HomeMy WebLinkAboutPV2019-030 - PermitsOWNER -BUILDER DECLARATION I
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 So the applicable item(s)
(Section 7031.5, Business and Professions Code: Any city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for
the permit to file a signed statement 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
Professions 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 for a permit subjects the applicant to a civil penalty of
not 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 work, and the structure is not intended or offered for sale (Section 7044,
Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who, through employees' or personal effort, builds or improves the property, provided that the
improvements 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
im roved for the purpose of sale).
I, as owner GfIMproperty, am exclusively contracting with licensed Contractors to construct the project (Section 7044, Business and Professions Code: The Contractors' State License Law does not
apply to an ownerO property who builds or improves thereon, and who contracts for the projects with a licensed Contractor pursuant to the Contractors' State License Law),
I arfi�)xempffForp licensure under the Contractors' State License Law for the following reason: -
By my gignature betWi-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 legally
sell a structure that% have built as an owner -builder if it has not been constructed in its entirety by licensed contractors. I understand that a copy of the applicable law, Section 7044 of the Business and
Firofedslons Code, is available upon request when this application is submitted or at the following Web site:http://www.leginfo.ca.gov/calaw.htmi.
Sjfttdtg of PropgrlyrQMner or Authorized Agent Date
LICENSED COMTR&CTOR'S DECLARATION /
I hereby affirm and er ped alty of perjury that I am licensed under provisions of Chapter 9 (commencing with ction 7000) of Division 3 of the Business a d Profs s n ode, and my license is in full force
aatl elfeci.
L19epgCMass ' License No Date Contractor Signatur
V1OhKF:RS' COUB&1jSATION DECLARATION
wABNIyGFAILURE TO SECITRE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOY TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($700,000), IN ADDITION TO THE
COST OF OOMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
Ihere�iy affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a certificate of consent to self -insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Section 3700 of the Labor Code, for thf
performance of the work for which this permit is issued. Policy No.
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' compensatior
ounce carrier and policy number are:
rrier Policy Number Expiration Date
me of Agent Phone #
certify that, in the pelormance of the workwhich this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' laws of California, and agref
I, if I should become ubject to the workers' pensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions.
nature of Applicant Dat ellp Z,
CLARATION REGAIWING CONSTRU [ON LENDING AGENCY '
)reby affirm under p nalty of perjury t art is a construction lending agency for the performance of the work for which this permit is issued (Section 309/civil, Code)
Ider's Name Lender's Address
my signature below, I certify to each of the following:
I am the property owner or authorized to act on the property owner's behalf.
I have read this application and the information I have provided is correct.
I agree to comply with all applicable city and cc ty ordiEve-identified
d state laws relating to building construction.
I authorize representatives of this city or county o enter property for inspection purposes.nature of Property Owner or Authorized Agent Print Property Owner's or Authorized Agent's Name
ACTION DATE BY
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