HomeMy WebLinkAbout14484 CITY OF DIAMOND BAR � x \�(`�'�`-�
"rt - DEPARTMENT OF COMMUNITY 8c LIEVELOPMENT 5ERVI�S
21660 E.Copiey Drive Suite 140
(904)860-3295 Faa�(909?861-3117 PRESS
. �.;4�°�j BUiLDING PERMTI'APPLICATIUN FlRM�Y
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� SUBJECT AN EMPLOYER�O C,WMINAl P&NALTiES ANP CiVll FINES UP TO ONE NUNORED THOUSAND �NERGY PERMIT ��� �'� ' '
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� SECTI6N 3loe OF THE fABQfi(700E-1NTER'eST,FNO FTiOflNEV`5 FEES. RETEN7ION FEE �, ._._.____.�______.`�`.�"
6 CONSTRUCTION LENDING AGENGY �J���E: ``L'�f''__ _.
� 1 NEFiEBY AKfIRAA UNDER PENALTV OF PERJURV THAT THEftE IS A CANSTRUCTtON 4END�NG AGENCY �(W _ _. _
a" FOR THE PERFORMANCE OF ME WOftK FOA WHICH TH�S PEftMii IS�SSUELIISFC.3oB�,dV.C_).
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� t AGRE'e TO COMPLY Wlili ALI.GI(Y ANO COUNTY ORDINANCES 0.tiD STpTE LAWS NEI.ATING Tp 8U4.0lNG _ Q+ .-�' �� i �
CONSTRl1CT10N,nN0 HERE$Y AUTfiDPoZc`REPRESENTATIVES OF THIS GOUNTYTO ENTEA VPON THE � !`�1 t,.��
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CITY OF DIAMOND BAR 0 X i re-'
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVI
ES
21660 E.Copiey Drive Suite 190
(909)860-3195 Fax(909)861-3117 PRESS
BUILDING PERMIT APPLICATION FIRM�Y
JOBSITE
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ADDRESS
APN�OT TRA
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APP�ICANT Ddp:14 9.->"ff
CONTRACTOR�Jtvil!r
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CITY yj L-fQEr..,V.jjU ZIP TEL.'?/4 3-r5�TCP
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DESIGNER?C]C]L
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CITY AA 4 4-.1..-�ZIPq u2 TEL.),q-6x}-'00
OWNER-BUI�DER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE�AW FOR THE FOL�OWING REASON(SEC.7031.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
COUNTY WHICH REQUIRESA PERMIT TO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY 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 CONTRACTORS LI-
CENSE IAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESS)ONS 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).):
^ l,AS OWNEROF 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 SA�E(SEC. 7044, BUSI-
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE�AW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUI�DS OR IMPROVES THEREON.AND W40 DOES SUCH WORK HIMSELF OR HERSE�F 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 SO�D WITHIN ONE YEAROFCOMPLE-
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 EXC�USIVE�Y CONTRACTING WITH �ICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI'
CENSE t_AW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUI�DS OR IMPROVES THEREON.AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAG
TORS LICENSE�AW.).
^I AM EXEMPT UNDER SEC. B.&P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DEC�ARATION
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY THAT 1 AM�ICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7050)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY�ICENSE IS IN FUL�FORCE AND EFFECT.
LICENSE CIASS LTC. NO.
�4
CONTRALTO
DATE
WORKERS'COMPENSATION DECLARATION 3 � r
I HEREBY AFFIRM UNDER PENA�TY OF PERIURY ONE OF THE FOLLOWING DECLARATIO I
I HAVEAND WI�L MAINTAIN A CERTIFICATE OF CONSENT TO SE�F-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 37000F THE IABOR 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,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS'CO PENSATION INSURANCE CA TER O.ND POLICY NUMBER AR
CARRIER L/�L�_�,•�J
PO�ICY NUMBER_
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HIS S�CIIDN NEED NOT BE COMPLErEDOF TFE PERMIT FOR ONE MII,OR DO(310D
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALT. NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUB]ECT TO THE
V
WORKERS'COMPENSATION LAWS OF CALIFORNIA.AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE lABOR
CODE,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE: APP�ICANT:
WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 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 3709 OF THE I.ABOR CODE,INTEREST,AND Al-fORNEY'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. 3097,CIV. C.).
LENDER'S NAME
LENDERS ADDRESS
f CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 AGREE TO COMP�Y WITH A�L CITY AND COUNTY ORDINANCES AND STATE IJaWS RE�ATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
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PE ITfE E(PRINT)
tRIMARME OF PERMII-fEE TE
APP�ICATION PERMIT! L g PI
DATE UMBER[
ISSUE TYPE OCC
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WHITE-Department Copy,YE�LOW-Finance Copy, PINK-Assessor Copy,GOLDENROD--File Copy,GREEN-Applicant's Copy