HomeMy WebLinkAbout19000 ____�� CITY Ok'DIAMOND BAR
DEPARTMENT OF COMMUNTfY&DEVELOPI�NT SERVICES
d 21825 E.Coptey Drive
(909)860-3195 Fax(909)861-3117 PR ESS
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PRESS FIRMLY
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY 84 DEVELOPMENT SERVICES 21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
JOBSITE 6 i
.2.- 4.1 1„
ADDRESS itiz 9., •
APN LOT TRACT
OWNER
ADDRESS
CITY ZIP TEL.
APPLICANT TEL
CONTRACTOR -6,7 ,,Affirmatmzug
ADDRESS 0_!V310 .111PIi III PP.._,M,.._'6.4011MUNIIIMMII
CITY. ._fittrA ZIP d I t TEL. ( Mfg/
ARCH/ENG/t
DESIGNER Vv^-• vt. -
ADDRESS
CITY ZIP TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM 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 PERMIT TO CONSTRUCT,ALTER,IMPROVE,DEMOLISH,OR REPAIR ANY STRUC-
TURE,PR/OR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISK>NS OF THE CONTRACTORS LI-
CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 70001 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 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(SS00))
0 I,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 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 WU HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OF/
IMPROVE FOR THE PURPOSE OF sAi.g)
0 I,AS OWNER OF THE PROPERTy,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT 71-1E PROJECT(SEG. 7044,BUSINESS AND PROFESSIONS CODE.THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN °INNER 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)
0 I AM EXEMPT UNDER SEC. B&P.0 FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY oF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 70001 OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
V, I--; 6- I(:.; i3 \
LICENSE CLASS - LIC N0. 74
DATE i k-s-0'2," CONTRACTOR
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PEFtJURY ONE OF THE FOLLOWING DECLARATIONS
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATK)N,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE,FOR THE PERFORMANCE
. OF THE WORK FOR WHICH THIS PERMIT IS ISSUED
/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 WORKERS' MPENSATION INSURANCE C4RRIEFI AND POLICY NUMBER ARE.
CARRIER 4ceAt ,
POLICY NUMBER I. kko-i.
(THIS SECTION NEED NOT BE COMFtETED OF THE PERMIT IS FORONE HUHDREDIXILARS(5100)ORLESS).
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
7. SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS
1
1 DATE APPLICANT.
1
1 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(8100.000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
:I SECTION 3705 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
.1
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.)
il
LENDER'S NAME
r.
. LENDER'S ADDRESS
9
:., 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 PURP SES
5
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0 SIGNATURE OF PER IT.7" ., .0•0111/
E DATE
APPLICATION
DATE
t\--.5 -v)-4ERMIT
UMBER (r0-0 P/C 011,
1
ISSUE
DATE
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4 ST. GROUP
FRONT SEfBACKS
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QUANTITY DESCRIPTION FEE
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RECPT. N0. Ig PAID BY VALIDATION Illir
WHITE—Department Copy, LLO mance Copy,—ssessor Copy„ —
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