HomeMy WebLinkAboutB0901387l ~, ~ G~ l/~J ~ ~_I~-Y~ ~' J 1-~ n A `l~- ~~.~-is n ~,li (7 f'7 U - ~J~ - ~J ~/ _nivY)'
~`i~~~~Na7 ~1n~t NO.
1. CALIFORNIA LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (krommencing with Section 7000) of
Division 3 of the Business and Professions Code, and my license is in full force and effect.
License Class C ~ U License No. / '7 C7
Contractor Signature Date ! ~ a~
2. ONMER-BUILD S DECLARATION
I hereby affirm urMer penalty of perjury that I am exempt from the Contractors' State License Law for the reason(s) indicated below
by the cradcmark(s) 1 have placed next to 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 pernit to file a signed staberrerrt That he or she is licensed pursuant to the provisions of the Contractors' State
License Law (Chapter 9 (commenting with Section 7000) of Division 3 of the Business and Professions Code) or chat 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 ddlars (x500).):
(_,) I, as owner of the property, or my employees with wages as heir sok compensation, will do U all of or U portions of
the work, and the structure is not irrterxded ar 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 k was not built or improved for the purpose of
sale. ).
U I, as owner afi the property, am exclushrety contracting with licensed Contraceors to construct the project (Section
7044, Busrc>ess and Professions Code: The Contractors' State License Law does not apply to an owner of Properly who builds or
improves thereon, and who contracts for the projects with a licensed Contractor pursuant to the Contractors' State License Law.).
U I am exempt from Ilcensure under the Contractors' State License Law for the following Wesson:
By my signature below 1 acknowledge that, except for my personal residence in which 1 must have resided for at least one year
prior to completion of the improvements covered by his permit, I cannot legally sell a stricture that I have buiR 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 Professions Code, is available upon request when this application is submitted or at the following Web site:
htt~:/Jwww leyinfo_ca_~ov/calaw_h_tml.
Property Owner or Authorized Agent (Print Name)
Signature Date
3. WORKERS' COMPENSATION DECLARATION
WARN/N(i: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN
EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (5100,000), IN
ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,
INTEREST, AND ATTORNEY'S FEES. -
I hereby affirm under penalty of perjury one of the following declarations:
(, 1 have and will maintain a certifik~te of consent to setfansure for workers' compensation, issued by the Director of
Industrial Relations as provided for by Sek~ion 3700 of the Labor Code, for the performance of ifre worts for which this permit is
issued oliCy No.
I have and will maintain workers' com on Insurance as wired
pensaH req by Sectan 3700 of the Labor Cade, for the
performance of the for idt this pem-it is issued. My workers' compensation insurance carrier a ~ number are:
Cartier S% ~e ~f- y~ Policy No ~~3 - t~`~ ry 7l' Expiration Date r
Name of Agent Phone No.
(, 1 certfy- thst, in performance of the work for which this permit is issued, I shall not employ any person in any
manner so as to subje workkers' compensation laws of California, and agree that, if I should become subject
to the workers' compens rovisi ion 3700 of the Labor Code, 1 shall forthwitJh compy(-with those provisions.
Signature of Applicant: Date: cam/ / l //Cj
4. DECLARATK) RE ARDING CONSTRUCTION LENDING AGENCY
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 (Section 3097, Civil Code).
LendePs Name Lender's Address:
3. CAL-0SHA AND HAZARDOUS MATERIAL DECLARATION
wfl there be any excavation five (5) or more feet in depth into which a person will be required to descend? L) Yes LJ No
Will the building or tenant space be used to store or display any hazardous materials? U Yes (~ No
B. Declaration of Compliance and Authorization for Entry: By my signature below, I certify b each of the following:
I am the property owner or I have been authorized to act on the property owner's behalf.
I have read this construction permit application and the information 1 have provided is true and coned.
I agree to comply with all applicable city and county ordinances an fate 1 "ng to building construction.
I authorize repn>sentatives of the city of San Bernardino to enter a ro
p party for inspection purpose .
Signature of Licensed Contractor, Properly Owner` or Authorized Ag Date ~ ~ ~
` Requires compbbd "Notice to Property t>Mrrrer" Form " R I ftra owner to canpbbe "Authorizatlon of
Agent" Form