HomeMy WebLinkAbout15467 CITY OF DIAMOND BAB � '
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES '�
a 21660 E.Copley Drive Suite 190 .�
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(909)860-3195 Fax(909)861-3117 PRES$
'� . BUILDING PERMTT APPLICATION _ FIRMLY
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ADDRESS � DATE � � � � NUMBER�# r�A
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7URE,PRIOR TO IT$ISSUANCE.AL50 REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
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Z WILL DO THE WORK,AND TNE STRUC7URE IS NO71N7ENDED OR OFFERED FOF SALE(SEC.7a4,BU51- J
� NE33 AND PROFESSIONS CODE:THE CONTMCTOPS LICENSE LAW DOES NOTMPLY TO AN OWNER OF =
PROPEflTY WF10 BURDS OR MIPROVES THERC-0N,AND N7i0 OOES SUCH WOpK HIMSELF OR HERSELF OR
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� � ,OFFEREDFORSALEIF,HOWEVERTMEBUIL�INGORIMPROVEMENTISSOLDWITHINONEVEAROFCOMPIE-
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W OI,ASOWNEqOFTHEPROPERf`/,NAEXCLUSIVELYCONTRpCTINOWITMLICENSE�CONTflACTORS
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� 1 HEHEBYAFFIRM UN�ER PENPLTV OF PE0.IURY 7HAT I AM UCENSED UNDFR PROVISIONS OF CHAPTER �
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V DATE_���„Q � c1U CONTRACTOR _ _ a
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� WORKERS'COMPENSATION DECIARATION a
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O �I HAVE ANO WILIAIAINTAIN A CERTIFICATE OF CONSENT TO SELFINSURE FOR WOqNERS' _
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Q OFTHE WOPoC FOR WHICH THIS PERMIT IS ISSUED. �
� _I HAVE Ml�WILLMAIMAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION
Q 37000FTHE LABOR OODE,FORTHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED.MY WOqKEfiS'COMPENeSATIO.N,INS�UrR�AN/CE CARRIEH AND PDUCY NUMBERARE: CONSTRUCTfON
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C�J SNALLNOTEMPLOVANY7ERSONINANYMANNERSOASTOBECAMESl19JECTTOTHE
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SU&IECT 70 THE WORKERS'COMPENSATION PROVlSIONS OF SECiION 37000F THE LA R
s COUE,ISHALLFOfiTHWITHCOMVLYWITHTH EPROVISIONS. ISSUANCE '��A -
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p DATE � '� � APPLICANT. _� SMIP _
J WARNINO:FAILUHE TO SECURE VJOHKFAS'CAMPENSATION CAVERAGE IS UNLAWFUL,AND SHALL BE ENERGY P/C F��` C�
LL SU&IECTPNEMIPLOYERTOCRIMINALPENAL7IESANDCIVILFINESUPTOONEHUNDFEDTHOUSAND � � _
OOLURS(i/00.000),IN ADDITION TO THE COSTOF COMPENSATION,DAMAGESAS PROVpED FOR IN ENERGY PERMIT � ?- � . -.
� SECTbN37080FhIELABORCODE,INTEREST,ANDATTORNEI"SFEES � RETENTIONFEE: e -'Af�(`,�����P�E3+ .9�
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d CONSTRUCTION LENDING AGENCY pRE- LT F -t � �.t="i'-t� �'�x' � �-
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FOR THE PERFORMANCE OF THE WORK Wfi WHICH THIS PERMIT IS ISSUE�(SEC.3097,CIV.C).
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� LENDER'S NAME
F- LENDER'SADDRESS
� TOTAL FEES
� I CERTIFY THAT 1 HqVE READ THISAPPLICATIONAND STATETHATiHE ABOVE INFORMATIDN IS CORRECT.
w IAGREE TO CAMPLY WITH ALL CIN AND CAUN7V ORDINANCES AND STA7E LAWS RELATING TO BUILDING
� CONSTRl1CTION,ANDHEREBVAUTHOFIZEFEPRESENTATIV6SOFTHISCOUNTYTOENTERUPONTHE
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PRESS FIRMLY
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
JOBSITE
ADDRESS 2 gq't AAA La...,,te
APN LOTRACT
OWNER C/Hrlig f s 51 0 XIVC g
ADDRESS /ts-ti of 7ritt4A/
CITY 1P TEL.
APPLICANT TEL.
CONTRACTOR At (LA '2.,
ADDRESS 037 I • tot•
CITY4.4__teidezeiAzt ZIP os TEL.(2g11,..g1Z1
ARCH/ENG/1.13, OIt-X-1-'24i L
DESIGNER . 37�f4 .
ADDRESS 4. P.- . 0/
CITY '774,.•YVtirkre ZIPeAcj,71 TEL')•6-1-7/. 497/
# Iif
I
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 DIVISIONS 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 FORA PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(WM.):
CI L 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 FOR SALE IF, HOWEVER,INE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE-
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 BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS UCENSE LAW.).
0 I AM EXEMPT UNDER SEC. B.&P.C. 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 DIVISIONS OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
LICENSE CLASS C*--/4 LIC NO rt43 r
DATE 8t—00—oo CONTRACTOR FRA 7Z11
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 Ralik:met .2.1OC9.4.11214,1 0 rx, .
POLICY NUMBER 0 3 0/cr 6
(THIS SECRON NEED NOT BE COMPLETED OFTHE PERMIT IS FOR ONE HUNDRED DOLLARS($100)OR LESS).
I CERTIFY THAT IN THE PERFORMANCE 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
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 37000F THE IA R
CODE,I SHALL FORTHWITH COMPLY WITH T E PROVISIONS.
DATE S-10. 0.40 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 4100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON 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. 3097,CIV.C.).
LENDERS 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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MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT F .
(e i
.WO
--3q560
11101r-
-- wrAillIP
,r,, 1.)p,,sl., ..A,-,' ci ..(AeJ
L(-f-/.7 11-,;-.811\l l{3:13'11.11
- - - Ki+:l f
,-N; ;IS
I':,
TOTAL FEES 71/63e)
COMMENTS
RECPT. N0. PAID BY VALIDATION A I(
WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy
CITY OF DIAMOND BAR
INSPUDN RECD
1...1N"J!
• L.0 MT S
UCT
IT • •
ELECT k G R(„72.)" LAP,
, '3gRAD1NG
7:TRIC-Na NG
5