HomeMy WebLinkAbout18764 �� CITY OF DIAMONb BAR �
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, � � DEPART'ME!VT OF COMMUNTfY&�DEVELOPMENT SERVICES �,[,
21825 E.Copley Drive `
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CITY OF DIAMOND BAR
DEPARTIVLENT OF COMMUNITY&'DEVELOPMENT SERVICES 21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
JOBSITE i, . ,...
ADDRESS_10/6 S k Aj E,_
)1_4.,
APN LOT TRACT
OWNER 1 ', •_•,
ADDRESS; , A- A 0
CITYfiI A/eV Li ZIP q / EL
APPLICANT TEL.
CONTRACTOR
ADDRESS 21 ,Ai,4'..,ArAltv i Tr C
crry el Do-oxoelt ZIP 72..5"71 TEL ratfil"1
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER-BUILDER DECLARATION CONTRAcTORS LI-
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CODE ANY CITy oR
CENSE LAW FOR THE FOLLOWING REASON (SEC 7031 5 BUSINESS AND PROFESSIONS REPAIRANY STRUC.
COUNTY WHICH REQUIRESA PERMITTO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR TO FILE A SiGNED
TURE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT coNTRACTORs Li.
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE AND RAO-
CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS ALLEGED EXEMp-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE THE APPLICANT TO
TION ANY VIOLATION OF SECTION 7031 5 By ANY APPLICANT FOR A PERMIT SUBJECTS COMPENSAT,ON,
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOUAAS($Ooo)) (SEC 7044. BUSI.
0 I,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AST HEIR SOLE TO AN OWNER OF
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE OR HERSELF oFt
NESS AND PROFESSIONS CODE THE CONTRACTORs LICENSE LAW DOES NOT AppLy NOT INTENDED OR
PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF YEAR OF COmPLE-
THROUGH HIS OR HER OWN EMPLOYEES, pROVIDED THAT SUCH IMPROVEMENTS ARE DID NOT BUILD OR
OFFERED FOR SALE IF, HOWEVER,THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE coNTRAGTORS
TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE CONTRACTORS LI-
IMPROVE FOR THE PURPOSE OF SALE). THEREON,AND
0 I.AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED TO THE CONTRAC-
TO CONSTRUCT THE PROJECT(SEC 7044,BUSINESS AND PROFESSIONS CODE THE FOR THIS REASON
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY wHo BuILDS OR IMPROVES
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S)t'CENSE°PURSUANT
TORS LICENSE LAW)
0 I AM EXEMPT UNDER SEC B&P C
DATE 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 PPOFESS,ONS CODE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT
4
LICENSE CLAS AI LIC NO 7 2'7 T3 7
DATE a 0 2-) CONTRACTOR 6:
.19.6126.13
I ...
WORKERS'
PERFORMANCE
WORKERS'COMPENSATION DECLARATION By SECTioN
I HERESY AFFIRM UNDER PENALTy OF PERJURY ONE OF THE FOLLOWING DECLARATIONS THIS PERMIT IS
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR ARE
COMPENSATION,AS pROVIDED BY SECTION 3750 OF THE LABOR CODE,FOR THE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED
Ni. I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH
ISSUED MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER
CARRIER se-(c
POLICY NUMBER ei.q..2—•0,-..^ r 0 LI 6"1
.0
(DISSECTION NEE) NOT BE CCMPLETED OFTHE PERMIT IS FOR ONE HUNDRED DOLLARS
I CERTIFY THAT IN THE pERFORMANCE OF THE WORK FOR WHICH THIS PERMIT ($I oo)OFI LESS)
SHALL NOT EMPLOy ANy PERSON IN ANY MANNER SO AS TO BECOME SUBJECT IS ISSUED, i
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOuLD TO THE
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SEGTION 3700 BECOME
CODE,SHA FORTHWITH COMPLY WITH THOSE PROVISION OF THE LABOR
DATE 0 Ca.)APPLICANT Elect/iv ea-I P—) "eV
WARNING FAILU TO SECURE WORKERS'COMPENSATION cOVERAGE IS uNLAWFU la
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDIWD AND H .. 'gra
DOLLARS($100,000). IN ADDITION TO THE COST OF cOMPENSATION, DAMAGES AS PR TH•u -P D
SEcTioN 3709 OF THE LABoR CODE. INTEREST,AND ATTORNEYS FEEs VIDE* ^ R
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PEFUURY 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
LENDER'S ADDRESS
i CERTIFY THAT i HAvE READ THIs APPLIcATION AND sTATE THAT THE ABOvE INFoRmATioN is cORREcT
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATiNG TO BUILDING
CONSTRUCTION,AND HEREBy AUTHORIZE REPRESENTATIVEs OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES
PERMITTEE NAME(pRiN7)
SIGNATURE OF PERMITTEE DATE
APPLICATION
DATE
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NUMBEiII #/C ly):.
ISSUE
DATE
TYPE OCC
CONST. GROUP
FRONT SEfBACKS
ZONING REAR
SIDE RW 0
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SIDE/SIDE STREET RW 0
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QUANTITY DESCRIPTION FEE
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INS2ECTION FEE
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE. ) ig 1SZ
1 O1'13.
541 ,-(1"-
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41' --L''
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TOTAL FEES 36/. -'1"-'
COMMENTS 30, 12_,....
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RECPT NO PAID BY (.1,4'T/• 7.-.5' VALIDATION
WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy
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