HomeMy WebLinkAbout17325 (10) _!� CITY OF DIAMOND BAx -�/
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190 ����"�(;� PRESS
(909)860-3195 Fax(909)861-3117 /�
�������W BUILDING PERMIT APPLICATION �/'� � FIRMLY
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NRE,PRIOR TO ITS ISSUANCE,ALSO REOUIRES iHE APPIICANT FOR SUCH PENMIT TO FILE R SIGNED
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CENSE LAW�CHAPTER 9(COMMENCINO WITH SECTION 7000�OF DNISION 9 OF THE 9USINE55 AND PAO- LL POOUSpd
FESSqNS OODE)OR THAT HE OR SHE IS EXEMPT THEREFFiOM AND THE BASIS FOR iHE ALLEOED EXEMP�
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NESS AND PROFESSIONS(%1DE:THE CONTRACTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF
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� Q TO CONSTHUCT THE PR0.IECT(SEC.]ou,9USINESS AND PROFESSIONS CODE THE CONTRACTORS LI- VelUellOfl ADJ.AREA
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� i�COMMENGM!(3WITHSECTION7o00)OFOIVISION30FTHE9USINESSANDPROFESSIONSCODC.,AND Z " ��
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� COMPENSATION,IS PROVIDED BY 3ECTION 3'l0o OF THE LABOR CA�E,FOR THE PERFORMANCE `U
OF THE WORK FOR WHICH THI$PEFMIT IS ISSUED. �
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Q � 3Joo OF THE LABOF C[bF,FOR THF PERf-0RMANCE OF THE WORK FOq WHICH THIS PEHMIT IS �
ISSUE�.MV WORMEqp�COMPENSRTION INSt1R�E CAR ERANO POLICV NUAABE�E�. CONSTFjUCTION -`
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(3 SHALL NOT EMPLbV ANV VERSON IN ANY MANNER SOAS TO BECOME SUBJFCT TO THE
� NVRKEHS'COMPI:NSATIONUWSOFCALIFORNIA,AN�AGREETHATIFISHOl1LD8ECAME INSPECTIONFEE , � /' '
SU&IECTTOTHE'AbRNERS'GOMIPENSATIONPROVISIONSOFSECTpN3]OaOFTHELABOR � ("1 V` '�
� CODE,I SHALL FOHTHWITH COMPLY wITH iHU�E' ROVISIONS. ISSUANCE _ �� 'I
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p DATE' . ' D�-� APPLICANT. .- _.___—
w ENERGY P/C � �
� WARNING.FAI�URE 70 SECURE N'ORKERS'COMPENSATION COVERAGE IS UNLAWFVL,AND SHALL BE
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� I GEPTIFY TMFT I HAVE READ THIS APP�ICATION AND STATE THAT THE ABWE MFORMATION IS CORRECT. TOTAL FE ES ��� �C.�.}�'
w 1 qGREE TO CAMPLV WlThl All GITY AND CAUNiY OADINANCES AND STATE LAWS RELATINO TO 6UI�DINd � V\ J
I' � CONSTRVCTION,AN�HEHEBYAUTMORRE FE RESENTRTIVES OF THIS GOUNTYTO ENTER UPON THE
I z PBOVE�MENTIONED PflOPEFTY F�R INSPEC r+vuavosEs. COMMENTS
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVE�OPMENT SERVICES
21660 E.Copiey Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
lA
PRESS
FIRM�Y
ADDRESS G
APN OT TRACT
OWNER u/•
ADDRESS.r� Ulm
CITY ZI TEL.
APPLICANT TE�.
CONTRACTOR-A-id
ADDRESS-
CITY ZIP TE�.
ARCWENG/
DESIGNER_,��f/U_ffpJ
ADDRESS emu./
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CITY 7�'!1 E
OWNER-BUI�DER DECLARATION 679 7-
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE�P,W FOR THE FOL�OWING REASON(SEC.7031.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
COUNTY WHICH REQUIRES A PERMITfO CONSTRUCT ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY STRUC-
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 CONTRP,CTORS LI-
CENSE�AW(CHAPTER 9(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 PENA�TY OF NOT MORE THAN FIVE HUNDRED DOL�ARS($500).):
^I,AS OWNER OF THE: PROPERTY,OR MY EMP�OYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WI�L 00 THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044,BUSI-
NESS AND PROFESSIONS OOOE: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).
^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 LI-
CENSE IAW DOES NOTAPPLY TOAN OWNER OF A PROPERTY WHO BUI�DS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S)�ICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE�AW.).
^ I AM EXEMPT UNDER SEC. 8.&P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECIJaRATION
I HEREBY AFFIRM UNDER PENA�TY OF PER7URY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7050)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE AN EFFECT.
jN�_
LICENSE CLASS
_LIIC. NO. 1
Y
DATE iNJYJ�. Ny FONTRACTOR
WORKERS'COMPENSATION DECLARATION
I HERE AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DEC�ARATIONS:
1 HAVE AND WIL�MAINTAIN A CERTIFICATE OF CONSENT TO SE�F-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE t.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,FOP THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
CE CAR ER AND POLICY NUMBS*
E:
f
ISSUED. MY WORK 0 cOMPEN!ATIQN INSURRANN
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CARRIER t�� 1 �'•
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PO�ICY NUMBER y}�-_]1
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HISS S NEH)NOT BE COMP�ETED OF THE PEMNT B FOR ONE NIPDRED 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 SUB]ECT 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 SHALL FORTHWITH COMPLY WITH THO,E ROVISIONS
DATE:APPLICANT:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERP,GE IS UN�AWFUL.AND SHAL�BE
SUBJECT AN EMPLOYER TO CRIMINA�PENALTIES AND CIVI�FINES UP TO ONE HUNDRED THOUSAND
DOLLARS($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
SECTION 3705 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
H
THIISPERMT IS ED(SEC. 3097,CIV. C.).
• FOR THE PERFORMANCE 0 THE WORK FO
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LENDER'S NAME_Vi::/V V_--
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITH AL�CITY AND COUNTY ORDINANCES AND STATE LAWS RE�ATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE RE RESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPEC NPURPOSES.
)PERMIIT NAME(PRI)
SIGr OF PERMITB7 DATE
APPLICATION C I PERMIT f'�JI
P/1 (�n
DATE NUMBER -
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ISSUE I
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RETENTION FEE: )N•j
PRE-ALT FEE:
TOTA�FEES ao,3-1
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COMMENTS
RECPT. NO. PAID BY VALIDATION
WHITE-Department Copy,YE�LOW-Finance Copy, PINK-Assessor Copy,GO�DENROD-File Copy,GREEN-Applicant's Copy