HomeMy WebLinkAboutBLDG-2680-2023-PERMIT APPLICATION�. iwUli %A LAwIPUll �� riiUL _ : �UJr%i9t38}
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- .... 9 f 9 ?aim Street:: Sail _;is Obispo, CA 9340^.-3218 F 805-781.7182
01 10EN r1FY Y0LIP BUILDING PROJECT OWner elna"' : 0-60' Y raoe L•�@zt,, C. col -
Property Address'
Property Owner: 4-1
Owner's Mailing Address:
.: zrzz ar's Parcail 4' ( - 01A -V
Phone:
[Licensed Design Professional In Responsible Charge or ONon-Licensed Designer (when allowed by statutes):
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Flame: I /' �Lt)f /' l� F— tint �f�. ��•� �, License No.
Address: (� I > �i"' S ��,`-t-��^ r� �' �, `; L�U Phone:
Description of work: (r,F� _ .-� Cze b�iT%.�( Dwelling Units:
Occupancy Group: _Coast Type Fire Sprinklers Project Value $ IPA CX�e
Floor Area (Sq. Ft): Living
Garage
Deck Other
Permit Types Required: ❑Building ❑Mechanical ❑Electrical ❑Plumbing OGrading-C.Y ❑Demolition
Select Plan Check Consultant: ❑CCC E]WILLDAN ❑BUREAU VERITAS
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I_I 2a — CALIFORIYIA LICENSED CONTRACTOR'S DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 commencing with Section 7000 of Division 3 of the Business and Professions Code, and my license is in full force and effect.
C ntractor Name: License Class License No.
— Ow 1FR.BW!_Cc'S DELL a?.3 i IO;1 I hereby affirm under penalty of perjury that I am exempt from the Contractors' Slate License Law for
the reasons) indicated below by the checkmarl<(s) have placed next to the applicable items) (Section 7031.5, Business and Professions Code: Any
city or county that requires a permit to constn:ct, 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 Divlsion 3 of the Business and Professions Code) or that he or she is exempt from licensure and the basis for the alleged exemption.
Anv vi tton of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not mogirKlan rive hundred dollars ($500).):
1, as owner of the proparty, or my employees with wages as their sole compensation, wilf do Eall of oroportions 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 improved for the purpose of sale)
I, as owner of the property, am exclu3ively contracting with licensed Contractors to construct the project (Section 7044, Business and
Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for
the projects with a licensed Contractor pursuant to the Contractors' State License Law).
F-1I am exempt from Iicansure under the Contractors' State License Law for the following reason:
By 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 legally sell a structure that I 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 taw is available upon request or at !�z- r s -, •;jr,:", %;, r �z,a•
$3 0ENfi;= r 6ORKERS' COMP'ENSTAT ON COVERAGE AND LENDING AGENCY (Complete 3a sad 3bi
WARNING: Failure to secure workers' compensation coverage is unlawful, and shall subject an employer to criminal penalties and civil fines up to
$100,000 in addition to the cost of compensation, damages as provided for in section 3706 of the labor code, interest, and attorney's fees
3,? •'d�!OPKERS' COMPEdSATiON DECI-AR.ATIO, I I hereby affirm under penalty of perjury one of the following declarations:
F�I have and will maintain a certificate of consent to Self -insure r`or workers' compensation, issued by the Director of Industrial Relations
provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Policy No.
I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for
w ich this permit is issued. My workers' compensation insurance carrier and policy number are:
Ca! er Policy No _ Expiration Date Phone
2'T certif, t , that, in the performance of the work for which this permit is issuedshall not employ any person Many manner so az to
become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation
provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions.
31) - CONSTRUCTION LENDING AGENCY DEC L 4R ATION 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) as follows:
Lender's Name and Address
#4 7ECLARAT?ON BY CONSTRUCTION PERMIT APPLICANT
By my signature below, I certify each of the foilawi g:
I amQa California licensed contractor or the property owner" orOauthorized to act on the property owner's behalf".
I have read this permit application and the information I have provided is correct. I agree to comply with applicable city and county ordinances and state
taws relating to building construction. I authorize re resentatives of this city or county to enter the above -identified property For inspection purposes.
This permit is to be issued in the name of theLLicensed Contractor or[:]the Property Owner as the permit holder of record who will be
responsible and liable for the construction.
Print Name Ny:rim-) 11 —y t { Signature Date
*requires separate verification form "*requires separate authorization form � APPLICATION # Revised 2014
Email:
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