HomeMy WebLinkAbout12-0012CITY OF DIAMOND BAR /
DEPARTMENT OF CONIMUNITY & DEVELOPMENT SERVICES V
21825 Copley Drive, Diamond Bar, CA 91765
(909) 839-7020 Fax (909) 861-3117 Building Inspection Hotline (909) 839-7027 PRESS
BUILDING PERMIT APPLICATION FIRMLY
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CONTRACTOR
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DESIGNER
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OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS L4
CENSE LAW FOR THE FOLLOWING REASON (SEC. 70.7,.3 BUS W ESS AND PROFESSIONS CODE ANY CITY OR
COUNTYYNHICH REQUIRES A PERMIT TO 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 VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (S500).):
O I. AS OWNER OF THE PROPERTY. OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK. AND THE STRUCTURE 1S NOT INTENDED OR OFFERED FOR SALE (SEC. 70.11, 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 BULDING OR IMPROVEMENT IS SOLD WrrHIN ONE YEAR OF COMPLE-
TTON, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
O J. AS OWNER OF THE PROPERTY: AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 7011, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS FOR SUCH PROJECTS WITH ACOW RACTOR(S) LICENSED PURSUANT TO THE CONTRAC-
TOPS LICENSE LAW).
❑ 1 AM EXEMPT UNDER SEC. B. A PC 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 O THE BUSINESS AND PROFESSIONS CODE_ AND
MY LICENSE IS IN FULL FORCE AND EFFECT. J
LICENSE CLASS �/ ,c'C a LIC. NO. q /5 ,
DATE •�1 � Z 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 SELFWSURE 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 M1WTAL4 WORKERS' COMPENSATION INSURANCE. AS REQUIRED BY SECTION
37000E THE LABOR COOS. FOR THE PERFORMANCE OF THE (YORK FOR WHICH THIS PERMIT IS
ISSUED. MY
%VOOAK:RS' COMPENSATION/I SSURAN/CE CARRIER aI:D POLICY NUMBER ARE:
CARRIES rL7[�f -r ��'F�-ijl �Ji- `'�
POLICY NUMBER � i %t r X 7� /Z V
(THLSSECTIONNEED"OT BE C00% UTEDGFTHEPEWST5FORCNE HUNDAMDOULARS($,m)OALESS)
I CERTIFY THAT IN THE PERFORMANCE OF THE WORT( 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 CALIFORt IA AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS' COMPENSATION VISIONS OF SECTION 37M OF THE LABOR
CODE.I SH FORTHWITH COMPLY WITH 5E P VIS NS,
DATE: ',J/ f� APPLICANT:
WARNING: FAILURE TO SECURE WORKERSAPENSATION COVERAGE IS UNLAWFUL. AND SHALL BE
SUBJECT AN EMPLOYER TO CRIAWAL PENAL IES AND CIVIL FRIES UP TO ONE HUNDRED THOUSAND
DOLLARS (S 100.000). IN ADDITION TO THE COST OF COMPENSATION. DA)AAGES AS PROVIDED FOR IN
SECTION 3705 OF THE LABOR CODE. INTEREST AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097, CIV CJ.
LENDER'S NAM-
LENDERS ADDRESS
1 CERTIFY THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 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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SIQNA / fi ._I DATE
CATION I (f I
PERMIT Iv _ -WIP/C
DATEAPPLI
ISSUE `
NUMBER
TYPE
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DATE
CONST,
GROUP
ZONING SETBACKS
FRONT
RW
❑
REAR
❑
SIDE/SIDE STREET
RW
❑
SIDE
❑
PROPOSED USE
NO. DWEL. NO.
NO.
UNITS STORIES
BEDROOMS
DESCRIPTION SO. FT.
FACTOR PSF
ADJ. AREA/VALUATION
SFR/ADD/REM
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Garage/Carport
Palio/Deck
LWL
LL
PooUSpa
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LU
Valuation
ADJ-AREA
QUANTITY DESCRIPTION
FEE
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ELECTRIC
PLUMBING
MECHANICAL
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INSPECTION FEE
ISSUANCE
0
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE -ALT FEE:
TOTAL FEES
COMMENTS
RECPT. NO. PAID B
VALIDATION :S&E:d
WHITE—Department Copy. YELLOW --Finance Copy, PINK—Assessor Copy, UUL.DENHUU—Flla COPY, UHEEN—AppliCanCS Copy