HomeMy WebLinkAbout17913 (224) CITY OF DIAMOND BAR
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p� ' OWNEA-BUILDER DECLARATION I
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p I HEREBV AFFIRM UNDER PENALTV OF PERIURV THAT I AM E%EMPT FiiOM 7HE CONTRACTOFiS LI- G3f8(JB/CBfPOh
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Z TURE,PRIOR TO ITS ISSUANCE,ALSO REOUIRES THE APPLICANT FOR SUCM PEHMIT TO FILE A SIGNED w Patio/Deck
W STATEMENT THAT HE OR SHE IS LICENSED PURSUAN7 TO THE PROVISIONS OF THE CONTRACTORS LI� w
� CENSE LAW(CHAPTER B(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO� � POOVSPB
0 FESSIONSCODE)ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFOR7HEALLEGEDEXEMP- (�
V TION.ANV VIOUTION OF SECTION 7031.5 BV ANV APPLICANT FOR A PERMIT SU&IECTS THE APPLICANT TO Z Re-Roaf
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(5500J.):
Z ❑I,ASOWNEAOFTHEPROPERTY,ORMYEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSA710N, � CORIfflOfClal -
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7044,BU51- J
� NE55 AND PROFESSIONS CODE:7HE CANTRAC70RS LICENSE LAW DOES NOT APPLV 70 AN OWNER OF �
PROPER7Y NhiO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
' Q THROUGH HIS OR HER ONRJ EMPLOVEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR m
w OFFEREDFORSALE.IF,HOWEVER,THEBUILDINGOHIMPROVEMENTISSOIDWITHINONEYEAROFCOMPLE-
� TION,THE OWNER-BUILDEFi WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
Z IMPROVE FOR THE PURPOSE OF SALE). I
_ ❑I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WITH UCENSED CANTRACTORS
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� 70 CANSTfiUC7 THE PR0.IECT(SEC.70a�,BUSINESS AND PROFESSIONS CODE:THE CON7RAC70Fi5 LI� V21Ue�lOf1 ADJ.AREA �
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� WHOCON7RAC7SFOHSUCHPR0.JEC7SWITHACON7RAC70R(S)LICENSEDPURSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FEE I
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� ❑I AM EXEMPT UNDER SEC. B.d P.C.FOR THIS REASON Q
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� UCENSED CONTRACTORS DECLARATION W
� I HEREBV AFFIRM UNDER PENALTV OF PERJURV THAT I AM LICENSED UNDER PROVISIONS OF CHAP7ER � " \ Q �t' 1
d e(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CADE,AND � Z J v u
`X MY LICENSE IS M FULL FOflCE AND EFFECT. m .
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� WORKERS'COMPENSATION DECLAFATION ¢
� 1 HEREBV AFFIRM UNDER PENALTY OF PERIURV ONE OF THE FOLLOWING DECURATIONS: Z
� I HAVE AND WILL MAIN7AIN A CERTIFICATE OF CONSENT 70 SELF�INSURE FOR WORNERS' a
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CAMPENSATION,AS PROVIDED BY SECTION 37000F THE UBOR CODE,FORTHE PERFORMANCE w
Q OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. �
w �_I HAVEAND WILL MAINTAIN WORKERS'COMPENSA710N INSURANCE,AS REOUIRED BV SECTION
Q 37000F THE LABOR CODE.FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED.MV WORK S'C MPENSATIOKINSURANCE RflIER AND POLICV NUMBER ARE: CONSTRUCTION
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Z I CERTIFV THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL ���^_-+-��.
(.'} SHALL NOT EMPLOY ANV PERSON IN ANV MANNER SO AS TO BECOME SUBJECT TO THE _?� / -"�^'-�--
�/j WOFKERS'COMPENSATION lAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME INSPECTION FEE � �� � .%�� I� � i � �
= SU&IECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 700 0F THE LABOR � � � ,, � ' 1�
CADE,I SHALL F THWITH COMPLY WITH TH E PROVISIONS. ISSUANCE v
p DATE: � '1 APPLICANT. .L� SMIP i APR 9 9 ?nn�
J WARNING:FAILURE TO ECURE WORKERS'COMPENSATION COVERAGE IS U WFUL,AND SHALL BE ENERGY P/C �
� SUBJEC7ANEMPLOVE TOCRIMINALPENAL7IESANDCIVILFINESUPT00 HUNDREDTHOUSAND ENERGYPERMIT I�R�7'.
} DOLURS(S1o0.000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN �_���__ , � '
� SEC710N 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. FETENTION FEE: � -� -= --- I
� CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
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� 1 HEREBV AFFIRM UNDER PENALTV OF PERJURV THATTHERE IS ACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH 7HIS PERMIT IS ISSUED(SEC.3097,CIV.C.).
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� LENDER'S NAME
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� I CERTIFV THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
� I AGREE TO COMPLY WITN ALL CITY AND COUNTV OFDINANCES AND STATE LAWS RELATING TO BUILDING ��
� CONSTRUC710N,AND HEREBV AUTHORIZE REPRESENTATIVES OF 7HIS COUN7Y TO ENTER UPON 7HE
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