HomeMy WebLinkAbout15419 C .-'t
_ � CITY OF DIAMOND BAR �i
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES ''�
� 21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117 PRESS
�'�9�°" BUQ,DING PERMIT APPLICATION FIRMLY
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OOWNER-BUILDER DECLARATION SFR/ADD/REM
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� STATEMENf THAT ME OH SHE IS UCENSEO PURSUANT TO TME PqOVIS10N9 OF TME CANTRACTORS LI• W PDOVS
CENSE UW(CHAPTER e(COMMENCINO WITN SEC7)ON 7000)OF DNISION 9 OF THE BUSINESS AND PRO- � Pa
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W!LL DO THE WORK,MID 7HE STRUCTURE�N071N7ENDED OR OFFERED FOR SALE(SEC 7041,BUSI- J
NESS AND PqOFESSIONS COOE 7NE fANTRACTOFS LICENSE t,AW DOES NOT AVPLY TO AN OWNER OF �
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� IICENSED CONTRACTORS DECLARATION �
� �HEqEBV�FFItiM UNDER PENALN OF PERJURY THAT 1 NA LICENSED UNDEFI PROVISIONS OF CHAPTER �i �
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� IICENSE CLAS `I�LW K CLIC NO. � II /
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� DATE O 0 CONTfiACTOR�OV �/T�,C
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0 �IHAVEANDWILLMAINTAINACERTIFICA7EOFCONSENTTOSELFINSUREFORWORKERS' _
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Q �7000F THE LABOR CODE,FORTHE PEHFOqMANCE OF THE WORK WR WHICH THIS PEPMIT 15 CONSTRUCTION
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y SUBJECTTOTHEWORKERS'GOMPENSATIONPROVISIONSOFSECTION37ooOFTHELABOR }
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� DOLURS(5100,DOO�,IN ADDITIONTOTHE COST OF COMPENSATION,DAMAGESAS PROVIOED FOR IN ENERGY PERMIT
� SECTION37aeOFTHELABORCODE,INTEREST,ANDATTORNEI"SFEES RETENTIONFEE.
d CONSTRUCTION LENDING AGENGY PRE-ALT FEE:
� 1 HEREBYAFFIRM UNDER PENAL7V OF PENURV THA7THEHE 13 A CONSTAUCTION LENOING PGENCY
d FORTHEPERFONMANCEOFIHEWORKFORWHIGMTY113PERMIT19159UED(SEC30B�.CIVC).
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� I AGqEE TO CAMPLV WITH AI.L CITY AN�COUNTV ORDINANCESAND STATE UWS RELATMG TO BUILDING W �•
CONSTRUCTIOM,PND HEREBY AUTHORIZE REPRESENTA7IVES OF THIS CIX/NTYTO ENTEA UPON THE
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C
PRESS FIRMLY
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
ION
BUILDING PERMIT APPLICAl
JOBSITE
ADDRESS ill'702 1,-,Z eie 5 I AZ
APN LOT TACT
OWNEF-1-7cc hi-FtSa—
ADDRESS 71 , ,,,ST 4 r
CITY) eik i, ' ZIP WT4C-TE"J71,4-7. 7
APPLICANT/1.'d 4 Titrmeit - TEL 6Z criS.214,5
CONTRACTORI
ADDRESS .47....P.S/WOVP4M11771-ir,
CITY 1 I ZIP 026_45TE gr- '. •,
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
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 11-IE 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 FORA PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500))
DI,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 THE BUILDING OR IMPROVEMENT IS SOW 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).
CI,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 WITHA 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 DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE SIN FULL FORCE AND EFFECT.
LICENSE CLASk cro a6 f-qe-Lic N0. 7Si
EW/rhI
DATE $ o d% CONTRACTOR Jih 4 7it f Ter
WORKERS'COMPENSATION DECLARATION
D
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS t
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
,>e`
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED,MY WORKERS'COMPENSATION INSUVNCE CARRIER AND POLICY NUMBER ARE.
CARRIER 57-47-e. Fe-'-
POLICY NUMBER 2,_7..4 0(!::'—.-X)O1)OLS-
I- (11-95 SECTION NEH)NOT BE COMPLETED OF'RE PERMIT IS FOR ONE HUNDRED DOLLARS(5100)OR LESS).
I I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I
i SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
j ,r-WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT III SHOULD BECOME
. SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
COD . I FORTHWITH COMPLY WI THOSE PROVISIONS
S
)
VIIA.42-65 6 L irdali
DATE- APPLICANI ,iri
I
i WARNING. FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
- SURJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP To ONE HUNDRED THOUSAND
DOLLARS($100.000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
; SECTION 3709 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES
3 CONSTRUCTION LENDING AGENCY
5
C 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).
3
LENDER'S NAME
.C.
- LENDER'S ADDRESS
9
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT
LI 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
e. ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES
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CI PER NAME(PRINT)
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DATE
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