HomeMy WebLinkAbout18719 l� CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY 6t DEVELOPMENT SERVICES
�1 , 21660 E.Copley Drive Suite 190
(904)860-3195 Fax(909)8613117 PRESS
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PRESS FIRMLY
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION
JOBSITE L,
ADDRESS_,_bI_ I tilt,
APN LOT TRACT
OWNER I
ADDRESS 5 •A.
crriPia max .. -Y"ZIP TEL.
APPLICANT ,r r, TEL.
CONTRACTOR I- ,- „ r . • '4
ADDRESS---•—-z I'..- - V
....-_,--
art, 1.)- i_. ZIP- ..141 TEL. "'.6 zr......AO-e:n
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIF64 UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQUIRES A PERMITTO CONSTRUCT.ALTER,/MPROVE,DEMOLISH,OR REPAIR ANY STRUC-
TURE. PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE 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(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.AM(VIOLATION OF SECTION 7031 6 6Y ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($soci)).
O1.AS OWNER OF THE PROPERTY OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044,BUSI-
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY INHO BUILDS OR IMPROVES THEREON,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 IMPROVEM ENT IS SOLD WITHIN ONE YEAR OF COMPLE-
TION.THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALEF
0 I.AS OWNER OF THE PROPERTY AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTFIACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE THE CONTRAC,TORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
EI I AM EXEMPT UNDER SEC B.&P C FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
/HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENC/NG WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
IAY LICENSE IS IN FULL FORCE AND EFFECT
LICENSE CLASS 43 0, 'C AI LIC NO ...5 /5/5".I
DATE 9 L.421 6--o a CONTRACTOR C 1/V49
aF..,,,,0
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIFIM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTtON 3703 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKER'COItaISATION INSURANCS CARRIER AND POLICY NUMBER AFIE
CARRIER 4t.. hAria
POLICY NUMBER
ale IF-60----
ILI
(TFIIS SECTION NEE) NOT BE CCMPLEIED OF THE PERMIT IS FOR ONE HUNE/REDDCIIARS(SI CO)OR LESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I
.,..,,t.-��„� •��,,. ..,p....„�r� ����E� •� P•—•:,r....,:..e".e .crT TO THE
,,,c.4., E,z C.:40: EI.:A T.O,Lp„ ....: 'Au, :He,. ...C.A•IAEE inai ii 1 ..,....LID BECOME
....m.E..11.- 1.E.."...1,E.I. .c....,,-vi...,,,,, ,. I .1 •C.. E r .../. • '
• ..,,THE LABOR
CODE.I SHALL FORTHWITH COMPLY WITH THO E PRO a. •Ak Ii^
)
) DATE. (9-a 6•-ool APPLICANT: .JY),11,...,
^Y**-N
WARNING FAILURE TO SECURE WORKERS'ODIAP ATION COV v E I N FUL,ANO SHALL BE
- SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINE 1 Ti TO 0 HUNDRED THOUSAND
DOLLARS($100.000),IN ADDITION TO THE COST OF COMPENSAT• ' . ,AMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
3
CONSTRUCTION LENDING AGENCY
>
. I HEREBY AFFIF9A UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
- FO11 THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC 3097,CIV C).
Z LENDER'S NAME
- LENDER'S ADDRESS
6
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 REP RESENTATRIES OF THIS COUNTY TO ENTER UPON THE
••• ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES
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CITY OF TIP,AiI INSPECTgOr.l -71 -
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