HomeMy WebLinkAboutBLDG-2268-2023_application and signed permit.412 Building & Safety Division
Construction Permit Application
tt Community Development
T 805.781.7180
o
.... 919 Palm Street, San Luis Obispo, CA 93401-3218
F 805.781.7182
#1 IDENTIFY YOUR BUILDING PROJECT.-' 1 \G,%\ -
Property Address I � $-1 ', , Ccw in s , ann L-, L,
Assessor's Parcel # - -
t(
Property Owner: l'Lyl-a 1�Lt i
Phone: Kd S76 V*-`3Z() 2
Owner's Mailing Address:
❑Licensed Design Professional In Responsible Charge or
❑Non -Licensed Designer (when allowed by statutes):
Name:
License No.
Address:
Phone:
Description of work: _ � � YES Lek� ct/i u��� L� l t� l-�'r% I f
+� <
� r Dwelling Units:
Occupancy Group: Const Type
Fire Sprinklers Project Value $ t, /6 JU
Floor Area (Sq. Ft): Living Garage
Deck Other
Permit Types Required: ❑Building ❑Mechanical ❑Electrical []Plumbing []Grading-C.Y []Demolition
Select Plan Check Consultant: ❑CCC ❑WILLDAN ❑BUREAU VERITAS
#2 IDENTIFY WHO WILL PERFORM THE WORK (Select and Complete either 2a or2b)
❑ 2a - CALIFORNIA 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.
ootractor Name: License Class License No.
2b - OWNER -BUILDER'S DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for
' reason(s) indicated below by the checkmark(s) I 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
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.
An 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).):
nI, as owner of the property, or my employees with wages as their sole compensation, will do ❑all of or❑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 improved for the purpose of sale)
❑ I, as owner of the property, 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 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).
❑ I am exempt from licensure 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 law is available upon request or at littq:l/www.legrnfQ.ca.govicalaw.html.
#3 IDENTIFY WORKERS' COMPENSTATION COVERAGE AND LENDING AGENCY (Complete 3a and 3b)
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.
3a -WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a certificate of consent to self -insure for workers' compensation, issued by the Director of Industrial Relations
rovided 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
which this permit is issued. My workers' compensation insurance carrier and policy number are:
arrier_ _ _ _ Policy No Expiration Date_ _ _ Phone
1 certify that, in the performance of the work for which this permit is issued, 1 shall not employ any person in any manner so as to
come 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.
3b - CONSTRUCTION LENDING AGENCY DECLARATION 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 DECLARATION BY CONSTRUCTION PERMIT APPLICANT
By my signature below, I certify each of the fall wing:
I am ❑ a California licensed contractor or1tte property ownee or❑ authorized 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
laws relating to building construction. I authorize Le resentatives of this city or county to enter the above -identified property for inspection purposes.
This permit is to be issued in the narne of theLLlcensed Contractor orMjhe Property Owner as the ^rmit holder of record who will be
responsible and liable for the construction.
_ �� r II II
Print Name ,\ N a_t_�_ Signatures (; va ��`^ _ Oated ,L1, 23
"requires separate verification form "requires separate authorization fo # Revised 2014
APPLICATION
/ y�®
city of San lul S OBI Spo
Building & Safety Division • 919 Palm Street a San Luis Obispo, CA 93401 a (805) 781-7180 • (805) 781-7182 Fax
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
Dear Property Owner:
3G_ i - 2ZkD �- 2D23
Building Permit Application No. has beerl submitted in your name listing yourself as the builder of the property
improvements specified at 2 it C(2e
We are providing you with this Owrier-Builder Acknowledgment and Information Verification Form to make you aware of your
responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We will not issue a
building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our
official address indicated above. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior
approval of the permitting authority.
Ap DIRECTIONS: Read and initial each statement below to signify you understand or verify this information.
ATip
1 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder" building permit that erroneously
hes that the property owner is providing his or her own labor and material personally. I, as an Owner -Builder, may be held liable and subject to
serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's
insurance may not provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for
injuries to workers on my property.
I
(am',) 2. 1 understand building permits are not required to be signed by property owners unless they are responsible for the construction and are not hiring
cia ensed Contractor to assume this responsibility.
3 1 understand as an "Owner -Builder' I am the responsible party of record on the permit. I understand that I may protect myself from potential
ncial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own.
4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts.
IL 5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at
I t five hundred dollars ($500), including labor and materials, I may be considered an "employer" under state and federal law.
16. 1 understand if I am considered an "employer' understate and federal law, I must register with the state and federal government, withhold payroll
to _ s, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my
fa 're to abide by these laws may subject me to serious financial risk.
7, 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential structures cannot legally
b Id them with the Intent to offer them for sale, unless all work Is performed by licensed subcontractors and the number of structures does not exceed
four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor,
,1
� 8. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries
sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials.
9 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue Service, the United States
all Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I
may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.csib.ca.gov for more information about licensed
contractors.
10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party legally and
fi ncially responsible for proposed construction activity at the following project address:
11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and
r uirements that govern Owner -Builders as well as employers.
12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on this
ibrm Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the
Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy
agalnst unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that
individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner -Builder and wish to hire
Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation
insurance coverage.
Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the
agency responsible for issuing the permit. Note: A copy of the property owner's driver's license, form notarization, or other
verification acceptable to the agency is required to be presented when the permit is issued to verify the property owner's
signature.
IkMW Name of Property Owftr
.A
.'as*. w ` 219 - 2-;
city of san Luis osispo
Building $ Safety Division . 919 Palm Street • San Luis Obispo, CA 93401 • (805) 781-7180 • (805) 781-7182 Fax
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Note: This form shall be completed by the property owner only when designating an agent of the property owner for purposes related to a construction
permit for the Owner -Builder.
Project Location or Address:
Scope of Construction Project (or Description of Work):
Excluding the Owner's Acknowledgment and Verifi„atinn of lnfnrmetinn Pnrmr the execUtinn
of which I understand is my personal responsibility, I hereby authorize the following person(s)
to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner -
Builder Permit for my project.
Name of Authorized Agent:
Phone
Address of Authorized Agent:
I declare under penalty of perjury that I am the property owner for the address listed above
and I personally filled out the above information and certify its accuracy. Note: A copy of the
owner's driver's license, form notarization, or other verification acceptable to the agency is
required to be presented when the permit is issued to verify the property owner's signature.
Property Owner's Name (please print):
Property Owner's Signature:
Date: Building Application No.
CITY OF
BUILDING PERMIT
!;an WIS OBISPO Alt/Addition - Single Family
CALIFORNIA
BLDG-2268-2023
Building & Safety Division • 919 Palm Street • San Luis Obispo, CA 93401-3218 Issuance Date: 8/29/2023
Project Address: 1284 San Carlos Dr Assessor's Parcel Number: 004-773-007
Unit or Suite(s): Square Footage: 0.00
Project Description: DRYWALL GARAGE WALLS Legal Description:
Owner: JENEE HALL
Owner/Builder: JENEE HALL
Fire Sprinklers: Not Provided Stories 1_00 Code Year: 2022 Dwelling Units: Motel Rooms:
Census: Construction Type:
Occupancy:
Valuation
Group Type Sq. Ft Factor Valuation
Manual $1,000.00
Fees
Payments
Fee Name
Fee Amount
Date
Receipt #
Amount
Green Building Fee
$1.00
8/28/23
40,495-08-29-2023
$414.83
Supplemental Plan Check (Building) - BLDG
$133.70
Total Paid:
$414.83
IT Surcharge
$12.23
Supplemental Inspection (Building) - BLDG
$267.40
SMIP (Residential)
$0.50
Total Fees: $414.83
Plan Check Account Payment by Contact
Contact Name Account Name
Status
Total Credits Total Debits
Account Balance
Total Account Balance:
Balance Due:
$0.00
Legal Declarations
#2 IDENTIFY WHO WILL PERFORM THE WORK
2b — OWNER -BUILDER'S 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 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).):
1, as owner of the property, or my employees with wages as their sole compensation, will do all 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)
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 law is available upon request or athttp://www.leginfo.ca.gov/calaw.html.
#3 IDENTIFY WORKERS' COMPENSTATION COVERAGE AND LENDING AGENCY
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.
I certify that, in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as 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.
#4 DECLARATION BY CONSTRUCTION PERMIT APPLICANT
By my signature below, I certify each of the following:
I am the Property Owner.
;✓� i.J�-� • August 29, 2023
Signature 01 Contractor, Authorized Agent or Owner Date