HomeMy WebLinkAbout14667 I 1F� CITY OF DIAMOND BAR �����
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �D
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$ " ISSUE � TYPE OCC
N LOT�� TRACT � DATE CONST. GROUP
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ADDRESS � �'1 V�C � , ZONING SEfBACKS
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N DES TION SQ.FT. FACTOR PSF ADJ.AREANALUATION
Q OWNER-BUILDER DECLARATION SF ADD EM /. �
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I HEREBY AFFlfM UNDEP PENALTY OF PERIUHY THAT I AM EXEMPT FROM THE COMRACTORS LI� G8l896/CBfpOff
W CENSEUWFORTHEFOILOWINGREASON(SEC.7037.SBUSINESSANDPROFESSIONSCODE:ANYCI7YOR (n
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��� TUHE,PRIOR TO ITS ISSUANCE,ALSO RE�UIHES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w
STATEMEHT THAT HE OR SHE IS LJCENSED PURSUANT TO THE PROVISIONS OF THE CONTRAC70RS LI�
� CENSE UW(CHAPTER P(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINE55 AND PRO- � PooVSpa �
FESSqNS OODE)OH THAT HE OR SHE IS EXEMPT 7HEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TpN.ANVVIOl.AT10NOF5ECTION7031.5BYANYAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Roof
� A CIVIL PENALTV OF NOT MORE THMI FIVE HUNDRED DOLURS(i5o0).): �
� ❑�.ASONMEROFTHEPROPERTY,ORMVEMPLOVEESWITHWAGESASTHEIHSOLECAMPENSATION, � COffIfilOfClfll
WILL DO THE WORI(AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.70N,BUSI� J
N NESS ANO PROFESSIONS CODE:THE CONTRACTORS IICENSE UW DOES NOT APPLY TO Ml OWNER OF � ^
PROPERTYWFiOBUIIDSORIMPROVESTHEREON,ANDWHODOESSUCHWORKHIMSELFOHHERSELFOR m V
Q THROUGH HIS OR HER OWN EMPLOVEES,PROVIDED THAT SUdi IMPROVEMENTS ARE NOT INTENDED OR
QOFFEREDFOHSALEIF,HOWEYE0.7HEBUILDINOORIMPROVEMENiIS50lDWITHINONEVEAROFCOMPLE-
Z �'TIOH,THE OWNER�BUILDER WILL HAVE THE BURDEN OF PROVINQ 7HAT HE OR SHE DID NOT BUILD OR
� IMPROVE FOR THE PURPOSE OF SAIE).
w ❑I,ASOWNEROFTHEPROPEHfY,AMEXCLl151VELYCOMMCTINGWITHLICENSEDCOMRACTORS
Q TO CONSTRUCT THE PRQIECT(SEC.70ta,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- V81U2Si0f1 ADJ.AREA
� CENSE UW DOES NOTAPPLY TOAN OriNER OFA PROPERTY WHO BUILDS OR IMPHOVES THEREON,AND .
N'FpCOMMCTSFOR5UCH7R0.1ECTSWI7HACONTRACTOR(S)LICENSE�PURSUANTTOTHECONTRAG pUANTITY DES RIPTION� FEE �
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❑i AM EXEMPT UNDER SEC. B.8 P.C.FOR THIS REASON J �
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3 DATE y OWNER M�
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� LICENSED CONTRAC S DECLARATION
� I HEREBY AFFIRM UNDER PENALTY OF PERIURV THAT I AM�ICENSED UNDER PROVISIONS OF CHAPTER
d Y(COMMENCiN(i WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE.AND �
X AIY LICENSE IS IN FULL FORCE AND EFFECT. .
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0 UCENSE CUSS LIC.NO. j � ' , .
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� WORKERS'COMPENSATION DECLARATION �
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� I HEREBV APFlHM UNDER PENALTV OF PERJURY ONE OF THE FOILOWING DECURATIONS �Z
� _IHAVE/WDWILLMAIN7NNACERTIFICATEOFCANSENTTOSELF-INSUREFORWORKERS' 2
COMPENSATION,AS PROYIDED BY SECTION�70o OF THE 1A80R CADE,FOR 7HE PERFOqMANCE W
OF THE WORK FOR NM1iICH THIS PERMIT IS ISSUED. `
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w _I NAVE AND WILL MAIMAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTION �J
Q 77o00F THE LABOR CODE,FOR hiE VERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS / �/
ISSUED.MY WORKERS'COMPENSATION INSURANCE C�HRIER AND POLICV NUMBER ARE: CONSTFiUCTION
jCARRIER PLAN AEVIEW �
� POLICYNUMBER ELECTRIC
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� (fF-0SSECI%JNNE�NDTBEWA4�lET�OFTi#PERMTISR�RONEFM1I�DHEDDOLtARS(t100)OqLESS� PLUMBING
Z 1 CERTIFY THA7 IN THE PERFORM/J10E OF 7HE M/ORN FOR WHICH THIS PERMIT IS ISSUED,I MECHANtCAL
� SHALL NOT EMPLOV ANY PERSON IN MIY MANNER SO AS TO BECAME SUBJECT TO THE
� WORKERS'COM7ENSATIONUWSOFCALIFORNIA,ANDAGREETHATIFISHOULDBECOME INSPECTIONFEE
S SUBJECT 70 THE WORNERS'tbM�ENSA710N PROVISIONS OF SECTION 3700 OF THE UBOR � /T
fA�E,I SHALL FOflTHWITH COMPLV WITH THOSE PROVISIONS. ISSUANCE C-'U_'
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p DATE: APPLICANT:
J WARNINO:FAILURE TO SECURE M/ORKERS'COMPENSATION CAVERAGE IS UNUWFUI,AND SHALL BE ENEAGY P/C , o
LL SU&IECT AN EMPLOYER TO CRIMINAL PENALTIES AND qVIL FINES UP TO ONE HUNDRED THOUSAND ENERGY PERMIT
DOLURS(5100,000).IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PFOVIDED FOR IN �
� SECTION 3708 OF iHE LABOR CODE,INTEREST,AND ATfORNEV'S FEES. � RETENTION FEE: �
� CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
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� I HEREBV AFFIRM UNDER PENAITV OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK fOR WHICH 7HI5 PERMIT IS ISSUED(SEC.7a�7,CIV.C.).
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� LENDER'S NAME
F= LENDER'SADORESS /
� I CERTIFY TMA71 HAVE READ 7HIS APPLICATION AND STATE THA7 7HE ABOVE INFORMATqN IS CORRECT. TOTAL FE ES ` ,� 7- I D� / /
1 AGREE TO CAMPLV WITH ALL CRY AND COUNTY ORDINANCES AND STATE UWS RELA7ING TO BUILDING n/n�� ///''jjj���/� /�� ��
� CONSTFUCTION,AND HEREBY AUTT�IOfi1ZE REPRESENTATIVES OF THIS COUN7V 70 ENTER UPON THE �� �(A ��� �
Z ABOVE-MENTIONED 7ROPER7V FOR INSPECTION PURPOSES. COMMENTS t
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RECPT.NO. PAID BY VALIDATION
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