HomeMy WebLinkAbout17489 (25) , , . - EXPIRED
CITY OF DIAMOND BAR
`�---��`` -- DEPARTIvIENT OF COMMUMTY&DEVELOPMENT SERVICES �U�I 1� 1QQ� ,
21825 E.Copley Drive
(909)860-3195 Fa�c(909)861-3117 PRESS
`�"%���� BUILDING PERMIT APPLICATION FIRMLY
N JOBSITE ��/1, .�j ���Q/��i��� APPLICATI9 OI / PERMIT P/C
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� OWNER-BUILDER DECLARATION SFR/ADD/REM
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I HEREBY AFFIRM UNDER PENALTY OF PERJURV THAT I AM E%EMPT FROM THE CANTRACTORS LI- Gef8J6/CefpOR
W CENSEUWFORTHEFOLLOWINGREASON(SEC.7031.5BUSINESSAN�PROFESSIONSCODE:ANVCITVOR (f�
U COUNTYWHICHREOUIFiESAPERMITTOCANSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANVSTRUC- W Patio/Deck
w TURE,PHIOR TO ITS ISSUANCE,ALSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNE� w
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PFiOVI510NS OF THE CONTMC70R5 LI�
� CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINE55 AND PRO- � PooVSpa
Q FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BA515 FOR THE ALLEGED E%EMP� (�
V TION.ANVVIOLATIONOFSECTION7031.SBVANYAPPLICANTFORAPERMITSU6IECTSTHEAPPLICANTTO Z Re-Roo(
A CIVIL PENALT/OF NOT MORE THAN FIVE HUNDRED DOLLARS(f500)J:
� ❑I,ASONRJEROfTHEPFOPERTV,ORMVEMPLOVEESWITHWAGESASTHEIR50lECAMPENSATION, 0 COff1RlBfCl81 �
Z WILL DO THE WORK,AND THE STRUCTURE IS NO7INTENDED OR OFFERED FOR SALE(SEC.704�,BU51� J
� � NESS AND PROFESSIONS CADE:THE CANTRACTORS LICENSE lAW DOES NOT APPLY TO AN OWNEF OF �
� PROPER7VNMOBUILDSORIMPROVESTHEREON,ANDWHODOESSUCHWORKHIMSELFORHERSELFOR
� THROUGH HIS OR HER OWN EMPLOYEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT MTENDED OR m
w OFFEREDFORSALEIF,HOWEVERNEBUILDINGORIMPROVEMENTISSOLDWITHINONEYEAROFCAMPLE-
� TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
Z IMPROVE FOR THE PURPOSE OF SALE). �
_ ❑I,AS ONTJER OF THE PROPERTY,AM EXCIUSIVELV CONTRACTING WITH LICENSED CONTRAC70RS
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� TO CONSTRUCT THE PR0.IECT(SEC.704�,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS ll- V8IU8�10l1 ADJ.AREA
W CENSELAWDOESNOTAPPLVTOANOWNEROFAPROPERTYWHOBUILDSORIMPROVESTHEREON,AND
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� ❑I AM ExEMPT UNDER SEC. B.8 P.C.FOR THIS REASON Q /(/
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� LICENSED CONTRACTORS DECLARATION w
� I HEREBV AFFIRM UNDER PENPLN OF PERJURV 7HA71 AM LICENSED UNDER PROVISIONS OF CHAPTER � �
� Y(COMMENCING WITH SECTION 7000)OF DIVISION 3 0F THE BUSINESS AND PROFESSIONS CADE,AND Z
X MY LICENSE IS IN FULL FORCE AND EFFECT. �/�
� LICENSE CLASS ���/� LIC.NO. `��/� j
V DATE /� ��-f.�� CONTRACTO a
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� WORKERS'COMPENSATION DECLAAATION a
NI HEREBV AFFIpM UNDER PENALTV OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: Z
� IHAVEANDWILLMAINTAINACERTIFICATEOFCONSEN770SELF-INSUREFOfiWORKERS' _
� CAMPENSATION,AS PROVIDED BV SECTION 37000FTHE LABOR CODE,FOR THE PERFORMANCE w
�WORK FOR WHICH THIS PERMIT IS ISSUED. �
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w I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS RE�UIRED BV SECTION
Q 37000F THE LABOR CADE,FOR7HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED.MY WORKE�RS�'CA' MPENSATION INSURANCE CA IER AND POLICV NUMBER ARE: CONSTRUCTION
¢ CARRIER �/rr"� �� PLAN REVIEW
7
Z POLICYNUMBER � ELECTRIC
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� (IFVISSECTIONNE�NOT8E00MPLEfEDOFTHEPERIMISFORONEF0.11�DREDDOLLARS(5100)ORLESS). PLUMBING � I q.
' Z I CERTIFV THAT M THE PERFORMANCE OF THE WORN FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
C} SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECAME SUBJECT TO THE �--�----- __
, � WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECAME ' INSPECTION FEE ��� � -1 % •.� � - .
= SU&IECT TO THE WORKERS'CAMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR �L -�/ �� •\, � '` , I _�J { G"
CODE.I SHALL FORTHWITH COMPLV WITH THOSE PROVISIONS. ISSUANCE � ��/•�
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p DATE: APPLICANT. SMIP 1 Il r� �{ O ?fl t��j .
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J WARNING:FAILURE TO SECURE WORKEHS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALLBE ENERGY P/C I �
� SU&IECT AN EMPLOYER TO CRIMINAL PENAL71E5 AND CIVIL FINES UP 70 ONE HUNDRED THOUSAND � �
r DOLLARS(510o,000),INADDI710NTOTHECOSTOFCOMPENSATION,DAMAGESASPROVIDEDFORIN ENERGYPERMIT I o
� SECTION 3708 OF THE LABOR CODE,MTEREST,ANDATTORNEY'S FEES. RETENTION FEE: I�'���.--.. I _
� CONSTRUCTION LENDING AGENCY PRE-ALT FEE: �
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� I HEREBV AFFIRM UNDER PENALTY OF PERJURV THAT THERE IS A CONSTRUCTION LENDING AGENCV
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.C.). -
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� LENDER'S NAME
� LENDER'SADDflESS f
� I CERTIFY THAT I HAVE fiEAO THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. TOTAL FE ES /��1 ��
� I AGREE TO COMPLV WI7H ALL CI7V AND COUNTV ORDINANCES AND S7A7E LAWS RELATING 70 BUILDING ��
� CONSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF THIS COUNTV TO ENTER UPON THE
Z ABOVE�MENTIONED PROPERTV FOR INSPECTIO uarosEs. COMMENTS
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GROUND PLUMBING �' UNDER FLi�OR CUI�IDUIT- :. �' j - �� ______
SLAB GRADE � FIREPLAG'E'FOUNDr�TIUN '__ � ' `
TEMP POWER � FIREPLAGE BONQ BEAM � -
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ROOF SHEATHIfVG . ' . . i 8 FT. BaNt� B�Ap�! .. � ' , . . . �
FRAMINGNENTIUATION � _ � FINAL BOND BEAM _ _ _
ROOF COVER � PRE-GFiADiNG �
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ROUGH PLUMBING ,'1;�`' ; ---�---.�� FIMSH GRA�ING
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FINAL CONST. ' ' ' • ',` �[RE �1�Pi. FINA� � --
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