HomeMy WebLinkAbout18744 CITY OF DIAMOND BAR �
� � DBPARTMENT OF COMMiJNTPY&�DEVELOPMENT SERVICES
21825 E.Copley Drive
� (909)860-3195 Fax(909)861-3117 PRESS
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PRESS F LY
CITY OF DIAMOND BAR
DEPARTIVIENT OF COMMUNrCY&'DEVELOPMENT SERVICES 21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
JOBSITE
ADDRESS
APN— LOT TRACT
OWNEFI—Tilf• itill'il ..
ADDRESS
CITY ZIP TEL.
APPLICANT TEL
CONTRACT•R Fr. * 0 t viz /.._ .
ADDRESS .,... b SaIkAVIZIIIVIWZIMIRIBEW
CITY A. nal ZIP lik 4 .IMMO,
71-E
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJUFIT THAT I AM EXEMPT FROM THE CONTRACTORS LI.
CENSE LAW FORTHE FOLLOWING REASON(SEC. 7031.5 BUSINESS AND PROFESSIONS CODE ANY CITY OR
COUNTY WHICH REQUIRESAPERMITTO CONSTRUCT,ALTER,IMPROVE,DEMOLISH.OR REPAIR ANY STRUC.
TURE,PRIOR TO ITS ISSUANCE,ALSO REWIRES 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 ANY VIOLATION OF SECTION 7031 s BY ANY APPLICANT FOR A PERMIT SUBJEC rs THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500)),
0(,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK,AND TFIE STRUCTURE 15 NOT INTENDED OR OFFERED FOR SALE(SEC 7044,SUSI.
NESS AND PROFESSIONS CODE THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO 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 IMPROVEMENT 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 SALE)
0 I,AS OWNER OF THE PPC.PE,47)44.4 E. :, • : ...1, -N)Pe,'I..): h.).• L. rh'Eu ..NIA,..1 •H
TO CONSTRUCT THE PROJECT 1: E.: ... E),:,4E' ANI•), P :•):): :. .., . .: :4'•,: I H, .. :•,,,,,,..: ^ :•,,,
1 )
CENSE LAW DOES NOT APPLY T.:,AP, .-,./NE A.'•r.)4 44.4-4 A• ,A.:..- .4. '•A),1,A' + E 7 AF A.' ..ld 1Ja.
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S) L ICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW)
0 I AM EXEMPT UNDER SEC B&P C FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDEFl PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCiNG WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PPOFESSONS CODE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT
A
LICENSE CLASS3 lg e 7 7 LIC NO 5W5e„
DATE CONTRACTOR eteSre di 1/Le
7
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS
I HAVE AND WILL lAAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION.AS PROVIDED BY SECTioN 3700 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
3703 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED MY WORKERLCOMPENSATIO 5URANCE• RRIER AND POLICY NUMBER ARE
CARRIER 5-T4-62. - ..,,,
POLICY NUMBER 144
(THIS SECTION NEED NOT BE COMPLETED OF THE PERM)"IS FOR ONE HUNDRED COLLARS($100)OR LESS)
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
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 PROV IONS
DATE 10"?"..Crad APPLICANT CI4-st43./.../44,
$
i WARNING FAILURE TO SECURE WORKERS'COMpENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
" SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(5100.000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
1 SECTION 370e OF THE LABOR CODE.INTEREST,AND ATTORNEY'S FEES
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY oF PERJURy 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
1144 VIA
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DATE (..H 02_, PERMIT t -i-fiL P/C
1 NUMBER # 1
ISSUE i. TYPE CC
DATE e"Itr2- CONST. GROUP
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RECPT NO PAID BY VALIDATION
HITE—Department Copy, —mance Uopy, —ssessor OOpy, —
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