE,ALSO RE�UIfiES THE APPLICANT FOR SUCH PERMIT 70 FILE A SIGNED w Patio/Deck
S7A7EMEN7 7HA7 HE OR SHE IS LICENSED PURSUAN7 TO THE PROVISIONS OF THE CAN7RACTORS LI�
� CENSE UW(CHAPTER e(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO� � POOUSPa
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V TION.ANV VIOLATION OF SECTION 7031.5 BV ANY APPUCANT FOR�PERMIT SU&IECTS THE APPLICANT TO Z Re-Roof
A CIVIL PENALTV OF NOT MORE THAN FIVE HUNDRED DOLLARS(fSooJ.�:
Z ❑I,ASOWNEROFTHEPROPERTY,ORMVEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSA710N, � COrt1rtIBfCl91 -
WILL DO THE WORK,AND THE STRUCiURE IS NOT IN7ENDED OR OFFERED FOR SALE(SEC.704�,BUSI- J
� NESS AND PROFESSIONS CODE:THE CANTRAC70RS LICENSE LAW DOES NOT APPLV 70 AN OWNER OF �
PROPERTY WHO BUILOS OR IMPROVES THEREON,AND WHO DOES SUCH WOHK HIMSELF OR HERSELF OR
CL THROUGH HIS OR HER OWN EMPLOVEES,PROVIDE�THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR m
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Z TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
� IMPROVE FOR THE PURPOSE OF SALE).
w ❑I,ASOWNEROFTHEPROPEHTV,AME%CLUSIVELYCONTRACTINGWITHLICENSEDCANTRACTORS
� TO CANS7RUC7 THE PRQIECT(SEC.70�4,BUSINE55 AND PROFESSIONS CODE:THE CANTRACTORS LI� V81Ue�lOf1 ADJ.AREA
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� ❑I AM EXEMPT UNDER SEC. B.8 P.C.FOR THIS REASON Q
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2 I HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER �
d 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 0F THE BUSINESS AND PROFESSIONS CODE,AND Z
X MY LICENSE IS IN FULL FORCE AND EFFECT. .� l
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� WORKERS'COMPENSATION DECLARATION � �
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� I HEREBY AFFIRM UNDER PENALTV OF PERJURV ONE OF 7HE FOLLOWING DECLARATIONS: Z � '
0 I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF�INSURE FOR WORKERS' = 1 (� � I a. �"�'
Z COMPENSATION,AS PROVIDED BV SECTION 37000FTHE LABOR CODE,FOR THE PERFORMANCE U —� O
Q OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. w
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w I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS RE�UIRED BY SECTION
Q 3700 OF THE LABOF CODE.FOR THE PERFORMANCE OF THE WORK FOR WHICH 7HIS PERMIT IS
ISSUED.MY WORKERS'COMPENSA710N INSURANCE CARRIER AND POLICY NUMBER ARE: CONSTRUCTION
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Z I CEFTIFV THAT M THE PERfORMANCE OF THE WORK FOR WHICH THIS PEHMIT IS ISSUED,I MECHANICAL
CJ SHAIL NOT EMPLOY ANY PERSON IN ANV MANNER SO AS TO BECOME SUBJECT TO THE /� +{�7^�•[��^��—
N WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF 1 SHOULD BECOME INSPECTION FEE � /l.a.\ I f I I 111
= SUBJECTTOTHEWORKERS'CAMPENSATIONPROVISIONSOFSECTION37000FTHELABOR I�` �� � � � ^'•-^ A�/ "'�
CADE,I SHALL FORTHWITH COMPLV WITH T�E PRO�. � ISSUANCE iS 7
O DATE:�0 �� D� SMIP I � 1 r n n?
� APPLICANT.
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J WARNING FAILUFE TO SECURE WORKEflS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE ENERGY P/C A �
� SUBJEC7ANEMPLOVEH70CRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT I�c-.
DOLLARS(Stoo.000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN � .� �
J SECTION37080FTHEUBORCODE,INTEREST,ANDATTORNEV'SFEES. RETENTIONFEE: �+�...�.-- —
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a CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
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� I HEREBV AFFIRM UNDEH PENALTY OF PERJURV THAT THERE IS A CONSTFUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.J097,CIV.C.). ,
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� LENDER'S NAME
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� I CERTIFV THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. TOTAL F E ES ����O
� 1 AGREE TO COMPLV WITH ALL CITV AND COUNTV ORDINANCES AND STATE LAWS REUTING TO BUILDING �J
� CONSTRUCTION,AND HEREBV AUTHOPIZE flEPRESENTATNES OF THIS COUNTY TO ENTEF UPON THE
Z ABOVE�MENTIONED PROPERTY FOR IN�CTION PURPOSES. COMMENTS �
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= RECPT.NO. �PAID BY � VALIDATION
~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENRO�File Copy,GREEN—Applicant's Copy
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ROUGH PLUMBING � � F(NiSH GRADING
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DRYWALL NAILIiVG � � DEDICATIONS j�
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FINAL ELECTRIC � � DEV. FEES PAID
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