HomeMy WebLinkAbout11329 LOS OSOS VALLEY Building Application• Building & Safety Division Construction Permit Application
Community Development
919 Palm Street, San Luis Obispo, CA 93401-3218
#1 IDENTIFY YOUR BUILDING PROJECT
T 805.781 .7180
F 805.781 .7182
Property Address: 11329 Los Osos Valley Road Assessor's Parcel #~-...22..!_-~
Property Owner: _c_L_ln_ve_s_to_rs_LL_c ___________________ Phone: (559) 733-4328
Owner's Mailing Address: 3130 W . Main Street, Suite A -Visalia, California 93291
Oucensed Design Professional In Responsible Charge or □Non-Licensed Designer (when allowed by statutes):
Name: ________________________________ License No. ______ _
Address: Phone: ________ _
Description of work: Demo stairs/landing -fix structural issues & replace stairs Dwelling Units: __
Occupancy Group: __________ Const Type ___ Fire Sprinklers __ Project Value $ 7 ,500.00
Floor Area (Sq. Ft): Living _______ Garage ______ Deck _____ Other _______ _
Permit Types Required: 0Building □Mechanical □Electrical □Plumbing []Grading-C.Y __ □Demolition
Select Plan Check Consultant: 0CCC QwlLLDAN □BUREAU VERITAS
IDENTIFY WHO WILL PERFORM THE WORK (Select and Complete either 2a or 2b)
✓ 2 -CALIFORNIA LICENSED CONTRACTOR'S DECL Tl N I hereby affinn 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: Greg Moore Construction, Inc. License Class B C13 License No. 643022
0 2b -OWNER-BUILDER'S DECLARATION I hereby affinn under penalty of perjury that I am exempt from the Contractors•-s-tat_e _u_·ce_n_s_e_L_a_w_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 pennlt 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 (oommencing 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.
~elation of Section 7031 .5 by any applicant for a pennit subjects the applicant to a civil penalty of not more than fi~hundred dollars ($500).):
LJ I, as Qwner of the property, or my employees with wages as their sole compensation, will do Qall 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, 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
JL.was 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). 0 I 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 at http://wwwJegJnfo.ca.goy/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 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
~
vided for by Section 3700 of the Labor Code, for the performance of the work for which this pennit is issued . Policy No. B C1 3
I have and will mai ntain workers' compensation insurance, as requ ired 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 pol icy number are:
Carrier State Fund Policy No 9146707-16 Expiration Date 10/01 /2017 Phone (888) 782-8338
0 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 worl<ers' compensation
provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions.
3b • CONSTRUCTION LENDJNG AGENCY DECLARATION I hereby affinn under penalty of perjury that there is a construction lending agency for the
perfonnance of the work for which this pennit 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 am[l]a Callfomla licensed contractor or0the property owner* orOauthorlzed to act on the property owner's behalf"*.
I have read this pennlt application and the infonnation I have provided Is correct. I agree to comply with applicable city and county ordinances and state
laws relating to building construction. I authorize ,!!Wresentatives of this city or unty to enter the above-identified property for Inspection purposes.
Thi• permit Is to be Issued In the name of theLJLlcensed Contractor or the Prope,ty Owner as the permit holder of record who will be
responslble and liable for the construction.
Print Name f)a me/(&. M.6n:i15Cil1)e41 Signature -""'-' ,...'""' _..:... _=_""':_ __ ...... _~=-c.:_::.:~:~~..,.~.:-_-_ -___ ,_~ /rs)J 7
*requires separate verification form **requires separate authorization form .._ ______ :::.:~t:_,_=--'---' Revised 2014
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