HomeMy WebLinkAbout13700 (7) _ �,�„ CITY QF DIAMdND BA� �
� DEPARTMENT QF COMMUNITY&DEVBLQPMENT SERVICES
w 21660 E.Copley Dreve Suite 190
(909�860-3195 Faz(409)$61-3117 PRESS
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� i CERTtFYTHAT iN T1iE PERFORMANCE OG THE WUftK F4R WHiCH TNI$PERMIT IS ISSUE0,1 MECHANICAL _ _
('� SHALL NOT EMPLOV ANY PERSON IN M!Y MANNEfl SOAS TO BECAME SV&IEGT TOIHE
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- SU&IECT Tq THE NN)RKERS'CCMAGENSATION PROVISION5 0F SECTION J700 qF THE LAB4P ,��+!�� -�J�rY�— '
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�„C i HEREBY AFFHiM UNDEti PENt1TY OF PEAJURY TtiAT LMERE Ifi A CONSTRUCTI�t I.ENDING AGENCY _
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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
PRESS
FIRAII�Y
ADDRIES9���p p I wI � �
APN�OT TRACT
OWNER f i^ �---
ADDRE O N/'>! ��
CITY���' ZIP TEL. 6
APP�ICANT
ALf�2,TE�.
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CONTRACTORl 2�fC/��o't,
ADDR SS is O/I/_d
CIl'Y��I-(�i(�� ZIP 4/T��TE�.
ARCH/ENG/�
DESIGNER
N � I/_ cOG�.
ADDRESS
CITY ZIP TE�.
OWNER-BUI�DER DECLARATION
I HEREBY AFFIRIA UNDER PENA�TY OF PER7URY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSELAW FOR THE FOU.OWING REASON(SEC.7031.5 BUSINESSAND PROFESSIONS CODE:ANY CI7V OR
COUNTY WHICH REOUIRE:iA PERMR TO CONSTRUCT ALTER,IMPROVE,DEMOLISH,OR REPAIR ANV 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 CONTRP,CTORS LI-
CENSE t_AW(CHAPTER Y p�MMENCINrJ WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONSCODE)ORTHAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE A�LEGED EXEMP-
TION.ANY VIOLATK7N OF SECTION 7037.5 BY ANY APPLICANT FORA PERMIT SUBJECTS THE APPI.ICANT TO
A CIVI�PENA�TY OF N07 hK)RE THAN FNE HUNDRED DO��ARS(5500).):
^ i,AS OWNER OFTHE PROPERTY,OR MV EMPLOYEES WITH WAGES AS THEIR SO�E COMPENSATION,
WI�L DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SA�E(SEC. 70a,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 GOES 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).
^ l,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WRH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJiECT(SEC. 701, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE�P,W DOES NOT APPLY TO AN OWNER OFA PROPERTY WHO BUI�DS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SU(71 PROJECTS WITH ACONTMCTOR(S) LICENSED PURSUANT TOTHE CONTRAG
TORS�ICENSE LAW).
^ I AM EXEMPT UNDER SEC. B. 8 P.C. FOR THIS REASON
DATE OWNER
LPCENSED CONTRACTORS DEC�ARATION
1 HEREBY AFFIRM UNDER PENALTY OF PER]URY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
0(COMMENCING WITH SEC7KX170o0)OF DIVISKX]3 OF THE BUSINESS AND PROFESSKNS CODE,AND
MY LICENSE IS IN FUL�/F�QFICE AND EFFECT.
LICENSE C
LAS�
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7
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CONTRACTORL
DATE �C�L
WORKERS'COMPENSATION DECLARATION
1 HEgF�V AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOL�OWING DECURATK7NS:
/
{^'(^'
I HAVE AND WIL�M/dNTAIN A CERTIFICATE OF CONSENT TOSELF-INSURE FOR WORKERS'
/
COMPENSATION,AS: PROVIDED BV SECTION 3700 OF THE LIBOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WIL�MA,INTAW WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTKXJ
3700 OF THE IJaBOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS'COMPENSATKN INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER 5��
PO�ICY NUMBER �.� �11�
(THIS SECfTDN NEED NDT BE OOI.MLETED OFTI# PERMIT IS FOR CNE FiUFDRED OO�lAFIS(5700)Oq�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 707HE
WORKERS'COMPENSATKO)UWS OF CA�IFORNIO.AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISKNS OF SECTION 3700 Of THE�P,BOR
CODE.I SHALL FORTHWITH COMPLY WITH THOSE PROVISKNS.
DATE:APPLICANT:
WARNING: FAILURE TO SECURE VIORKERS'COMPENSATION COVERAGE IS UN�AWFU�,AND SHAL�BE
SUBJECT AN EMPLOYER TO CRIMINAL PENA�TIES AND CIVIL FINES UP 700NE HUNDRED THOUSAND
DOL�P,RS(5100.000),IN ADDITION TO THE COST OF COMPENSA7K)N,DAMAGES AS PROVIDED FOR IN
SECTION 3708 Of THE LABOR CODE,INTEREST,AND ATl'ORNEY'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. 3087,CIV C.).
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATgN IS CORRECT.
I AGREE TO COMPLY WITH AIL CRY AND COUNTY ORDINANCES AND STATE LAWS RE�P,TING 70 BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OFfHIS CWNTY TO ENTER UPON THE
ABOVE-TKKJED PROPERTY
FORINSPECTK)N PURPOSES.
/
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PER AME INT
IGNATUREO PE E DATE
WHITE-Department Copy,YE�LOW-Finance Copy, PINK-Assessor Copy,GOLDENR06--File Copy,GREEN-Applicant's Copy