HomeMy WebLinkAbout11351 Los Osos Valley Road Building ApplicationBuilding & Safety Division
Community Development
919 Palm Street, San Luis Obispo, CA 93401-3218
#1 IDENTIFY YOUR BUILDING PROJECT
Property Address
Property Owner:
Uwner's mailing Aooress:
❑Licensed Design Professional In Responsible Charge or
Name: LWIY11-LI
Address:
Description of work: 611
Occupancy Group:
Floor Area (Sq. Ft): Living
Const Type
Construction Permit Application
T 805.781.7180
F 805.781.7182
Parcel #
one: (�� 543��1�{5
❑Non -Licensed Designer (when allowed by statutes):
�C License No. (oT 3ozz
Phone: 54I • . gQ, g
A wal f Dwelling Units:
Fire Sprinklers Project Value $ ItIODO
Garage Deck Other
Permit Types Required: [Rguilding ❑Mechanical []Electrical ❑Plumbing ❑Grading-C.Y ❑Demolition
Select Plan Check Consultant: ❑CCC ❑WILLDAN ❑BUREAU VERITAS
P2 ,IDENTIFY WHO WILL PERFORM THE WORK (Select and Complete either 2a or 2b)
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 7 0 of Division 3,91' the Business and Professions Code, and my license is in full force and effect.
Contractor Name 1n& 1 U ' iii L11 icense Class License No.
[:]2b—OWNER-BUILDER'SOW RATIONI 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.
An violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than fiv hundred dollars ($500).):
bl, as owner of the property, or my employees with wages as their sole compensation, will do [-]all of orLjportions of the work, and the
structure is not intended or offered for sale. (Section 7044, Business and Professions Code: The Contractors' Slate 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
bas 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).
❑1 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 htto://www.leoinfb.ca.00v/calaw.html.
03 IDENTIFY WORKERS' COMPENSTATION COVERAGE AND LENDING AGENCY (Complete 3a and 3b)
WARNING: Failure to secure workerscompensation 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.
OMPENSATION-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.
�(jl 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:
Carrier Policy No Expiration Date Phone_
❑ I 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
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
04 DECLARATION BY CONSTRUCTION PERMIT APPLICANT
By my signature below, I certify each of the following:
I am California licensed contractor or❑the property owner' or❑authorized to act on the property owner's behalf".
I havAread 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 theLicensed Contractor or❑the Property Owner as the permit holder of record who will be
responsible lid liable for the construction.
Print Name iI r it1G` mw-tqukvl Signature tlr i Date
'requires separate verification form —requires separate authorization form APPLICATION # Revised 2014