HomeMy WebLinkAbout17767 (10) 1� CITY OF DIAMOND BAIL
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190 PRESS
�� I BU)ILDING PERMTT APPLICATION FIRMLY
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0 I HEREBY AFFIRM UMOER PENN.rV OF'PERJURY 1HAT I AIA EXEMPT FAOM THE CONTqACiORS L6 � GBfdJB/GdfPOfl
W CENSEUWfORTHEFOILOWINGREA:AN�SEC.]D31.SBVSMESSANDPRO{ESSIONSCODE:RNVCITVOR
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W NRE,PFIOR TO ITS ISSUMICE,AL50 REOUIqES THE APPLICANT FOR SUCH PEP.MIT TO FILE A SIGNED �
STATEMENT THAT HE Ofi SHE IS UCENSED PURSUANi 70 IHE PROVI510N5 OF THE CON'I'FAGTORS LI�
� CENSE LAW(CHAPTER 9�l%MIMENCING WRH SECTION 7C00)OF DIVISION 3 OF THE E3USINE55 nN�PRO- � PooUSpe
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TION.ANV VIOI_ATION OF SECTION 7031.5 BY ANV APPLICANT FOR A 7ERMIT 5U&lECTS THE APPLICANT T0 Z Re-Roof
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MALL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFEREO FOR SALE(SEC.lo��,BU51� J
NE55 AND PROFESSIONS GODE:THE CONTRACTOflS LICENSE LAW DOES NOT AP?LV TO AN OWNER OF
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� I HEREBY AFFIRM UNDER PENALTY OF PERIURY TH�T 1 AM LICENS[D UNDER PROVISIONS OF CNAf�TER � L �
d Y(COMMENCING WITH SECTION]000J OF DIYISIOIJ]OF TnE Bt151NE5S AND FRCFESSIONS CODE,AND Z ___ J _, �
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OFTHE'NORK FOR WNIGI TMIS 7F_flMiT IS ISSVED. � �
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W I HAL'EAH�WILL MAl1f�AIN WORNEPS'COMPENSATION iNSUaANCE,AS P�E�UIREO BY S`cCTION
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Q� 3100 S;F fNE UdOq LYNJE,FOR TV:E PFRFORAlANCE OF 1'HE WORK FOR WHICH THIS PFRMIT IS
ISSUE[`.MY WOFKERS COMPENSATION INSl1RANCE�AH91FA AND F�L'CV NUMBERAf�C:-. ; CONSTRUCTION .._ ___._.
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� WUHKcftS COMPENSA�ION lAWS OF CNL�fORNI C AG ET F I .UlD BECGME INSPECTION FEE __ ___ ,__ r.�/�^ �^'
SU&IECT TO THE WOHKERS'WMPtNSATIQ VI510 O 3�Ga OF THE IABOR — _y� (i�
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DOLLARS(5100.000),INADDITIONTOTHECOSTOFCDMPENSA� N.DAMAGE ASPROVIDEDFOPIN -�-�-�-- �� � - ' �--- -
¢ SECTION 37a80F THE U.BOR CODE,INTEREST,AND ATTOflNEY' FEES. - RETENTION FEE: .__
a CONSI�ftUCTION LENDING AGENCY PRE-ALT FEE: _
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� I IIEREBYAFFIflM UNDEII PtNpL7Y UF PEFJUf7YTHAT THER�IS A GONSTRUCTiON LENDING AGENCV _
d' FOR THE�ERFORMANCI;OFTHF_WOFK FOH WMICH tH15 PERMIT IS ISSUE)��SEG.3081,CI'J_C.).
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� LENDER'SNFME___ _-- -. _
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wI GEFTIFY THA71 HAVE READ THIS APPIIGATION AND STPTE TMAT THE ABOVE INFORMATION IS CARRECT. TOTAL FE ES � l,i ��`j u
� I AGflEE TO CAMPLV W17H ALL CITY qND GOUNTY ORDINANCES AND STATE LAWS flELATING TO BUILDING
CONSTRUCTION,AND H[HEBY AUTHOfi2E REPRESENTATNES OF 1 HIS COUNTY To ENTER VPON THE
� ABOVE�MENTIDNfDPROPERTYFOPINSPECTION �(l�ES. COMMENTS_
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fu (909)861-3117
BUILDING PERMTT APPLICATION
PRESS
FIRMLY
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CITY ZIP TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF' PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSELAW FOR THE FOLLOW LNG REASON (SEC. 7031.5 BUSINESS AND PROFESSK)NS CODE: ANV CITY OR
COUNTY WHICH REWIRESA PERMITTO CONSTRUCT,ALTER,IMPROVE,DEMOLISH,OR REPAIR ANV STRUC-
TURE,PRKKL TO ITS ISSUANCE.ALSO REQUIRES 7HE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI�
CENSE LAW(CHAPTER 9(IX3MMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSK)NS OODE)ORTHAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANV VIOLATK)N OF SECTION 7031.5 BY ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
ACML PENALTY OF NOT AMORE THAN FIVE HUNDRED DOLLARS (f500).):
0 1,AS OWNER OF THE PROPERTY,OR MV EMPLOYEES W ITH WAGES AS THEIR SOLE COMPENSATION,
MALL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED fOR SALE(SEC. 7044, BUSI-
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE IAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUHDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THRWOH HIS OR HER OMM EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS APE NOT INTENDED OR
OFFERED FOR SALE IF, HOWEVER THE BUILDING OR IMPROVEMENT IS SOLO WITHIN ONE YEAR OF CAMPLE-
TION,THE OWNER-BUILDIER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
(7 1,AS OWNER OF THE PRCIPERN AM EXCLUSIVELY CONTRACTING WI?'H LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT ISEC. 7041,BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI�
CENSE LAYf DOES NOT APPLY TO AN OWNER OF A PROPERTY V+HO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONITRACTOR(S)LICENSEG PURSUANT TO THE CON7RAF
TORS LICENSE LAW.).
^I AM EXEMPT UND'eR SEC._-__._B.&i�.C. FOR i!-,IS REASON
DATE- --- rJWNER - -
IJCENSEU CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER
0(COMMENCING WITH SECTION 7000)OF DIYISIOIti 30F THE BUSINESS AND PROFESSIONS CODE,AND
MV LICENSE IS IN FULL FORCE AND EFFEC?.
LICENSE CLASS���- LTC. N0. �� r-
DATE CONTRACTO
WORKERS'COMPENSAT?ON DECLARATI
I HERE81'AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DE RATION
I HAVE AND WILL MAINTAIN A CERT IFICATE OF CONSENT TO SELF-INSURE F ORKERS'
COMPENSATK)N,AS PROVIDED BY SECTION 3700 0�THE LABOR CODE, FOR THE PERFURMAIiCE
OF THE WORK fOR WHICH THIS PERMIT IS ISSUED.
- I HAVE ANb WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS P�EOUIRED BY SECTION
37000E THE LABOR(.'ODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THI5 PERMIT IS
ISSU EL?. MY WOFIKERS COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:-.
CARRIER
I POLICY NUMBER -
(THL4 SECTKJN NEf-'J NOT RECX7IJPIFfEDOF TfiE 7EPMff 6S F{JR ONE HUPI)RED DJLLAkS(f100)OR LESS).
I CERTIFY TNAT iN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEC,I
{
SHALL NOT EMP,OY ANY PERSON IN ANV MANNER 50 BECOM_T T^,THE
j WORKERS'CCIMF'ENSATION LAWS OF CALIFORNI U AG E T F I . ULD BECOME
SU&IECT TO THE WORKERS'COMPENSATIO VI510 0 370a OF THE LABOR
E,I SHALL FORTH 1 H COMPLY WITH T ISI
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DATF. . PPLICANT: -
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j WARNING FAILURE TO SECURE WOFKERS'COMPENSATION COV GE IS LAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER?0 CRIMINAL PENALTIES AND CIVIL FIN UP TO ON HUNDRED THOUSAND
DOLLARS(f10o,000J,IN ADDITION TO THE COST OF COMPENSAT N. DAMAGE AS PROVIDED FOR IN
J SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY' FEES.
J CONSI�RUCTION LENDING AGENCY
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_ 1 HEREBY AFFIRM UNDEfi PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE;OF THF_WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CI'/C.j.
J LENDER'S NAME
LENDER'S ADDRESS -
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOV'e INFORMATION IS CORRECT.
� I AGREE TO COMPLY W17H ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
� CONSTRUCTION,AND HEREBY AUTHOR2E REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE�MENTKJNED PROPERTY FOR INSPECTK)N P-O�ES.
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D PERMITTEE NAM RINT
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0 SIGNATURE OF PEfI"EE� DATE
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WHI E-Department Capy,YELLOW-Finance Copy,PINK-Assessor CGpy,GOLDENROD-tue copy,Gr+ttN-nppucanrs copy
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