HomeMy WebLinkAboutE2022-0669 - Permitsil;. do t3adSn, U DuAl i iaararas
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OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the reason(s) indicated below by the checkmark(s) I have placed next to the applicable items)
clion 7031.5, Business and Professions Code: Any city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior Io Its Issuance, also requires the applicant for
permit to file a signed slatomcnt that he or she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
lessions Code) or that he or she is exempt from licensure and the basis for the alleged. exemption. Any violation of Section 7031.5 by any applicant fora permit subjects the applicant to a civil penalty of
more than five hundred dollars ($500).
I, as owner of the property, or my employees with wages as their sole compensation, will do (_) all of or U portions of the vac k, and the structure is not intended or offered for sale (Section 7044,
;iness and Professions Code: The Contractors' State License Law does not apply to an owner of property who, through emplo ees' or personal effort, builds or improves the property, provided that the
rovements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion the Owner -Builder will have the burden of proving that it was not built or
roved for the purpose of sale). -
I, as owner of the property, am exclusively contracting with licensed Contractors to conslmcli'. the project (Section 7044, Bushss and Professions Code: The Contractors' State License Law does not
ly to an owner of property who bullds or improves thereon, and who contracts for the projects with a licensed Contractor PUISL ant to the Contractors' State License Law).
J I am exempt from licensure under the Contractors' State License Law for The following reason: , f, ,- _ - ..,......__. _.,.._.__ _m.. _.,
I y my signature below I acknowledge that, except for my personal residence in which I must have resided for at least one year prior to completion of the improvements covered by this permit, I cannot legs
ell a structure that. I have built as an owner -builder if it has not boon constructed in its entirety by licensed contractors- I understand that a copy of the applicable law, Section 7044 of the Business and
Irci ions Code, is available upon request when this application is submitted or at the following Web site: httpliww'w.feginfo.ca. ov/calaw.html,.
signature of Property Owner or Authorized Agent- _Date.
.ICENSED CONTRACTOR'S DECLARATION
hereby affirm. under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section W afjliy{r' gjl3 of the Business an essio • C din nse istCt; in full force
nd effect. License Class _ License No Dat GG ,T?; Confracior Si
COMPENSATION DECLARATION
IARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES
DST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES,
hereby affirm under penalty of perjury one of the following declarations:
I hav ,and will maintain o cerlifoste of consent to self -insure for workers' compensation, issued by the Director of Inc
r nce of the work for which this permit is issued. Policy No.
Kave and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the perfor
ys ce carrier and policy number area
,artier Policy Number
CIVIL FINES UP TO ONE HUNOREOTf19USAND DOLLARS ($100,000), IN AOonION TO THE
Relations as provided for by Section 3700 of the Labor Code, for
of the work for which this permit is issued. My workers'
Date
to of Agent I Phone ff
certify that, in the performance of the wor which this Is issued, I shall not employ any person in any manner so as o become subject to the workers' compensation laws of California, and agre
if I should become subject to the wor rs•' comp an provisions of Section 3700of the Labor Code, I shall forthwith corn, flywitti those provisions.
leture of ApplicantL �W
:LARATION RErARDOING, CON ON LENDING AGENCY
hereby affirm under penaIty`1gLP9TTFTthat there is a construction lending agency for the performance of the work for which this
onder's Name Lender's Address
ly any signature below, I Certify to each of the following:
I am the property owner or authorized to act on the property owner shelf.
I have read this application and the information I have provided' correct.
I agree to comply with all applicable city and county ordinances and s laws rig to building construction.
I authorize representatives of this city or ccunter the above -idle
t�i ,e property for inspection purposes.
or Aumorizec H Yrint rro erry uwner s or Aumoriz
DATE ' LA ON OF COMPLIANCE WITH CODE OF FEDERAL '', FOR OFFICE USE
e LATIONS PART 61 OF TITLE 40 AND AQMD RULE
1403
PERMIT CANCELLED
UE PA
PERMITEXTENDED
r._ 0AQMO
PERMITFINAL
_
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_ _
,J� CTASBESIDS NOTIFICATION 15 NOT APPLICABLE TO
CERTIFICATE OF
(
PROPOSED DEMOLITION
OCCUPANCYIS.iUED
i SIGNATURE:
is issued'. (Section 3097, Civil Code).
VI