Section 1 of 1 in this document

Building Permit Application

Please fill out all parts of the application completely - failure to do so will delay processing. Construction plans may be required for some projects. Please visit the Building Division Web Page for minimum plan submittal requirements.

PART I - PROPERTY INFORMATION

PART II - SCOPE OF WORK

PART III - APPLICANT INFORMATION (person completing application)

Relationship to Project

PART IV - PERMIT CONTACT INFORMATION (to receive Box.com emails/notifications)

PART V - BUILDING / PROJECT INFORMATION

Existing Building Area

Area of Construction

Type of Construction

Occupancy Group (Select All That Apply)

Residential Work

Type of Work Proposed Residential (Select At Least One)

Non-Residential Work

Type of Work Proposed Non-Residential (Select At Least One)

PART VII - CONTRACTOR INFORMATION

PART XIII - DECLARATIONS

LICENSED CONTRACTOR DECLARATION

I hereby affirm under penalty of perjury that I am licensed under provision of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Profession Code, and m license is in full force and effect.

Licensed Contractor

WORKER’S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations:

I 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:

Workers Compensation

I have and will maintain a certificate of consent to self-insure for workers’ compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.

Carrier

CERTIFICATE OF EXEMPTION FROM WORKER’S COMPENSATION DECLARATION This section need not be completed if the permit is for one hundred dollars ($100) or less

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.
WARNING: Failure to secure worker's compensation coverage is unlawful, and shall subject an employer to criminal penalties and civil fines up to one hundred thousand dollars ($100,000), in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fee

Certificate of Exemption from Workers Compensation

OWNER/BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor’s License Law for the following reason (Sec.7031.5 Business and Professions Code).

I, as owner of the property, building or improving structure thereon, or appurtenances thereto, will do the work myself or through my own
employees with wages as their sole compensation. None of the structures, with or without the appurtenances thereto, are intended or offered for sale (Sec. 7044(a), Business and Professions Code). NOTICE TO APPLICANT: In all actions brought in the Contractor's State License Law, proof of the sale or offering for sale of any structure by the owner-builder within one year after completion of same constitutes a rebuttable presumption affecting the burden of proof that such structure was undertaken for purposes of sale. Proof of the sale or offering for sale of five or more structures by the owner-builder within one year after completion generally constitutes a conclusive presumption that the structures were undertaken for purposes of sale (Sec. 7044(c)(3), Business and Professions Code).

Confirm Affirmation 1

I, as owner of the property, building or improving structures thereon, or appurtenances thereto, will contract with a contractor(s) or
subcontractor(s) licensed pursuant to the Contractors' State License Law to construct the project. I will not construct more than four (4) single- family residential structures which are intended or offered for sale within a calendar year, except that such limitation shall not apply if I contract with a general contractor for the construction (Sec. 7044(b), Business and Professions Code).

Confirm Affirmation 2

I am a homeowner improving my principal place of residence, or appurtenances thereto, and the following conditions exist: (1) the work will
be performed prior to sale, (2) I have resided in the residence for the twelve months prior to completion of the work, and (3) I have not used this exemption from the Contractor's State License Law on more than two structures more than once during any three-year period (Sec. 7044(c), Business and Professions Code).

Confirm Affirmation 3

I hereby affirm under penalty of perjury that the information I acknowledged on this form is true and correct to the best of my knowledge.

Confirm Affirmation 4