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Home My WebLink AboutBLDG-1276-2023 ApplicationBuilding & Safety Division Construction Permit Application u I Community Development T 805.781.7180 919 Palm Street, San Luis Obispo, CA 93401-3216 F 805.781,7182 #1 IDENTIFY YOUR BUILDING PROJECT Property Address �'IL'i �G�� (��'l0. r 12i . 5 L tJ Assessor's Parcel #0 S - Sit I - 001 Property Owner: S L pb (A_ Phone: Owner's Mailing Address:_ Sec ❑Licensed Design Professional In Responsible Charge or ErNon-Licensed Designer (when allowed by statutes): Name: G AV%ylc&GQ C.OY, Zn h c . License No. Address: 1560 Srx.t�dc, K k+^ C4 g3465 Phone: WS"Ll'-?L4-'a33�� Description of work: Dwelling Units: I Occupancy Group: K' ( _ Const TypeV Fire SprinklersALQ Project Value $ YC 00Q Floor Area (Sq. Ft): Living ;? 53 S_r Garage Deck _ Other Permit Types Required: Building Mechanical ®Electrical ®Plumbing []Grading-C.Y []Demolition Select Plan Check Consultant: ❑CCC ❑WILLDAN []BUREAU VERITAS 2 WENIIPY WHU WILL PEKFUKM THE WUKK (Seiect ano Complete elmerza orzo) Ma -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. Contractor Name: rl Cov%,,�k,%W'hoy) � n . License Class 6 License No. 1-1-6Vy F]2b-OWNER-13UILDER'SDVCLARATION 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. Anv 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 hiti)://www.leoinfo.ca.aov/calaw,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 rrnptoyer 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 provided for by Section 3700 of the Labor Code, for the 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 ch this permit is issued. My workers' compensation insurance carrier and policy number are: CarrierLA.;R ?)eoe,1fA-4. Policy Nolm W(.,0:1Exi5iratioonDate Phone 7, I Ci ❑ I certify that, In the performallite of the work for which this permit Is Issued, 1 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. 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 I v I L _ #4 DECLARATION BY CONSTRUCTION PERMIT APPLICANT By my, sqjnaftire below. I certify each of the following: I am a California licensed contractor or❑the property owner' or❑authorized to act on the property owner's behalf". I have ead 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 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 thl-icensed Contractor or the Property Owner as the permit holder of record who will be responsible and liable for the construction. ??lttY""---"' P n I�, Print Namely )' IhQ��Y\. _ Signature � Date �-(• 1223 "requires separate verification form ""requires separate authorization form APPLICATION # —1 Revised 2014