HomeMy WebLinkAbout18271 �x�'��d
CITY OF DIAMOND BAR
�-- ���`` ---� DEPARTNTE?�1T OF COMMUNTfY&�DEVELOPIvfENT SERVICES
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21825 E.Copley Drive
'� (909)860-3195 Fax(909)861-3117 PRESS
��-��� BUILDING PERMIT APPLICATION FI LY I
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� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
p� OWNEFi-BUILDER DECLARATION SFR/ADD/REM
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I HEREBV AFFlHM UNDER PENALTV OF PERJURV THAT I AM EXEMPT FROA�THE CON7RACTOqS L6 G8f8JQ/C2fpOR
W CENSE LAW FOR THE FOLLOWING REASON(SEC.7031.5 BUSINESSAND PROFESSIONS CODE:ANV CITV OR (n
U COUNTYWHICHREOUIRESAPERMITTOCONSTRUCT,ALTER,IMOROVE,DEMOLISM,ORREPAIRANYSTRUG
w TURE,PRIOR TO ITS ISSUANCE,ALSO REOUIRES THE APPLICANT FOR SUCH PEiiMIT TO FILE A SIGNE� w Patio/Deck i
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- �
� CENSE LAW(CHAPTER Y(CAMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO� � POOUS(18
FESSIONSCADE)OATHA7HEORSHEISEXEMPTTH�REFROMRNDTHEBAStSFORTHEALLEGEDEXEMP- (� ^ R '
� TION.ANV VIOLATION OF SECTION 7031.5 BY ANY APPLICAN�FOR A PERMIT SUBJECTS 7HE APPLICANT T0 Z Re-Roof l�O�J' �
A CIVIL PENALTV OF NOT MORE THAN FIVE HUNDRED DOLUflS�S50o).�: �
ZOI,ASOWNEROFTHEPROPERTV,ORMVEMPLOYEESWiTHWAGE5ASIHEIRSOLECOMPENSATiON, � Commercial
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTEND[D OH OFFERED FOH SALE(SEC.7014,BU51� J
� NESS AND PROFESSIONS CODE:THE CONTFACTORS LICENSE LAW DOeS NO�APPIV TO AN OWNER OF �
PROPERTV NM110 BUILDS OR IMPROVES THEREON,ANO WHO DOES SUCN WORK HIMSELF OR HERSELF OR
� THROUGHHISORHEROWNEMPIOVEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTENDEDOR m
w OFFEREDFORSFLE.IF,HOWEVER,THEBUILDINGORIMPROVEMENTISSOLDWI7HINONEYEAROFCOMPLE�
� TION,THE OWNER-BUILDER WILL MAVE 7HE BURDEN OF PROVING'HAT HE OR SHE DID NOT BUILD OR
Z IMPROVE FOR THE PURPOSE OF SALE).
_ ❑I,ASOWNEROFTHEPROPEHTV,AME%CLUSIVLLYCONT CTINGWITHLICENSEDCONTRACTORS
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� 70 CANSTRUC7 THE PRQIECT(SEC.70��,BUSINE55 AND PR ESSIUNS CODE:THF.CONTRACTORS L4 V8IU0�lOf1 � ADJ.AREA -
W CENSEUWDOESNOTAPPLYTOANOWNEROFAPROPERTV OBUIF. ORIMPROVES7HEREON,AND —
� WHOCONTRACTSFORSUCHPRQIECTSWITMACONTRACTO ( LICENSE PURS ANTTOTHECONTRAG QUANTITY DESCRIPTION FEE
Y 70R5 LICENSE LAW.).
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� LICENSED CONTRACTORS DECLARATION W
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� I HEREBY AFFIRM UNDER PENALTY OF PERJURV THA71 AM LICENSED UNDER PROViSIONS OF CHAPTER �
d 9(COMMENCING WITH SECTION 70W)OF DIVISION 30F THE BUSINESS AND PP.OfES5iON5 CODE.AND Z
`X MY LICENSE IS IN FULL FORCE AND EFFECT. m
� LICENSE CLASS _ LIC.NO. j
V DATE CONTRACTOR d
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� WOFKERS'COMPENSATION OECLARATION - Q
� I HEREBYAFFIRM UNOER PENALTV OF PE0.IUHV ONE OF THE FOLLOWING DECLARATIONS: Z
Z _1 HAVE AND WILL MAINTAIN A CERTIfICATE OF CANSENT TO SELFdNSURE FOR WORKERS' _
¢ CAMPENSATION,AS PROVIDED BV SECTION 37000FTHE LABOR COOE,FOR THE PERFORMANCE W
OF THE WO{iK FOR WHICH THIS PERMIT IS ISSUED. � .
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w _I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BV SECTION
Q 37000F THE LABOfi CODE,FOR THE PERFORMANCE OF THC-WORK FOR WHICH THIS PERMIT IS
ISSUED,MV WORKERS'COMPENSATION INSURANCE CARRIER AND POUCV Nl1MBER ARE: CONSTRUCTION �
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� CARRIER PLAN REVIEW �
ZPOLICV NUMBER ELECTRIC
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� (iHISSECTIONNEmNOT8E07MPLEfEDOFTiEPERMfiISFORONEHUPDREDDOLLARSRt00)ORLESSJ. PLUMBING
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Z I CERTIFV TFIAT IN THE PEHFOFMANCE OF THE WOHK FOR WHICH THIS PERMIT IS ISSl1ED.I MECHANICAL
(.'} SHALL NOT EMPLOV ANV PERSON IN ANV MANNER 50 AS TO BECOME SUBJECT TO THE
� WORKERS'COMPENSATION LAWS OF CALIFORNIA,ANO AGREE THAT IF I SHOULD BECOME INS?ECTION FEE
'= SU&IECTTOTHEWORKERS'COMPENSATIONPROVISIONSOFSECTION37000FTHEl1�BOR
CODE,I SHALL FORTNWITH COMPLY WITH THOSE PROVISIONS. ISSUANCE
� SMIP � •
p DATE: APPLICANT:
J WARNING:FAI�URE TO SECURE WORKERS'COMPENSATION COVERAGE IS�UNLAWFUL,AND SHALL BE ENERGY P/C
� SUBJECT AN EMPLOYEF TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDRED THOUSAND ENERGY PERMIT
OOILARS(f t0o.000),IN HDDI710N TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
� � SECTION 3700OF TNE LABOR CODE,INTEREST,AND ATTORNEV'S FEES. RETENTION FEE:
� CONSTRUCTION LENDING AGENCY PRE-ALT FEE: '
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� I HEREBV AFFIRM UNDER ENALTV OF PERJURV TMAT THERE IS ACONSTqUCTION LENDING AGENCV
FOR THE PEFFOqMANC F THE WOFK FOR WHICH THIS PERMIT IS ISSUED(SEC.]097.CIV.C.).
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j LENDER'S NAME
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� LENDER'SADD 5� +7
� 1 CERTIFV T I HAVE READ THIS AP LICA N AND STATE THAT TME ABOVE INFORMATION IS CAFHECT. TOTAL FE ES ( ,� J p
w I AGFi� COMPLY WITH ALL CITV A D UNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING '
� CON�$3 CTION,AND HEREBY AUTH RI REPRESENTATIVES OF THIS COUNTV TO ENTEF UPON THE
� ABW ENTIONE ROPERTV FO N EC710N PURPOSES.
Z COMMENTS
¢ PER 7TEE NAME(PRINT) � � � �
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� SIGNA7URE OF PERMITT E 0 E
_ � RECPT.�Q PAID BY VALIDATION
~ WHITE—De artment Co YELI.OW—Finance Co PINK—Assessoi Co GOLDENROD—File Co GREEN—A licant's Co
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DRYWALL NAIUNG� ' DEDIC�TIONS
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