HomeMy WebLinkAbout15143 (34)CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
—Nw3 BUILDING PERMrr APPLICATION . I I
JOSSITEN
ADDRESS
APN LOT TRACT
i OWNER T
ADDRESS o H- '
CITY Q.Ay.,_j 41An ZIP J I0 -V TEL a1 07
APPLICANT TEL.
i CONTRACTOR
ADDRESS
CITY ZIP TEL
ARCWENG/
DESIGNER
S ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
� 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LL
J CENSE JAW FOR THE FOLLOWING REASON (SEC. 7031.6 S1SINMAND PROFESSIONS CODE: ANYCIIYOR
COUNTYWHOCH RECUARESAPERMRTO CONSTRUCf,ALTER IMPROVE. DEMOUSH,OR REPAIRJWY STRUC-
TURF PRIOR TO ITS ISSUANCE, ALSO REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IN UCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LF
CENSE LAW (CHAPTER •(COMMENCING WITH SECTION TOOO) OF DIVISION 3 OF LINE BUSINESS AND PRO-
S S FESSIONS CODE) OR THAT XE OR SHE IB EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7031.5 BY ANYAPPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS 18600).):
O LAS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
2
WILL DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR &LLE (SEC. 7044, BUSI-
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVESTHEREOK 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 BUILDING OR IMPROVEMENT IS SOLD WITHNONEYEAROFCOMPLE-
TON, THE OWNER-BUSDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE E}
OF SAL
J 0 LAS OWNER OF THE PROPERTT: AM EXCLUSNWITH ITH LICENSED CONTRACTORS
M CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS U.
J CENSE LAW DOES NOTAPPLY TOAN OWNER OFAPROPERTYWHO BUILDS OR IMPROVES THEREON. AND
WHO CONTRACTS FOR SUCH PROJECTS MT N ACONTRACTOR(S) LICENSED PURSUANTTO THE OONTRAC-
C TORS LICENSE LAW j.
c ❑ 1 AM EXEMPT UNDER SEC. B. A P.C. THIS REASON
DATE 0 OWNER
[Z LICENSED CONTRACTORS DECLARATION
C I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED NYDER PROVISIONS OF CHAPTER
a (COMMENCING % SECTKN 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND
5 YY LICENSE IS lu Flu FORCE AND EFFECT.
LICENSE CLASS LIC. NO.
j GATE CONTRACTOR
. WORKERS' COMPENSATION DECLARATION
2 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN ACERTIFICATE OF CONSENT TO SELF -IN SURE FOR WORKERS'
OOMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE= FDR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE, AS REWIRED BY SECTION
? 3700 OF THE LABOR CODE- FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
15 SUED. W WORKERS COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
� CARRIER .
i POLICY NUMBER
Q
(TNGSECIDNIHE®MDT EE OOAPLETEDCFTIE POW BFOR ONEFLlEREO CUI/SLS (iID) OR LESS}
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1
2 SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
/� WORKERS COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF
�T..R
BUBJECTTO THE WORKERS'COMPENSATIN PROVISIONS OF SSCTKN
CODE. 11 ORrHMTH COMPLY WITH THOSEP ISIORS.
DA AN :
WARNING: ARURE TO SECURE WORKERS' COMPENSATION _64IL
COVERAGE IS UNLAWFUL. AND SHALL Be
y SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (!/00.000). IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN
J SECTION 3703 OF THE LABOR CODE. INTEREST, AND ATTORNEYS FEES.
3- CONSTRUCTION LENDING AGENCY
7
THEREBY ERFO MANCEUNDER OF THE OFPERJURYFOR WHICH
THIS
PERMIT 18
LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3057, CIV. C.).
.0
L
TENDER'S NAME
LENDERSADORESS
1 CERTIFY THAT I HAVE READ THIS APPLIO — AND STATE T ATTHE ABOVE INFORMATION IS CORRECT.
1 AGREE TO COMPLY WITH ALL CRY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATNES OFTHIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
c -I ern
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SIGNATURE OF PERMITTEE DATE k
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ISSUE TYPE
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DATE CONST
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DESCRIPTION San. FACTO PSF r
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WHITE Rment Copy, YELLOW-Ffnence Copy, PINK -Assessor Copy, GOLDENROD-FIIs GOV%GREEN-Appica TS COPY
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