HomeMy WebLinkAbout19008 �_ CITY OF DIAMOND BAR �
� � DEPARTMENT OF CO[vA�fUNTi'Y&bEVELOPMENT SERVICES
21825 E.Copley Drive
TM (909)860.3195 Fax(909)861-3117 PRESS
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVE�OPMENT SERVICES
21825 E.Copiey Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
PRESS
FIRM�Y
JOBSITE�4
ADDRESS'r3CL�Ei 1 1ItsI� �5�-•lTCE71f
APN LOT TRACT_
OWNER YVl'.t
ADDRESS L-r!>e)G-�u s P
CITY�--ZIP �11-11 (
TELL LX SL
APPLICANT TEL� '
CONTRACTOR
ADDRESS
CITY ZIP TE�.
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TE�.
OWNER-BUII.DER DECLARATION
I HEREBY AFFIRM UNDER PENA�TY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS�I
CENSE�P,W FOR THE FOL�OWING REASON(SEC.7031.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT,A�TER,IMPROVE, DEMO�ISH,OR REPAIR ANY STRUG
TURE, PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APP�ICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI'
CENSE�AW(CHAPTER B(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE A�LEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031.5 BY ANY APP�ICANT FOR A PERMIT SUBJECTS THE APP�ICANT TO
A CIVIL PP ALTY OF NOT MORE THAN FIVE HUNDRED DO�LARS($500)),
AS OWN ER OF THE PROPERTY,OR MY EMP�OYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WI�L THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044. BUSI'
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE�AW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUI�DS 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,THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE-
TION,THE OWNER-BUI�DER WIL�HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUI�D OR
IMPROVE FOR THE PURPOSE OF SALE).
O I,AS OWNER OF THE PROPERTY.AM EXC�USIVE�Y CONTRACTING WITH �ICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044,BUSINESS AND PROFESSIONS CODE.THE CONTRACTORS�I
CENSE IAW DOES NOT APPLY TORN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT T O THE CONTRAG
TORS�ICENSE�AW.)
G I AM EXEMPT UNDER SEC. P.C. FOR THIS REASON
DATE f I"'I�OWN
LICENSED CONTRACTORS DEClr4RATION
I HEREBY AFFIRM UNDER PENA�TY OF PER7URY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PPOFESSIONS CODE,AND
MY�ICENSE IS IN FUL�FORCE AND EFFECT
LICENSE CLASS LIC NO
DATECONTRACTOR
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY ONE OF THE FO�LOWING DECLARATIONS:
-1 HAVE AND WIL�MAINTAIN A CERTIFICATE OF CONSENT TO SE�F-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE�ABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WIL�MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE�ABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER
POLICY NUMBER
(THIS SECTION NEED NOT BE COMP�ETED OF THE PERMIT IS FOR ONE HUNDRED DOLLARS($100)OR�ESS)
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHAL�NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA.AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE(ABOR
CODE,I SHAL�FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE:APPLICANT.
WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UN�AWFUL,AND SHAL�BE
SUBJECT AN EMPLOYER TO CRIMINA�PENALTIES AND CIVI�FINES UP TO ONE HUNDRED THOUSAND
DOLI�,RS($100.000). IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATfORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC 3097,CIV C.)
LENDER'S NAME
LENDER'S ADDRESS
CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT
AGREE TO COMPLY WITH AL�CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION.AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE MENTIONED PROPERTY F NSPECTION PURPOSES.
PER l-1'
SIG TL E DATE
APPLICATION'0^ ' . 0
PERMIT��� � p/C 4 J
DATE del
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NUMBER 1 1# �DC
ISSUE TYPE OCC
DATE CONST.GROUP
ZONING SETBACKS
FRONT RW^
REAR^
SIDE/SIDE STREET RW^
SIDE^
PROPOSED USE
N0. DWE�. N0. NO.
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QUANTITY DESCRIPTION FEE
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COMMENTS
RECPT lOt PAID BY VALIDATION
WHITE-Department Copy,YE�LOW-Finance Copy, PIN Assessor Copy,GO�DENROD-File Copy,GREEN-Applicant's Copy
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