HomeMy WebLinkAboutApplication BLDG-1885-2017 1020 RailroadI ; , city of son Luis ow spo CONSTRUCTION PERMIT APPLICATION
Building & Safety Division • 919 Palm Street ■ San Luis Obispo, CA 93401 ■ (805) 781-7180 • (805) 781-7182 Fax
#1 IDENTIFY YOUR BUILDING PROJECT
Property Address: 1020 Railroad Avenue Assessor's Parcel # 003 - 657 - 007
Property Owner: Maro Partnership Phone: (805) 431-2971
Owner's Mailing Address: 1020 Railroad Avenue, San Luis Obispo, CA 93401
❑Licensed Design Professional In Responsible Charge or ❑Non -Licensed Designer (when allowed by statutes):
Name: Verizon Wireless c/o Tectonic Engineering - Robert McCormick License No.
Address: 2855 Mitchell Drive, Bldg 3, Suite 227, Walnut Creek, CA 94598 Phone. (310) 547-7413
Description of work: Installation of a rooftop cell site Dwelling Units:
Occupancy Group: S-2, LOW HAZARD STORAGE Const Type V -B Fire Sprinklers Y Project Cost $ 151,000
Floor Area (Sq. Ft): Living
Garage Deck
Other 633
Permit Types Required: ❑✓ Building ❑r✓ Mechanical ❑✓ Electrical []Plumbing ❑Grading-C.Y ❑Demolition
02 IDENTIFY WHO WILL PERFORM THE WORK (Select and Complete either 2a or 2b)
0 2a — CALIFORNIA LICENSED CONTRACTOR'S DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 commencing withSection7000 of Division 3 of the Business and Professions Code, and my license is in full force and effect.
Contractor Name: i 1� �► f 4 [ y S l ��+Lj t5 {L4 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
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 five hundred dollars ($500).):
] I, 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 hqg:flwww.leninfo.ce.gov/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
$100,000, in addition to the cost of compensation, damages as provided for in section 3706 of the labor code, interest, and attorney's fees.
a WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to self -insure for workers' compensation, issued by the Director of Industrial Relations
pro ' ad for by Section 3704 of the Labor Code, for the performance of the work for which this permit is issued. Policy No.
❑1 have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for
which this permit is issued. My workers' compensation insurance carrier and policy number are: i
YTC0�� Policy p' 1—�1��� Phone 10 43f'� 3S
Carrier Pali No°i flo3�1 2 �I$_ Expiration Date ) Y5
❑ 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.
3b - CONSTRUCTION LENDING AL:SNCY 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 am❑a California licensed contractor or❑the property owner*or❑✓ author zed to act on the property owner's behalf".
I have read this permit application and the information I have provided is correct. Voree to comply with applicable city and county ordinances and state
laws relating to building construction. I authorize re resentatives of this city or y to enter the above -identified property for inspection purposes.
This p permit is to be issued in the name of the✓Licensed Contractor or h Ptro e Owner as the per�lder of record who will be
responsible and liable for the construction. r+
Print Name Robert McCormick
ignature
09/29/17
*requires separate verification form **requires separate authorization form .. I
C nT 5 t V i 0 N S APPLICATION # /�� /��s—