HomeMy WebLinkAbout13611 + , _!� CITY OF DIAMOND BAR . ��(����� ��
DEPARTMENT OF COMMUNTfY&DEVELOPMENT SERVICES
� W 21660 E.Copley Drive Suite 190 �C P 1 O 2Ob 9 PRESS
� (909)860-3195 Fax(909)861-3117
I ����A�� BUILDING PERMIT APPLICATION FIRMLY
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c� ISSUE TYPE OCC
APN T T A T DATE CONST. GROUP
°C OWNER
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� APPLICANT TEL.
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CONTRACTOR T CD SIDE ❑
ADDRESS �
� CITY ZIP�'� TE . ROPOSED USE � 1J �D
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� DESIGNE ' � I r �
ADD ESS NO.DWEL. NO. NO.
� CITY �3 ZI TE . , UNITS STORIES BEDROOMS
y DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION
Q OWNER-BUILDER DECLARATION SFR/ADD/REM
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� I HEREBY AFFlPM UNDER PENALTV OF PEFiIURV THAT I AM ExEMPT FROM 7HE CON7RACTORS LI� G8f89B/CBfpOfl
W CENSEUWFORTHEFOILOWINGREASON(SEC.7031.5BUSINESSANOPROFESSIONSCODE:ANYCITYOR (n
U GOUNTYWHICHREOUIRESAPERMITTOCONSTRUCT,ALTERIMPROVE,DEMOLISH.ORREPAIRMIYSTRUG W P8f10/DBCk
� NRE,PRpR TO 1T3 ISSUANCE.ALSO RE�UIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO hiE PROVISIONS OF THE CONTRACTORS LI�
� CENSE UW(CHAPTER Y(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- � POOVSp2
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT 7HEREfROM AND THE BASIS FOR THE ALLEGED EXEMP-
TqN.ANYVqLATIONOFSECTION7W1.5BYANVRPPLICANTFORAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Rool
� A CIVIL PENALTV OF HOT MORE h1AN FIVE HUNDRED DOLURS(S5W).j: '-
� �I,ASOWNEROFTHEPROPERTY,ORMYEMPLOYEESWITHWAGESASTHEIqSOLECOMPENSATION, � COmmBfCi81 - �
VALL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.701t,BUSI- J
� NESS ANO PROFESSIONS CODE:THE CONTMCTORS UCENSE LAW DOES NOT APPLV TO AN OWNER OF � _. �
PROPEHfY NRiO BUILDS OF IMPROVES THEREON.AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
� TMROUGH HIS OR HER OWN EAIPLOYEES,PROVIDED 7HAT SUCH IMPROVEMEMS ARE NOT INTENDED OR m
Q .OFFEREDFORSALEIF.FIOWEVERTMEBUILDINGORIMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE-
'TION,THE OWNER-BUILDER WILL HAVE TME BURDEN OF PROVINO h1AT HE OR SHE DID NOT BUILD OR
� IMPROVE FOH THE PURPOSE OF SA�E). � �
w ❑I.ASOWNEROFTHEPROPERfY,AME%CLUSIVELYCAMRACTINGWITHLICENSEDCONTMCTORS I
� TO CONSTRUC7 TNE PRQIECT(SEC.7W4,BUSINESS AND PROFESSIONS CODE:THE CANifUCTORS ll- VfilU2fi0f1 ADJ.AREA
W CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTVHM1iOBUILDSORIMPROVESTHEREON,AND
� NRiOCOMRACTSFORSUCHPRQIECTSWI7HACONTMCTOR�S)LICENSEDPURSUANTTOTHECONTMG pUANTITY DESCRIPTION FEE
� 70RS LICENSE UW.).
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Q ❑I AM EXEMPT UNOER SEC. B.6 P.C.FOR THIS REASON Q
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DATE OWNER V
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� LICENSED CONTRACTORS DECLARATION w
� I HEREBV AFFIRM UNDER PENALTY OF PERIURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER � '
� Y(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CA�E,AND Z
��� W UCEHSE IS IN FULL PORCE AND EFFECL `
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� UCENSE CLASS LIC.N0.____��_�,'� � .
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V DATE CONTRACTOR d
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( � O KERS' OMPENSATION D CLARATION a
� I HEREBY AFFIRM UNDER PENAL7V OF PEiLIURV ONE OF THE FOLLOWING DECURATIONS: U � �
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0 I HAVE AND WILL MAIN7AIH A CERTIFICATE OF CANSEN7 TO SELF-INSURE FOR WORKERS' 2 ' � •
� CONPENSATION,AS PROVIDED BY SECTION 370o OF THE LABOR CADE.FOR THE PERFORMANCE W
OF 7HE WORK FOH WHIG1 THIS PERMIT IS ISSUED. �
�
w _i HAVE AND WILL MAINTNN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION i /M�
Q 970o OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 1 �ZLJ
ISSUED.MV WORKEAS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CONSTRUCTION
jCARRIER PLAN REVIEW �
ZPOI.ICV NUMBER ELECTAIC
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� (IFLLSSEi.'fqNNE�N0T8E00A�LEfIDOFTFEPEPo.R6FOROMEFAX�DREDDOUARS(L100)ORLESS� PLUMBING
Z I CERTIFV THA7 IN THE PERFORMANCE OF THE WORK fOR WHICH THIS PERMIT IS ISSUED.I MECHANICAL
(r} SHALL NOT EMPLOV ANV PERSON IN ANY MANNER 50 AS TO BECOME SUBJECT TO THE
�/j WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE TMAT IF I SHOULD BECAME INSPECTION FEE �
S SUBJECT TO THE WORKERS'COMPENSATION PROVISP[!S OF SECT N 370o OF THE LABOR �
COOE,1 SHALL FORTHWITH COMPLY WITH THOS ISIONS. ISSUANCE
p DATE: PPLICANT: SMIP ��
� ENERGY P/C
J WARNI : ILUHE SE E WORKERS'CO PE ATION CAVEHAGE 5 UNUWFUL,M!D SHALL BE
� SUBJECTANEMPL ERT CRIMINALPENALTIES DCIVILFINESUGTOONEHUNDREDTHOUSPND ENERGYPERMIT
DOLURS(5100,000),IN ADDITION TO7HE COST OF COMPENSATION,DAMAGES AS PROVIDED FOfl IN
J SECTION 370E OF lHE LABOR CODE,MTEREST,AND ATfORNEY'S FEES. RETENTION FEE:
�
d CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
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� I HEREBV AFFIRM UNDER PENAL7V OF PEFLIURY 7HAT THERE IS A CONSTRUC710N LENDING AGENCY
FOR THE PERFOfiMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3a97,CIV.C.).
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� LENDER'S NAME
F– LENDER'SADDRESS
� I CERTIFY THAT I HAVE READ THIS APPLICATION PND STATE THAT THE ABOVE INFORMATION IS CORRECT. TOTAL FEES ��
w I AGREE TO COMPLV WITH ALL CITV AND COUNTV ORDINANCES AND STATE LAWS REUTING TO BUILDING
� CONSTRUCTION,AND HEREBV AUTFiORIZE fiEPNESENTA71VE5 OF THIS COUNN TO ENTER UPON THE �
ZABOVE-MEHTIONED P ERTY FOR INSPEC710N PURPOSES. COMMENTS -
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