HomeMy WebLinkAbout15043 (19)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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APN LOT TRACT
OWNER u 1t•e, t�1um
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APPLICANT 1 TEL. Qz:2sj4_
CONTRACT R M -
ADDRESS
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DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER•EUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PCrLL: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
COLANTV V*IICH REGLMES A PERUD TO CO.SrFrJCT,ALTER. W.1'ROV _, DEA'OL'SH.On REPA:R ANY STRUC-
TURE. PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPLICJNT roil s,,ai PERM T 70 F.LE A S'GhED
STATEMENT THAT HE OR SHE IS LICENSED PUWL DANT TO THE PROVIS ONS OF THE CONTRACTORS LI.
CENSE UW (CFIAPTER Y (COMML'NCNO WITH SECTO:7000)Or DIVSION 3 O THE B:SINESSANO Pn0-
FESSNONS -CCE)OR TUT HC On SIZE 15 EXEMPT TICRE FROM AND THC BASIS FOR TIE ALLEGED EXEMI,
TION. ANY VIOLATION OF SECTION 7031 5 BY ANY AP PLJCANT FOR A PERM.I SULECTS THE APPLICANT TO
ACM: PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (3sa 3) 7
C LASOWNEROr THE PROPERTY.On MY EMPLOY[ES W.TH WAGESASTHE:n SOLE COMPENSA70N
WILL DO THE WOJW. AND THE STRICTURE L NOT RNTEK�CO On OFFERT D Fon SALE ISEC.7:46. BJSJ-
NESS ANO PnorESSKxNS CODE. TFC CONTRACTORS LICENSE LAW DOES NOT APPLY 10 AN OWNER OF
PROPERTY WHO BUILDS OR immovES THEnEON. ANO wHO DOES SL'CIN WORK H msrLF On HEnSELF Cn
THROUGH Itl5 On INE R OWN EMPLOYEES. PnOVDED TNA: SUCH W PRCVEMCNTS ARE NOT INTENDED On
OFFERED FOR SALE F, HOV EYER TIE BJLCBA OR Ni ROVEMENT 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 PIIOPEITTY. AM EXCLUSYE'_Y CONTRAIL?NO WTH LY_ENSF.O CONTRACTORS
TO CONSTRUCT THE PRO!ECT (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. AND
W 40 DONTRACTS FOR SUCH PROJECTS WTH ACONTRACTOn S: LICENSE:) PUPS:JANT TO THE CONI RAO
TORS LICENSE LAW).
O I AGI EXEMPT UNDER SCC. _B L PC. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTOnS DECLARATION
1 HEREBY AFFIRM UNDER PENALTY Or PERJURY THAT IAM LICENSED UNDER PRGVISKY•S OF CHAPTE FI
0 (COMMENCING WITH SECTION 70001 Or DIVISION 3 OF THE PUS:NESS AND PROrESSOA S CO.E. AND
MY LICENSE IS N FILL FORCE AND EFFEC T J
UCENSE 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 E VT TO SELF.NSURC FCR W'OME11
:
OOJPENSArio .AS PFtC'.DED BY SECTION 3'00 CF THE LABOn CFCE, FOn THC p[nrrpLiAN-_E
Or THE WORK FOR WHICH THIS PERMIT 15 153UED
—I FIAVE AND W'.L MA.NTAN WOnKERS' COM^ENSATCN INSUnAN; E. AS RCOLIIREO BY SECTK)N
37000F THE LABOR COLE. FOn THE PERFORMANCE CF THE WCr'X FOR WHICH TILS PERMIT IS
ISSUED. MY WOnP COMPENSATION INSURANCE CARRER AND POLICY NI3I:!En ART.
OAW:CR .
POLICY N'.Bin
(MC SECTION Nr CO NOT BE CMnE FM OF TTL PERMIT 15 FOS, O T HUNEWI.LD OOLLAftr R'X,OR L[551
I
1 CERTIFY THAT N THE pERfOMHLVCE OF THE WORK FOR W 111Ch1 THIS PENIIT IS ISSUCO.1
I $HALL NOT EMPLOY ANY PERSON IN ANY MANNE n SO AS 10 BF -COME SUU:E CT TOTH[
j W'OR(ERSIO
'COMPENSATNLA'YYSCr CA-IFCFN:A,ANOASREETFIATIr ISR10L!LDBECOMr.
SUBJECT TO THE WORKERS' COMPENSATION PRO'O SIONS OF SECTION 3700 CF TPE LAEOR
CODE, I SHALL FORTFTW'TH COMPLY INHC5 ROlISIOP
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
IOC.OXM. IN ArD:T10N TO THE COST OF COMPEN SAI ION, DAMAGES AS Pnov-EO Fort IN
1 SECTION 37050E THE LABOR CODE. INTEREST, AND AT 1ORNEYS FE E S.
J CONSTRUCTION LENDLdG AGENCY
i
1 FF[RCRY AFF IRM LTOFR PENALTY OF p[M:RY THAT THERE 15 A CONSTRI!C7104 LENDING AOr.NCY
FOR THE PE RFOnMANCE OF THE WORK FOR W7PCH TICS PL HMIT 15 ISSUED (SEC. 3 W F. CIV C)
J
LENDERS KALE
LEW)ERSADORESS
I CERT'FY THAT I HAVE READ THSAPPLICATDN AND STATE THAT TPC ABOVE INFORMATION 15 CORRECT.
I AGREE TO COMPLY WITH ALLCITY AND COUNTY ORCINANCES :) STATE ALAS RELATING TO B'x.WNG
CONSTR'JCTKIFLANDHEr1EllYAJTHOFIIZEP.CPRLSENTATIVESO' THIS COUNTY TO ENTER UPON THE
XENTIONCID PnOPE RTY nINSPECTIONPUFNCSES
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PAID BY
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