HomeMy WebLinkAbout15064s ` CITY OF DIAMOND BAR
4 DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
W - 21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION
JOBSITE
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DESIGNER
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OWNER -BUILDER DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS U
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESSAND PROFESSIONS CODE: ANY CIN OR
COUNTY WHICH REGUIRESAPERMTTO CONSTRUCT, ALTER, IMPROVE, DEMOLISH, OR REPAIR ANY STRUC-
TURE, 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-
FESSIONS CDDEI OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7031.6 By ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (3500).):
❑ 1. AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS 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 BUMS OR IMPROVES THEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF, HOWEVER THESUILDINGOR PAPROVEMENT IS SOLD WITHIN ONE YEAR OFOOMPLE-
TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
❑ 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 NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS FOR SUCH PROJECTS WITHACONTRACTORS) LICENSED PURSUANTTO THE CONTRAC.
TORS LICENSE LAW.).
❑ 1 AM EXEMPT LNDER SEC. B. & 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 SECTION 7000) OF DIVISION a OF THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS IN FULL FORCEAND EFFECT. �'% tea{
LICENSE SS LIC. NC 1%? %
DATE L-�� CONTRACTOR
WORKERS' COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENTTO SELF -INSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED SY SECTION
37000F THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBERARE:
CAREER
POLICY NUMBER
(THIS SECTION NEEDNOT BECOMPLErEDOF THE PERMIT IS FORCNE HUNDRED DCUARS 0))OR LESS)
1 CERTIFY THAT N THE PERFORMANCE OF THE K FO WHIC PERMIT ISSUED, I
SHALLNOT EMPLOYANY PERSON IN ANY MA R SOA OB U TO THE
WORKERS' COMPENSATION LAWS OF CALIF NIA, AN GRE HOULD BECOME
SUBJECT TO THE WORKERS'COMPENSAT NPRO ION 3700 OFTHE LABOR
X
WITH COMPLY WI PRODATE_ APPLICANT
WARNING: FAILURE TO SECURE WORKERS' COMPENSATICN COVERA IS U WFUL, AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES U TO ONE UNDREDTHOUSAND
DOLLARS (1100,000), IN ADDITION TO THE COST OF COMPENSATION DAMAGE S PROVIDED FOR IN
SECTION 3709 OF THE LABOR CODE, INTEREST AND ATTORNEY'S F ES.
CONSTRUCTION LENDINGA ENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE ISAdPNSTRU ION LENDING AGENCY
FORTHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 'SEC. 3D97, CIV. C.).
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT
I AGREE TO COM Y WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCT( D HEREBY AUTHORIZE REPRESENTATIVES OF THIS OOUNTYTO ENTER UPON THE
ABOVE -ME N PROPE INSVCTION PURPOSES.
PERMITTEE NAME NT)A
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SIGNATUREVBqCEE DATE o
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APPLICATI
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DATE
NUMBER
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TYPE
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DATE V L
CONST,
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SIDE/SIDE STREET
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PROPOSED USE
NO. DWEL. NO.
NO.
UNITS STORIES
BEDROOMS
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COMMENTS
RECPT NO. PAID BY
VALIDATION
Irepartment Copy, YELLOW—Finanoe Copy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—Applicant's Copy