HomeMy WebLinkAbout14896 (438)h-
J� CITY OF DIAMOND BAR
EXPIRED
DEPARTMENT OF COMMUNITY 8t DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190 J U L 3 12092
(909) 860-3195 Fax (909) 861-3117
WELDING PERMIT APPLICATION
JOBSITE
ADDRESS 1-315 Lt1Njs9W6VP LN
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OWNER _N0H1,A��T—�
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DESIGNERA
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CITY ��_ ZIP TEL
OWNER -BUILDER DECLARATION
I HEREBY AFFBY UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEG IO
7031.5 BUSINESS AND PROFESSIONS CODE: ANYCITY OR
COUIRYWHICH REOURESA PERMrTTO OONSTRUCTALTER IMPROVE, DEMOLISH, OR REPAIRANY STRUG
TURF PRION 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 LL
CENSE UW (CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PRO.
FESSIONS CODE) ORTHAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TDN. ANY VIOLATION OF SECTION 7071.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
ACIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS 19500).):
O L AS OWNEROFTHE PROPERTY. OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK, AND THE STRUCTURE IS NOT MENDED OR OFFERED FOR SALE (SEC. 7041, BUST,
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BURRS OR IMPROVES THEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THRDUGM MS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF.
THE
BUILDING OR IMPROVEMENT IS SOLD W MM ONE YEAR OF COMPLE-
TION. THE OWNER4NIDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
D LAS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 704, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS U•
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BULDS OR IMPROVES THEREON, AND
WHO CONTRACTS FOR SUCH PROJECTS WITHA CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC•-
TORS UCENSE LAW}
O 1 AM EXEMPT UNDER SEG B. i P.C. FOR THIS REASON
t
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER
e (COMMENCING WITH SECTION 7000) OF Dr%q= .30F THE BUSINESS AND PROFESSIONS CODE, AND
E IS N ML FORCE AND EFFECT. J/�
CUSS LIC. NO. � / 1i C) L O
A 1� mZ CONTRACTOR tt•B•DL�.✓CGh:LFEC.
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WORKERS' COMPENSATION DECLARATION
I HEREBY AFFIRM IUIYIER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
_I HAVE AND W LL MAWTAN A CERTIFICATE OF CONSENT TO SELFaNSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BY SECTION 37o00F THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WMCH TMS PERMIT IS ISSUED. .
�I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE, AS REWIRED SYSECTCN
3700 OFTHE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
GSUED. MYWORKERT COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE.
E C�1 .11
CARRIER K..�t&ewQOY\1 N7iTTITA]bL.� IA)41Ce
POLICY NUMBER I�O���
L (T1t5SEC(1CNNE®NOTDECgpl£TEDOFTLEPER,RSFCRCNEMR[ORE WIARS(SIOD)ORIESSi
I 1 CERTIFY THAT LATHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I
3� SHALL NOTEMPLOY ANY PERSON N ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS' COMPENSATION LAWS OF CALIFORNIA, AND AGREE THAT IF 151NOULD BECOME
SUEJECTTO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 7700 OF THE LABOR
CODE, I SHALL FORTHwRH COMPLY VAIN THOSE PROVISIONS.
7 OAT y APPLICANT -RDe e—ctiJ (A✓C.
iWARNING,- FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALLBE
SUBJECTAN EMPLOYER TO CFUMNAL PENALTIES AND CIVIL FRES UP TO ONE HUNDRED THOUSAND
DOLLARS (3100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
J SECTION 3705 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
J CONSTRUCTION LENDING AGENCY
I HERESY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FORTHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3007, CN. C.I.
—
LENDER'S NAME
LENDER'S ADDRESS
CU (CERTIFY THAT(HAVE READ THIS APPLICATION =STATE THATTHEABOVE -ELINFORMATION T CORRECT.
L I AGREE TO COMPLY WITH ALL CRY AND COUNTY ORDNANCESAND STATE LAWS RELATING TO BUILDING
,CONSTRUCTION. AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE•MENT)ONED PROPERTY FOR INSPECTION PURPOSES.
PERMITTEE NAM (PRINT)
4h)1-1160
A SIGNATURE OF PEAMITIEE DATE
PRESS
FIRMLY
APPLICATION PERmrr
VO NUMBER— #�—
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ❑
REAR ❑
SIDEISIDE STREET RW ❑
SIDE ❑
PROPOSED USE
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NO. DWEL NO. NO.
UNITS STORIES BEDROOMS _
DESCRIPTION SO. FT. FACTOR PSF ADJ.AREANALUATION
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Valuation ADJ.AREA
OUANTITY DE CRIPTION FEE
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ELECTRIC
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ISSUANCE \
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ENERGY P/C P
ENERGY PERMIT
RETENTION FEE:
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TOTAL FEES LL 3 W 53
COMMENTS0 / l " _ L
RECPT. NO.
PAID BY VALIDATION
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