HomeMy WebLinkAbout17327 (10) 1� CITY OF DIAMOND BAR �
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite l90 �
(909)860-3195 Fax(909)861-3117 ������� � � PRESS
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� CENSE UW�CH�VTER Y(I.'OMMENCINO WITH SECTION 7000)OF DIYISION 3 OF THE BUSINE55 AND PflO� � POOVSPB
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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
PRESS
FIRM�Y
ADDRESS 0 I t 4//6'
APN OT TRACT 52Z&7
OWNER/i-
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ADDRESS
CITY ZIP TE�.
APPLIbANT TE�.
CONTRACTOR_
ADDRESS-
CITY ZIP TE�.
ARCH/ENGJ
DESIGNER f-r
ADDRESS'7 F
CITY ZII WINTEL.?/
lJ O R-BUI�DER-BUILDER DEC�ARATION 7b}O 3/
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 PERMIT TO CONSTRUCT,A�TER,IMPROVE, DEMO�ISH,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 UCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE t_AW(CHAPTER 0(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 DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044. BUSI.
NESS AND PROFESSIONS CODE:THE CONTRACTORS�ICENSE�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 BUI�DING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMP�E-
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. 7041,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE IAW DOES NOT APPLY TO AN OWNER OFA PROPERTY WHO BUI�DS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS�ICENSE�AW.).
^ I AM EXEMPT UNDER SEC. B.&P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECIJ�RATION
I HEREBY AFFIRM UNDER 9ENALTY OF PER]URY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY�ICENSE IS IN FUL�FCRCE AND EFFECT.
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LIC. NO
LICENSE CLASS
JI�n-�/•-CONTRACTOR 5:-
DATE f---'
WORKERS'COMPENSATION DECLARP,TION
FAFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DEC�ARATIONS:
I HEREB
HE
1 HAVE AND WIL�IAAINTAIN A CERTIFICATE OF CONSENT TO SE�F-INSURE FOR WORKERS'
COMPENSATION.AS PROVIDED BY SECTION 3700 OF THE�ABOR CODE, FOR THE PERFORMANCE
F THE WORK FOR WHICH THIS PERMIT IS ISSUED.
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
COMPENSATION INSURANCE CARRIER AND POLICY NUMB ARE.
ISSUED. MY WORK
Fj
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CARRIER j°�.l'f�i 1°Y:s 3 .)'
POLICY NUMBER
S FOR ONE INUNDRED DOL�P,RS
$100
OR LES
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(LHLS NHED NOT BE COMPETEDOFTFE PERMI
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 SHALL FORTHWITH COMPLY WITH T E PROVISIONS.
DATE:y1_�APP�ICANT
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 3700 OF THE I.ABOR CODE. INTEREST.AND Al-fORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION�ENDING AGENCY
RK FO HIGH THIS PERMIT ISIS ED(SEC. 3097,CIV. C.).
THE W
FOR THE PERFORMANCE
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LENDER'S NAME r:-
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LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMP�Y WITH AL�CITY AND COUNTY ORDINANCES AND STATE�,4WS RE�ATING TO BUILDING
AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
CONSTRUCTION
ABOVE-MENTIONED PROPE
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SIGN F PERMII-fE. DATE
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RECPT. NO. PAID BY VALIDATION
WHITE-Department Copy,YE�LOW-Finance Copy, PINK-Assessor Copy,GO�DENROD-File Copy,GREEN-Applicant's Copy