HomeMy WebLinkAbout15043 (17)UI,1lIIl1U It:11►
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY
21660 G. Copley- Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
& DEVELOPMENT SERVICES
BUILDING PERMIT APPLICATION
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DESIGNER
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ONRdER•EUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PErLL:nY THAT I AAI EXEMPT FROM THE CONTRACTORS U -
CENSE LAW FOR THE FOLLOWNG REASON (SEC 7-31.5 BUS NE SSAN:) PROFESSIONS COC E. ANY CTTYCR
COL)NTV V*IIC 1 REGLMES A PERUD TO MfIS[FCJCT,ALTER, W.1'ROV _, DEA'OL'SH.On REPA:R ANY STRUC-
TURE. PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPLICJNT roil SLC11 PERM T TO FAE A S'GNED
STATEMENT THAT HE OR SHE IS LICENSED PUWL DANT TO THE PROMS ONS OF THE CONTRACTORS LI.
CENSE UW (OAPTER Y (COMML' NCNO WITH SEC -*N 7000) Or CIVSION 3 OF THE BUSINESS ANO Pn0-
FESSNONS COCE)OR THAT HC On SIZE 15 EXEMPT TICRE FROM AND THC BASIS FOR TH E ALLEGED EXEMI'-
T1ON. ANY VIOLATION OF SECTION 7031 5 BY ANY AP PLJCANT FOR A PERM.T SUWECTS THE APPLICANT TO
A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (Fsa 3) 7
C LASOWNEROr THE PROPERTY.On MY EMPLOYES W.TH WAGESASTHE:n SOLE COMPENSA70N
WILL DO THE WOJW. AND THE STRICTURE L NOT NTENnED On OFFERI D Ton SALE ISEC.7:44. BJSJ-
NESS ANO PROFESSIONS CODE. THE CONTRACTORS LICENSE LAW DOES NOT APPLY 10 AN OWNER OF
PROPER'7Y WHO BUILDS OR immovES THEnEON. ANO wHO DOES SUCH WORK H msrLF On HEnSELF Cn
THROUOII HS On HIE R OWN EMPLOYEES. PnOVDED THATSUCH W >nCVCUCNTS ARE NOT INTENDED On
OFFERED FOR SALE F, HOWEYEFL TIE BJILDING OR MPROVEJAENT ISSOLO W:THN ONE YEAR OF OOMPLC-
TON. THE OWNER BUILCER WILL HAVE THE BJrtrrN OF PROVING THAT Hf OR SHE DID NOT BJ:LD OR
IMPROVE FOR THE PURPOSE Or SALE).
C L AS OWNL n Or THE P110PEIT7Y. AM EXCLUSYE'_Y CONTRAIL?NO WTH LY_ENSF.O CONTRACTORS
TO CONSTRUCT THE PROTECT (SEC 7C..BUSI%r.SS AND PRCFr SS'ONS COVE Thi. CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER Or A Pno-ERTY WHO BUILDS OR IMPROVES TIEPLON. ANO
W 40OpHTJUCTS FOR SUCH PROJECTS WTH ACONTRACTOn S: LICENSE:) PUPSJANT TO THE CONI RAO
TORS LICENSE LAW).
O I AGI EXEMPT UNDER SCC. _B L PC. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY Or PERJURY THAT IAM LICENSED UNDEI PRGVISONS OF CHAPTE FI
0 (COMMENCING WITH SECTION 700n1 Or DIVISION 3 OF THE PUS:NESS AND PROrESSOA S CO.E. AND
MY LICENSE IS N FILL FORCE AND EFFEC T J
LJCENSE CLASS �� LIC. NO
DATE�� CJInRAGTOn[j�,Ly—L.R'_G/�
WORKERS' COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PFNALTY Or PCrWRY ONE Cr TH.E FOLLO'A-%G OLCLA-ATK3NS
1 HAVE ANO W LL MAN7AN A CE Trl"rATE GF' CONS ENT TO SELF-•NS'JRC FCR W'OME11
OOAPENSArioN. AS PFICVYJED BY SECTION 3700 CF THE LABOn CFC E, FOn THC p[nrrRLIAN-_E
Or THE WORK FOR WHICH THIS PERMIT 15 153UED
—I HAVE AVD W'.L MA.NTAN WOnKERS' COM^ENSATON INSUnAN; E. AS REOLIIREO BY SECTK)N
37000F THE LAHOR COLE. FOn THE PERFORMANCE CF THE WCr'X FOR WHICH TILS PEr1VITIS
ISSUED. MY WOnK COM�ENSATON INSURANCE CARRER AND POLICY NI3I:!En ART.
OAW:CR .
POLICY N'.Bin
(THC siC:IOFI NTm NDTBE 00.(tCTL+•OF n4DEL>/.ETGFa;OSFl►DrdD DOILAfC', R�7C:onl[551
I
1 CERTIFY THAT N THE pERfOMHLVCE OF THE WORK FOn W 111Oh1 THIS PENIIT IS ISSUCO.1
I $HALL NOT EMPLOY ANY PERSON IN ANY MANN[ n SO AS 10 BF -COME SUU:E CT TOTH[
j WORLERSIO
'COMPENSATNLA'YYSCr CA-IFCFN:A,ANOASREETFIATIrisi4oL&DBECOMr.
SUBJECT TO THE WORKERS' COMPENSATION PFIO'.+SKV S OF SECTION 37000F THE LAEOR
CODE, I SHALL FORTFTN'TH COMPLY WIT HC5 ROlISIO1•
1 _ JJ
H CATS: APPLICANT.
1
1 WARNING FA:LUnE TO SEc,,rrWORKERS' COMPENSATION COVEP.AGE ISUNAWTL"_, AND SNAIL BE
S=ECT AN EMPLOYER TO Cn:M:NA. PENAT:ES ANO C:V:L FINES UP TO ONE HUNCnro THOUSAND
DOLLARS IS
100.0XM. IN ArD:T10N TO THE COST OF COMPEN SAI ION, DAMAGES AS Pnov-EO Fort IN
1 SECTION 37050E THE LUIOR CODE. INTEREST, AND AT TON_YS FE E S.
J CONSTRUCTION LENDLdG AGENCY
i
1 FF[RCRY AFF IRM LROFR PENALTY OF p[M:RY THAT THERE 15 A CONSTRI!C7104 LENDING AOr.NCY
FOR THE PE RFOnMANCE OF THE WORK FOR W7P01 TICS PL HMIT 15 ISSUED (SEC. 3WF. CIV C)
J
LENDERS KALE
LEW)ERSADORESS
I CERT'FY THAT I HAVE READ THS APPLICATIN AND STATE THAT TPC ABOVE INfOMATION 15 CORRECT.
I AGRE E TO COMPLY WITH ALLCITY AND COUNTY ORCINANCES :) STATE LAWS RELATING TO B'x.WNG
CONSTFrJCTIOFLANDHE;iEIIYALrn101llZEP..CPRLSENTATIVESO' THIS COUNTY TO ENTER UPON THE
XENTIONCID PnOPE RTY RINSP[CTIONPUFNCSES
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PAID BY
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