HomeMy WebLinkAbout18372 (28) �� CTTY OF DIAMOND BAR
- - � DEPARTME?`'T OF COIvIIvIUNITY&�DEVELOPMENT SERVICES
� 21825 E.Copley Drive '
(909)860-3195 Fax(909)861-3117 PRESS
��'%9�� BUILDING PERMIT APPLICATION FIRMLY
o� JOBSITE APPLICATION ��/y� P�ERMIT ��1�/C
ADDRESS 1��1 ' iY� �Y• DATE - �IJUMBER
� ISSUE � TYPE OCC
APN LOT TRACT _ DATE CONST. GROUP
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� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
p� OWNER-BUILAER DECLARATION SFR/ADD/REM
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p I HEREBV AFFlRM UNDER PENALTV OF 7ERJURV THAT I AM E%EMPT FROM THE CANiMCTORS LI� Gefe98/COfPOfI
W CENSE UW FOR THE FOLLOWRIO REASON(SEC.7031.6 BUSMESSAND VAOFESSIONS CpDE:ANV CITY OR (n
U �p�J�.JTYWHICHRE-0UIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE,OEMOLISH,ORREPAIRANVSTRUC�
w TURE,VRIOR TO ITS ISSUANCE,�LSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w Patio/Deck
� STATEMENT THAT HE OR SHE IS LICENSED WRSUAIJT TO THE PqOVI510N5 OF THE CONTRACTORS LI� � � �
CENSE LAW(CHAPTER Y(COMMENCINO WITH SECTION�000)OF DIVISION 3 OF THE BUSINE55 AND PRO- POOUSPB
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V TION.ANVVIOLATIONOFSECTION7031.5BYANVAP7LICAN�FORAPEFMITSU&lEC�S'fHEAPPLICANTTO Z Re-Roo1 �
A CIVIL PENALTV OF NOT MORE THAN FNE HUNDRED DOLLAFS(f500�,):
0 ❑I,ASOWNEROFTHEPROPERTV,ORMVEMPIOYEESWITHWAGESAS1HE1qSOLECAMPENSATiON, � COrt1R1BfClfl1
Z WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDLD ON OFFERED fOP SALE(SEC.7ou,BU51� J
� NESS AND PROFESSIONS CODE:THE CANTRACTORS LICENSE LAW DOES NO'APPLV TO AN OWNER OF �
PROPERTV Vh10 BUILDS OR IMPqOVES THEREON,AND NM110 DOES SUCN WORN MIMSELF OR HERSELF OR
wTHRIXIGH HIS OR HER OWN EMPLOYEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT MTENDED OR m
� OFFEREDFORSALEIF,MOWEVER71-�EBUILDINGORIMPROVEMENTISSOLOWITHINONEVEAROFCOMRE-
Z TION,THE OWNEREUILDER WILL F1AVE THE BURDEN OF PROVING'MAT HE OR SFIE DID NOT BUILD OR
� IMPROVE FOR THE PURPOSE OF SALE).
�y,� ❑I,AS OWNER OF THE FROPEHTV,AM EXCLUSNELY CONTRACTIN�WITH UCENSED CANTRACTORS
[[ TO CONSTRUCT THE PR0.IECT(SEC.7oN,BUSINE55 AND PROFESSIONS CODE:THE CONTMCTORS ll� V81UBflOf1 � ADJ.AREA
W CENSE LAW OOES NOTAPPLV TO AN OWNER OF A PROPEHTY WHO dUII.DS OR IMPROVES THEREON,AND
� NRiOCANTRACTSFORSUCHPROJECTSWITHACONTRACTOR(S)I.ICENSEDPURSUANTTOTHECONTRAC� QUANTITY DESCRIPTION FEE
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� O I AM E%EMPT UNDER S . B.8 C.FOR THIS Q
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� LICENSED C TRA T RS DE ATION . w
� I HEREBY AFFIfUI UNDER PENALTV OF PERIURV THAT I AM LICENSED UNDER PROVi510NS OF CHAPTER �
� 9(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESSAND PP.OFESSIONS CODE.AND Z
�� MV LICENSE IS IN FULI FORCE AND EFFEC7. m
� LICENSE CLASS LIC.NO. �
V DATE CONTRACTOR a
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� WORKERS'COMPENSATION DECLARATION Q
� I HEREBV AFFIRM UNDER PEN.LLTV OF PERIURY ONE OF THE FOLLOWINQ DECLARATIONS: Z
�Z IMAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF�INSUREFORWOqKERS' a
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COMPENSATqN.AS PROVIDED BV SECTION�lao OF THE LABOR CODE,FOq TME PEHFORMANCE U
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. w
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w _I HAVE AND WILL MAINTAIN WORKERS'CAMFENSATION INSURANCE,AS REDUIRED BV SECTION
Q ]700 0F THE LABOR COOE,FOR THE PERFORMANCE OF hiE WORK WR WHICH THIS PERMIT 15 '
ISSUED.MV WORKEFS'CAMPENSATION INSURANCE CARRIER AND POLICV NUMBER ARE: CONSTRUCTION
� CARRIER PLAN REVIEW �
Z POLICYNUMBER ELECTRIC
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� (rrossEc��r��rioieEo�n.s�ErmoFn+eaEarRr�sroaoriEr�rnaEooal.uas(s�rolaa�Essl. PLUMBING
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Z �CERTIFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
C,�} SHALL NOT EMPIOV ANY PERSON IN ANV MANNER SO AS TO BECAME SUBJE�T TO THE
(/� WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECAME INS?ECTION FEE
SU&IECT TO THE WORKERS'CAMPENSATION PROVISIONS OF SECTION 37ao OF THE UBOR
S CADE.I SHALL FORTHWITH COMPIV WITH THOSE PROVISIONS. ISSUANCE '
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p DATE: APPLICANT: SMIP
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J WARNINO:FlJLURE TO SECURE M/ORKERS'COMPENSATION CAVERAGE IS UNUWFUL,M1D SHALLBE ENERGY P/C
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� SU&IECTAN EMPLOVER TO CRIMINAL PENALTIES M1D CIVIL FINES UV TOONE HUNDRED THOUSAND ENERGY PERMIT
} DOLLARS(Stao,oao),IN ADDIT70N TO THE COST OF COMPENSATION,DAMAOES AS PROVIDED FOR IN
J� SECTION 3�08OF THE LABOR CODE,INTEREST,AND ATTORNEV'S FEES. RETENTION FEE:
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: '
� I HEREBV AFFIRM UNDER PENALTV OF PERJURV THAT THERE IS A CANSTRUCTION LENDING AGENCV
� FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3087,CIV.C.).
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� LENDER'S NAME
F— LENDER'SADDRESS
w I CERTIFY 7HAT 1 HAVE READ THIS APPUCATION AND STATE THAT THE ABOVE INFORMATION IS CARRECT. TOTAL FE ES �`�V
� I AOREE TO CAMPLV WITH ALL CITV AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING ���/
� CONSTRUCTION,AND HERE9V AUTNORIZE FEPRESENTATIVES OF THIS COUNTV TO ENTER UWN THE
Z ABOVE-MENTIONED 7ROPERTV FOR INSPECTION PURPOSES. COMMENTS
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m PERMIT7EE NAME(PRINi�
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� SIGNATURE OF PER E DAT
= RECPL N0. � PAID BY VALIDATION '
~ - WHITE—DepeAment Copy,YELI.OW—Finance Copy,PINK—Assesso�Copy,GOLDENR ile Copy,GREEN—Applicant's Copy
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