HomeMy WebLinkAbout17248 ___
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��..�y CITY OF DIAMOND BAR
I�� DEPARTMENfi OF COI�9VCt3NITY&DEVEIAPMENT SERV[CES
21825 E.Gopley Drive
(909)$60-3195 Fax(909)861-3117 PRESS
BUILDING PERMIT APPLICATION FtRMLY
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Z TURE,PRIOR TO IT5 ISSIJiGNCE,ALSb PEQUIRES THE APPLICANT FOR SUGH PERMIT TO FILE A S�GNEp w
� 57AT�MENT THAT HE Qfl SHE IS tICEMSE6 PUfiSUhNT i'O THE PAOYISIONS RF 7HE GONTflAC?ORS ii-
"� CENSE LAW(GHAPTER 9((bMMENCMG WITH SECTI6N 7000)OF DIV1510N 3 pf THE BUSINESS AND PRO- � ��O�SDa
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� A CIVIL PENAI,TV OF NOT NipqE THAN FIVE HUNOREp DOLLARS(i500).):
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Z 'Mil DO iHE WORK.AND THE STRUCTt1RE�S NOT INTENDED OR OFFEREO FOR SA�E jSEC.�oda,BU5i� J
NE55 AN�PROFESSIONS C005:hIE CONTpACTOFS LICENSE LAW DOES N6T APPI.V TO AN OWNER OF
� PRQPERTYWl108UILDSORlMPAOVESTFFEREON,ANQWNODOESSUGiWOflKHlMSEirORHERSELFQR �
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= IMPROVEFORTHEPURP4'�iEOFSALE�.
(.7 I,AS OWNENOF TNE PROPERTV,AM E%CLU51VElY CONiRACTING W ITH LICENSE�CONTRACiOFS
� TO CCN75TflUGT THE FRO.lECT(SEC.70ad,BUSIN£53 AND PRdFESS10N5 GGDE-TNE CONTRACTIXiS t.t� VdlUdtlOtl ADJ.AREA_
W CEN5ELAWDOESNOTAPPLYTCIANOWNEpOFApROPERTYWHOBUII...DSORiMPPOVESTNEREON,ANL1
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1 t1ERE&Y AFFIflM UN�Eft PFNALTY OF PERJURY TNAT 1 AM LICENSED UNQER PROVIuIQNS OF CHAPTER (
(� 8 tCOMAAENCWG WITH SECTtON'Io00)Of DIVISION 3 OF iHE BU&INESS ANO PROFESSIONS CODE,A�D Z ��� � �� �� �'
�X MV UCENSE IS IN FULL FOFICE ANO EFFECT. 2(y
� LICENSE CIA S LIC:.NO. � •�^��� �
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� WORKERS'COMPENSATION DEC�AFiATtON Q 1.� .t- ,,,, .<7 ,\- � � ;�,
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� i HEftEBY AFfiRM UNDEfl PENId.TY Of?EPJI;flY ONE OF THE FQtLOYtMG 6EGlRftATiONS:
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0 IHAVEANpWILLM!\INTAINACERTIFlCATEOFCONSENTTOSEIF-INSUREFORWGpKERS' _
—~COMGfN5ATI6N.AS AR9YIDE0 8Y SECTION 3�W OF THE LABOR C6QE,FOR THE PERFORMANCE U
� OFTHE WORK FQR WHICH TNIS PERh11T IS ISSUE6. �
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� I HAVE AND WILLMI\INTAIN WORKE%S'GOMPENSATION INSURANCE,AS RE�UIRED BY SECTION
Q3�OOOF THE LABQFI CODE,FOR THE PERFQRMANCE OF THE WORK fOF WHICHTHI5 PERMIT IS
� ISSUED.MY WORKE:AS'COy1PEh75ATiON tNSURANCE CARRIER AND P,QLtCV� N(�FA@ER t.RE� CONSTRUCTION
''�d �y� '`� k��"��_ PIAtJ REVIEW
� CAAftIEA.,,�b_ �.,E� J�, ��V( �� �G , _......_
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� (niIS5EC7YJNNEEDIVotBEC�Mf'LE7EUOFTHEPEWMISFORONEHUN7REDDIX.lARS151W)ORLESSJ. PLUM6ING
W I CEflTIFY THA7 IN iHE PEiiFORMANCF�F THE WORK FOR WHICH iHI5 PERuIiT IS iSSUED,l MECHANICAL
� –
(.7 SHALL NOT FMPl.C11'ANV PERBQN IN ANY MANNEF 50 AS TO BECOME SJBJECT TO TI IE �NSPECTIQN FEE
� Wf1f1KER">'COMPENSATION tJ�WS OF CA�if-0RNIA,AND AGAEc THAT IF i SF10l�lD BECQME ---�����---���---
SU6JECTTO THE WORKERS'COMPENSATIqN PROVISIONS OF SECTIOFi 3]09 OF THE LA60R \�
� CODE,I SHALL FOR�HWITH GOMPL�WITH TNOSE GFOVISIONS. ISSUANGE Y�„�/.�+�
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� �L'� APPLICANL �_ SMIP j�� ( �T,.�_/f7���..,
� OATE;�_ �...._. � �-�---�i "..' _.
� WpRNING_FpILURE TO SECIJRE WORKEi�S GG#iPENSATi OV[RAGE IS UNIAVJFllL AND SH0.4L BE ENERGY PIC
� SUBJECTANEMPLOVERTOCRIMINALP[NALTIESANDC ILFINESUPTOONEHJNOREOTNOUSpN�
� �lLARS(5100.066}.WAQDITICNTOTriECQSf4FC4MPEN5ATIQN.DAMAGeSASPftOV'DEOFO�IN ENERGYPERMIT ,�_ ,,., _
� SECTION3tOBOFTHELABCRCbDE,INTEREST.ANL1hl70RNEV'SFEES. RETENTIONFEE: �. ._—....
� CONSTRUCTIt7N IENDiNG AGENCV PRE-AL7 FEE: _ ....— --.
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� i HEAEBYArFlRM VNDEft PENAl.7Y OF PEfS.,Uf1Y ItiAS THERE IS ACANSTRitCTiQN IENDiYCa AGENGY ^_ „
FOR THE VEtiFORMANCE 01=TH[WD(iK FOfl WHICH THI$PEflM1T IS ISSUED(5£C.3U9i,GIV,C J.
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� LENDER'S NAME ... .�- __ _ _
F,_ IENOEft5ADORESS__,��.__. ... . ...— /" /'i�. {�
� ICERTtFYTNATiNAVEREA[ISHtSAPPlICA71pNANDSTATETliATSHCAN6VEiNFOftMRTiONiSCORRECT. TOTAL FEES � F.� ) a�!'+'
W i AGREE TO COiAPL�WITH ALL CIT4 ANO COUNTY OROINANCES AND STATE LAWS fiELATING TO 9UIL�ING �
� CONS7FUCTION,AND NEREBV AUTHOHIZE REPRESENTATNES OFTHIS GOUNTV TO ENTER UPON THE
� ` ROFERTY FOfl iN5PEC��QN PURPOti6� COMMENTS ..
� �,/� _ _ _.._....
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� SIGNATUftEQFPERM EE � ~ 6ATE -- ' \
� RECPT.NO.._„ PAID BY �' � � VAL.IDATI6N �;,_,._
~ r WNITE—Department Capy,YELLOW—flnance Copy,PINK—Assessor Copy,GOIDEtVRpp—File Copy,GREEN—Appfcant's Copy
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CITY OF DIAMOND BAR
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DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
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APN LOT TRACT
OWNER
ADDRESS�� 1�� ' � , „ , �1�5
CITYiG��1 � �ZIp��1 ��TEL ���J��
APPLICANT TEL.
CONTRACTOp� �C v�� �\"-�'C
ADDRESS'L
CITY r aVI i� ZIP .���TEL.J
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM E%EMPT FROM THE CONTRACTORS LI-
CENSELAW FOR THE FOLLOWING REASON(SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT,ALTER,IMPROVE,DEMOLISH,OR REPAIR ANY STRUC-
TURE. PRIOR TO ITS ISSU,CNCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR :iHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSELAW(CHAPTER 9((:OMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS E%EMPT THEREFROM AND THE BASIB FOR THE ALLEGED EXEMP-
TION.ANV VK)LATION OF SECTION 7031.5 BV ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MIORE THAN FIVE HUNDRED DOLLARS(f500).J:
^I,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES W ITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 70da, BUSI-
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS 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, HOW EVER,THE BUILDING OR IMPROVEMENT IS SOLD W(THIN ONE V EAR OF COMPLE-
TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING TNAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
^I,AS OWNER OF TH E PROPERTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OFAPROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
^I AM EXEMPT UNDER SEC. B. 8 P.C. FOR THIS REASON
GATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FOFICE AND EFFECT.
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LICENSE CLA S
LTC. N0.
DATE���CONTRACTOR
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BV SECTION 37000E THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
_I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE LABOFI CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
RS, % ��1PENS����VNCE CA�TER A
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(RiLS SECTION NEED IWT BE COMPLETED OF THE PE
RMfi IS FOR ONE HUWRED DOLLARS(5100)OR LESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOI'ANV 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 37000E THE LABOR
C
ODE,I SH
ALL FORCHWITH COMPLY WITH THOSE PROVISIONS.
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DATE:
APPLICANT:
WARNING FAILURE TO SECURE WORKERS'COMPENSATI OVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES ANDC IL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(5100,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABCR CODE,INTEREST.AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE Oi=THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV.C.).
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE REACT THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE IAWS RELATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE�MENTIONED PROPERTY FOR INSPECTION PURP06fi$.
�75 ��C�lfl�^I
PERMITTEE NAME(PRINT)
Xll •����
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SIGNATURE OF PERM EE DATE
PRESS
FIRMLY
r�WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy