HomeMy WebLinkAbout671 HOWARD - Building Application• Building & Safety Division Construction Permit Application
Community Development
919 Palm Street, San Luis Ob ispo , CA 93401-3218
#1 IDENTIFY YOUR BUILDING PROJECT
Property Address : ~ ~ '1 Hew W ~ s+ fee, f
Property Owner: H•wo,rJ e . Trtw
T 805.781 .7180
F 805.781.7182
Assessor's Parcel# OOl -JR-01"(
Phone :
Owner's Mailing Address: p. C,. Box Is s (o t s l. 0 CA 13,., 0~
Olicensed • • ponsible Charge or ~on-Licensed Designer (when allowed by statutes):
License No. __ N __ /. ... RJ. ___ _ Name:
Address : Phone:(~) 64f ~ ~~~
Description of work: _...11'C.......;:e..:.a1rncrl-eL...:...:::.1...-illli,0 --b,-...;Pst:b~~.:.V:~@-Y'-.....:... ______________ Dwelling Units:
Fire Sprinklers __ Project Value $ ?tJ OD~ Occupancy Group: __________ Const Type __ _
Floor Area (Sq. Ft): Living _______ Garage ______ Deck _____ Other _______ _
Permit Types Required : □Building □Mechanical □Electrical □Plumbing []Grading-C. Y __ □Demolition
Select Plan Check Consultant: □CCC 0WILLDAN □BUREAU VERITAS
IDENTIFY WHO WILL PERFORM THE WORK (Select and Complete either 2a or 2b)
a -ALIFORNI I N DC NTRA TOR' DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of
hapter 9 commencing with Section 7000 of Division 3 of the Business and Professions Code, and my license is in full force and effect.
( t • \'IC.• License Class 8 C 13 License No. C, 'i '3 01.?. D .&.=J2W?J.l;B:lllu.l.lJl!iEtl:m~.Af.~®!{ I hereby Irm under penalty of pe~ury 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 Divisio n 3 of the Business and Professions Code) or that he or she is exempt from licensure and the basis for the alleged exemption.
A~iolation of Section 7031 .5 by any applicant for a permit subjects the applicant to a civil penally of not more than fi~hundred dollars ($500).):
LJI, as owner of the property, or my employees with wages as their sole compensation, will do Dan of orLJportlons 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, bu ilds 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
~as not built or improved for the purpose of sale) .
LJ 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).
D1 am exempt from llcensure 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 al http://www .leginfo.ca.gov/cataw.html.
#3 IDENTIFY WORKERS' COMPENSTATION COVERAGE AND LENDING AGENCY (Complete 3a and 3b)
WARNING: Failure lo 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 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
l vided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Policy No.
have and wlll 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:
Carrier Sf Aft fc,V\J Policy No '\lli,f,'101•1~ Expiration Date (0--1• (1 Phone ___ _ DI 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.
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 following:
I amOa California licensed contractor or0the 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 lo comply with applicable city and county ordinances and state
laws relating to building construction . I authorize ~resentalives of this city oµq>unty to enter the above-identified property for inspection purposes.
This permit is to be issued in the name of theLJ Licensed Contractor orLJthe Property Owner as the permit holder of record who will be
responsible and liable for the construct on.
Print Name --,~-=,L,,-..w::.1L.L-+,,t..=J..LL..1.1L.µ...:,"------·Signature U----Date (o • ~-17
**requires separate authorization to{[ APPLICATION ~(/J,,-0 !J-</ I Revised 2014
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