HomeMy WebLinkAbout19018 ___ �. __ CIT'Y OF DIAMOND BAR. �(� v 1�j � U�
DEPARTMENT OF COMMUNTfY&DEVELOPMENT SERVICES � ��
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CITY OF DIAMOND BAR Mf&DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
ON
JOBSITE ,e„447"
ADDRESS c•-4' 5rieode-zok)o<
APN LOTTRACT
OWNER DI 1<. 17----)0
ADDRESS 66-7 S 4• t,:ll./0(4
art r.f. IL,A • i 4:-ZIP TEL.
APPLICANT:4 AI aMraW/IIAIP ' TEL.w.:095:040g-
CONTRACT* R' :7- 1 -4 1-ii +x.r.._ix �ez),
ADDRESS ' -irliP IM.=11n1, E:y •Pr
art g " 1-4,-' ZIP lir TEL.Vii•736-OX_Y6
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PEFUURY THAT I AM EXEMPT FROM THE CONTRACTORS LI.
CENSE LAW FOR THE FOLLOWING REASON (SEC 7031.5 BUSINESSAND PROFESSIONS CODE ANY CITY OR
COUNTY INHICH REQUIRES A PERMIT TO CONSTRUCT,ALTER,IMPROVE,DEMOUSH,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 PFIOVISIONS 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 FOFITHE 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($500))
0 I,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH YVAGES 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 YEAROF 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 PROPERTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC 7044,BUSINESS AND PROFESSIONS CODE.THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW)
0 I AM EXEMPT UNDER SEC. B.8. P.C. 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 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
LICENSE CI4SS 13 ( LIC. NO 317' IS ..--17)
DATE 11/Pit 062--- CONTRACTOR Of-44-1-4 SI
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM 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 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'COMPENSATION INSU ANCE CARRIER AND POLICY NUMBER ARE.
CARRIER 5-rer-ra
POLICY NUMBER(s0 41-2 g
gm SECTICN NEED NOT BE CCMPLETEDOF THE PERK IS FORONE HUNDRED DOLLARS($100)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
SUBJECT TO THE WORKERS'COMPENSATION PROVISMS OF SECTION 3700 OF THE LABOR
CODE,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE. pl.-APPLICANT: lei atificp 77- i•rao
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($100,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 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.
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SIGN AT U R E OF PERMITTEE i •TE
PRESS FIRMLY
APPLICATION , ..-- r•
DATE tr.PERMIT r 017, ,--a _
..t)L '-IUMBER,i ...-
N.12 •— --
ISSUE - GROUP
DATE 4, 0.2....TYPE OCC
CONST. s'
SETBACKS
FRO NT
ZONING REAR
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SIDE RW 0
0
STREET
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