HomeMy WebLinkAbout18697 (19) CITY OF DIAMOND BAR
----�'� ----� DEPARTMENT OF CONIIvfUNTfY&�DEVELOPIviENT SERVICES
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o� JOBSITE �/�� �/��i/��Q J'rJ���/,GS APPLICATION q � �LPERMIT P/C
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v� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
p� OWNER-BUILDER DECLARATION
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I HEREBV AFFIfiM UNDER PENALTV OF PERIURV THAT 1 AM E%EMPT FROM THE CONTRACTORS LI- G8f8(JQ/C3fpOR
W CENSEUWFORTHEFOLLOWINGREASON(SEC.7o77.58USINESSANDPROFESSIONSrODE:ANVCITYOR (n
U COUNTVNMICHREOUIRESAPERMITTOCONS7RUCT,ALTER,IM?ROVE,DEMOLISH,ORREPAIRANVSTRUC-
w TURE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w Patio/Deck
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- .
� CENSE LAW(CHAPTER 9(COMMENCING WI7M SEC710N 7000)OF DIVISION 7 OF THE BUSINESS AND PRO- � PooUSpa
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED E%EMP- (!5
� TION.ANVVIOLATIONOFSECTION7031.5BYANYAPPLICANiFORAPERMRSUBJEC�S'fHEAPPLICANTTO Z �Re-Roof ��`SC � �
� A CIVIL PENALTV OF NOT MORE THAN FIVE HUNDRED DOLIARS�f500).): �
❑I,AS OWNER OF THE PROPERTY,OR MV EMPLOV EES WITH WAGES AS 7 HEIR SOLE COMPENSA7iON,
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WILL DO 7HE WORN,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.70��,BU51� J
� NESS M1D PROFESSIONS CODE:THE CANTRACTORS LICENSE lAW DOES NO'APPLY TO AN OWNER OF � I
PROPER7Y NM110 BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR �
Q THROUGHHISORHEROWNEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTENDEDOR m
w OFFEREDFORSALE.IF,HOWEVER7HEBUILDINGORIMPROVEMENTISSOLDWITHINONEYEAROFCOM7LE� � '
0 TqN,THE OWNER�BUILDER WILL MAVE THE BURDEN OF PROVING'HAT HE OR SHE DID NOT BUILD OR
� IMPROVE FOR THE PURPOSE OF SALE). li
w ❑I,ASOWNEROFTHEPROPERTY,AME%CLUSIVELYCONTRACTINGWITHUCENSEDCONTRACTORS ,
� TO CANSTRUCT THE PRQIECT(SEC.70�/,BUSINESS AND PROFESSIUNS CODE:THF.CONTRAC70R5 LI- ValUetlOfl � ADJ.AREA �
W CENSEUWDOESNOTAPPLVTOANOWNEROFAPROPERTVWF/OdUII.D50RIMPROVESTHEREON,AND
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� ❑I AM EXEMPT UNDER SEC. B.8 P.C.FOR THIS REASON Q
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� LICENSED CONTRACTORS DECLARATION W
� I HEREBY AFFIFM UNDEq PENALTV OF PERJURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER �
d D(COMMENCING WITH SECTION 7oW)OF DIVISION 30F THE BUSINESSAND FP.OFESSiONS CODE.AND Z
�X MV UCENSE IS IN FULL FORCE AND EFFECT. � m
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U OATE �'�17 ^ d Z� CONTRACTOR ��Nf�OF� d
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� WORKERS'COMPENSATION DECLARATION Q
NI HEREBV AFFIRM UNOER PENALTV OF PERIURY ONE OF THE FOLLOWING DECIAFAT10N5: Z
Z ,�I HAVE AND WILL MAINTAIN A CER7IFICA7E OF CONSENT TO SELF�INSURE FOR WORKERS' _ .
a COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE,FOFl THE PERFORMANCE W
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. �
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w _I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BV SECTION �ryy ///��� 777���
Q 370o OF 7HE LABOR CODE,FOR THE PERFORMANCE OF THE WORN FOR WHICH THIS PERMIT IS ��/ ,�
ISSUED.MV WORKERS'COMPENSATION INSURANCE CARRIER AND POLICV NUMBER ARE: CONSTRUCTION O
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� CARRIER PLAN REVIEW �
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� (iHI55EGTpNNE�NOTBE00MPLEfEDOF71iEPERMRISFORONEMIPDREDDOLLMS�St00�ORLESS). PLUMBING
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Z �CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOH WHICH iHIS PERIIIT,IS ISSUED,I MECHANICAL
(,�} SMAIL NOT EMPLOY ANV PERSON IN ANV MANNER SO AS TO BECAME SUBJECT TO THE
� WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGREETHATIFISHOULDBECOME INS?ECTIONFEE
= SUBJECT TO THE WORKERS'CAMGENSATION PROVISIONS OF SECTION 3700OF THE UBOR _
CODE,I SHALL FORTHWITH COMPIY WITH THOSE PROVISIONS. ISSUANCE
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p DATE: APPLICANT: �
J WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHAIL 9E ENEFGY P/C
� SU&IECT AN EMPLOVER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDRED THOUSAND ENERGY PERMIT
DOLURS(f700,000).IN ADDITION TO THE COST OF COMPENSATION,OAMAGES AS PROVIDED FOR IN
J SECTION37080FTHELABORCODE,INTEREST,ANDATTORNEV'SFEES. RETENTIONFEE: � •�
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� ' CONSTRUCTION LENDING AGENCY PRE-ALT FEE: �
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� I HEFEBV AFFIRM UNDER PENALTV OF PERJURV THATTHERE IS ACONSTRUCTION LENDING AGENCV
� FOR THE FERFORMANCE OFTHE WORK FOR WHICH 7HI5 PERMIT IS ISSUED(SEC.3oB7,CIV.C.).
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� LENDER'S NAME
� LENDER'S ADDHE55 � �
� I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT TME ABOVE W FORMATION IS CAFRECT. TOTAL FE ES � � ��
w I AGREE 10 CAMPLY WITH ALL pTY AND COUNTV ORDINANCES AND STATE LAWS REUTING TO BUILDING
� CONSTRUCTION,AND HEi7EBV AUTHORIZE HEPRESENTATNES OF THIS COUNTV TO ENTER UPON THE
ZABOVE�MENTIONED PROPERTV FOR INSPECTION PURPOSES. . COMMENTS
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SIG UREOFPERMITTEE DATE �
RECPT.N PAID BY VALIDATION
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