HomeMy WebLinkAbout18549 (11) ____ ,�.�_ CITY OF DIAMOND BAR ��p�
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES '
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117 l��,,� PRESS
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V511
PRESS FIRMLY
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21825 E. Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDIN
JOBSITE 02 A r/O.S LI Ai s el-c gassr",6g4/
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ADDRESS b I/1-Asi 4.01,0 0 PA /7�r
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APN LOT .q T TRACT .Z ..)6(7'4/,
OWNER /41J 4/A itri c Do,a 41.9
ADDRESS_ f' ,, C 0
CITY) ;fit, L i .i ZIP 9/765-TEL. e MS
APPLICANT gebtt.VA-/i/IC D cie A Z.0 TEL S'a 04C-
CONTRACTOR A
ADDRESS , IR
CITY r AIWA TEL.
ARCH/ENG
DESIGNE"Mk o^
ADDRESS VI
CITY 1111 IZIP 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 PERMITTO CONSTRUCT,ALTER,IMPROVE, 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.ANY VIOLATKXV OF SECTION 7031 6 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(BE00)y
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 FORSALE IF, HOWEVER,THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONEYEAR OFCOMPLE-
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 BUI DS OR IMP OVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS4 TH A CONTRACTO LICE T TO THE CONTRAC-
TORS UCENSE LAW)
��. ..
0 lAM EXEMPT UNDER SEC' / il9fir' . B.&P C FOR THIS REASON
4 .4
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DATE . 3-0-)._ OWNER .4 f,--
./171
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 CLASS LIC NO
DATE CONTRACTOR
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.
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 WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE-
CARRIER
POLICY NUMBER
(THISSECTON NEED NOT BE COMPLETED OF THE PERMIT IS FOR ONE HUNDRED COLLARS)$100)OR LESS),
I CERTIFY THAT IN THE PEFIFORMANCE 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
SUBJEGT TO THE WORKEFIS'COMPENSATION PROVISIONS OF SEGTION 3700 OF THE LABOR
CODE,I SHALL FORTHWITH COMPLY WITFI THOSE PROVISIONS.
DATE APPLICANT.
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. 3087,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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