HomeMy WebLinkAbout15167 (34)CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION
JOBSITE
ADDRESS
APN LOT TRACT
OWNER 1.0%
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APPLICANT
CONTRACTOR
ADDRESS
CITY
ARCk'ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
I HEREBYAFFIRM UNDER PENALTY OF PER.LnY THAT I AY EXEMPT FROM TIE CONTRACTORS LI-
CENSE
FCENSE UW FOR THE FOLLCW'MG REASON (SEC 7071 S BUS W ESS AND PROTESSIONS CODE ANY CITY 09
COUrlTY YA11d1 RECIARES A PERM:T TO CONSTRUCT,ALTER IMPROVE. DEMOL:511. OR PE PAR ANY STRUC•
TURE. PRIOR 70 173 ISSUANCE. ALSO RLOUMES THE APPLICANT FOR SUCH PERM.T TO FILE A S'CNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS 11
CENSE UW (CHAPTER i (COMMCNC:NG WITH SECTION ?DOC) OF D:V:SION 7 OF TIIEE BUSINCSS AND PRO-
FESSIONS COLE) CR THAT HE OR SHE IS EXEMPT TIEREPHONI AND THE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION F071.5 BY ANYAPPLICANT FOR A PERMIT SUB.IECTS TH[ APPLICANT TO
A CML PENALTY OF NOT MORE AN FIVE HU%CRCD DOLLARS (FSOC))
O LAS OW`IER OF THE PROPERTY. OR MY EMPLOYEES WITH WAGCS AS THEIR SOI E COMPENSATION.
WILL DO THE WORK. AND THE STRUCTURE C NOT INTENCCD OR OFFERCO FOR SALE ISEC. 7244. RUM-
NESS MA PROFESSIONS CODE THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PRCPERTY YAq BUILDS OR IMPRDVES THEREON. AND WHO DOLS SUCH W)FIK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES. PROVIDED THATSUCH MPROVEFIENTS ARE NOT INTENDED OR
OrFFnEO FOR SALE IF. IIOWTYCR THE BULDING OR:MPPAVEMEN: u SOLD IIITMNONE YEAR OF COM -1E•
TION. THC OWNER SU-.DCR WILL HAVE THE SURCEN OF PnOV'NO THAT HE OR SHE DO NOT BUILD OR
IMPROVE FOR THE RARPOSE OF SALFL
C LAS OWNER OF TIE PnopcnTY. AM EXU.` L'S WCLY CONTRACT3q %'TM L 10ENCED CCNTRACTOn3
TO CONSTnUCT 711E PROJECT (SEC. 7044. OUS:NESS AND PROFESSIONS CODE- THE. CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PRCPCnTY roto BU'LCS OR IMPROVES THEREON. M40
INNO COMRACTS FOR SUCH PROJECTS WITH A CONTRACTOR;$; LICENSED PLTS JAN.T TO THE CCNTRAv
TORS LICENSE LAW).
O IAM EXEMPT UNOCR SEC. B SPC FOR THIS REASON
DATE _.4 _ Ow7:CR
LICENSED CONTRACTORS DECLARATION'
I HEREBY AFF SM L'NTIEn PENALTY OF PE RIURY THAT I AM LICENSED UNOL R PFIOL".SIO NS OF CHAPTER
F (COMM ENCNO WITH SECTION 7000) OE DVAS-ON 7 Or THE BUS: NE SS AND PROSE SS'ONS COCE. ANO
MY LICENSE 15 N FULL FORCE AND EFFECT.
LICENSE CLASS LIC. NO _
DATE�� ___ COIN-FUCTOR, _
I
WORKERS' COMPENSATION DECLARATION
IHCRCBY A: o rCFIIUI YObI TOLLO GCC';ARATIONj
kf AT-
I IIIA L .1I.,A�E 4rONJ, N 7' [:F�•,S�•'C FOFI WORKCnS'
COMP SAION.AS PRONGED BY SECTION 310C•OF THE LABOR COOL. FOR TPE PEPfOnAIANCE
OF THE WORK FOR WHICII TH:S FEPMIT IS ISSUED.
1
_11,xn ANDWLLMAWANWOnKERS'COMPENSATKININS''- NC-c,ASRCOPAPEDBYSCCTKON
3:00 OF THE LA70FR CODE, ron TIC PERF011MANCE OF THE WORK FOR W`+:CN THIS PE FW.T IS
ISSUED. FAY WOnKERS' COMPENSA'ION W SL'1U NCE CARR ER AND PCLICY NUMBER ARE
I
: unR:ER
POLICY M 7.ICER
(11 l: SECTGNNLm NOT SE COMT.ETC Or THE PEF►NT G POF G14C M. FtIR130011AAS (S'x)OR LESS.
I CERTIFY TI AT N THC PERFORMANCE CF THC WORK FOR W-104 THIS PERMIT IS ISSUED. I
SHALL NOT EMPLOY A4Y PERSOd IN ANY MXNNCR SO AS TO REIXNAC SJ^JE CT TO I -E
j WOFV(ERS'COMPENSAIION LAWS OF CALIFOPNIAANO AGR[E TWT IF I SHOULDSECOME
3U0.:CCT 70 THE YYORIER� COMPENSATION PROYSIONS OF SECTION 7000.7 'LABOR
COCE, I SHALL FORTHWITH COMPLY WITH THOSE PRC YIISION'
r=te ul
7 DATE �L(IFILIOANT
j WARNING: FAILURE TO SCCVRC WORKFRS'COMPCNSA:IDN COVE PAGE IS UNLAWTIi. AND SHALL CE
_ SUBJECTAN EMPLOYER TO CnIMJNAL PENALT;LS AND C:YIL F7.CS UP TOONE HUNORL'D THOUSAND
OOLW' , IS 100000). N ADDITION TO THE COST OF COMPENSATION. DAMAGESAS PROVIDED FOR N
SECTION V0e OF THE LABOR CODE. INTEREST. AND ATTOR.N[Y'S FEES
CONSTRUCTION LENE)ING AGENCY
I HC RCBY AFFIRM LIN -Ell PEN. TY Or PENL'nY THAT THERE IS A CCNSTRUCTION LENDING AGCNCY
FORPEnFORMANCE OF TM: WORK Fon WHICH THIS PERM:T 15 ISS
(SEC. X97. C:V C.)
j
LEVOCFTS NAME
LENDEFRSADDRCSS
L ICEnTIrY THAT IMXdE READ THIS APPLICATION AND STATE THAT THE ABOVE NFCRMATION IS CORRECT
11 IArn[C TO 1.'CAIPIY W:TH ALLCRV AM) OnDINANCCS AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION. AND HEREBY AUngf:I=E REPRESCNTA'NES CF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONCO PROPERTY FOR INSPECTION PUIIPO SCS
U PER PEEN ER1R!YTr
OF
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DATE tom CONST. GROUP
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PROPOSED USE
NO. DWEL. NO. NO. ' 'ot
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CONSTFlUCTION
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INSPECTION FEE
ISSUANCE
SIM 11
ENERGYPIC =.
ENERGY PERMIT
FIETENTION FEE:
/ CPRE -ALT FEE. /
7—
TOTAL FEES
COMMENTS
RCCPT. NO. PAID BY VALIDATION
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