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PERMIT NO:
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ON-LINE PERMIT
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INSPECTION REQUEST LINE
(408) 555-1216
OR
SCHEDULE EXISTING INSPECTION
ON-LINE
www.crw.com
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PERMIT TYPE
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PERMIT SUB-TYPE
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JOB VALUE
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APN
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DESCRIPTION
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APPLIED DATE
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APPROVED DATE
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ISSUED DATE
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PERMIT INFORMATION
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FEE SUMMARY
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NOTE: This job copy of this permit shall be kept on the job
site to make the required entries thereon. The permit will expire if work is not
started in 180 days, is abandoned, or does not receive an inspection for more than
180 days. Additional fees will be collected to renew expired permits. This is a
Building Permit when properly filled out, signed and validated, and is not transferable.
Construction Hour: Construction is limited to the hours of 7:00am to 7:00pm each
day. No work shall be performed on certain holidays (MMC V-213-3(b)).
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LICENSED CONTRACTORS DECLARATION
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I hereby affirm 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.
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License No:
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Expiration Date:
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Contractor:
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OWNER-BUILDER DECLARATION
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I hereby affirm under penalty of perjury that I am exempt from
the contractors license Law for the following reason (Sec. 7031.5, Business and
Professions Code: Any city or county which requires a permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also requires
the applicant for such permit to file a signed statement that he or she is licensed
pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Pofessions Code) or that he
or she is exempt therefrom and the basis for the alleged exemption. Any violation
of Section 7031.5 by an 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 the work, and the structure is not intended or offered for sale (Sec. 7044,
Business and Professions Code: The Contractors License Law does not apply to an
owner or property who builds or improves thereon, and who does such work himself
or herself or through his or her own employees, provided
that such 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 burdon of proving that he or she did not build or improve for the purpose of
sale.)
_____ I, as owner of the property, am exclusively contracting with licensed contractors
to construct the project (Sec. 7044, Business and Professions Code: The Contractors
License Law does not apply to an owner or Property who builds or improves thereon,
and who contracts for such projects with a contractor(s) licensed pursuant to the
Contractors License Law.)
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I am exempt under Sec. _____________________
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B.P.C. for this reason _____________
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DATE ____________
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OWNER ______________________
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WORKERS COMPENSATION DECLARATION
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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, as provided for by Section 3700 of the Labor Code, for the performance
of the permit is ussued.
_____ 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:
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Carrier/Policy No: ________________________________________________
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(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 number so as to become subject to the workers'
compensation laws or 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.
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DATE _________________
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APPLICANT: ______________________________
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WARNING: FAILURE TO SECURE WORKERS' 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
FEES.
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CONSTRUCTION LENDING AGENCY
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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 (Sec.
3097, Civ. C.).
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DATE _________________
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APPLICANT: ______________________________
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* I certify that I have read this application and state that
the above information is correct. I agree to comply with all city ordinances and
state laws relating to building construction, and hereby authorize representatives
of this city to enter upon the above-mentioned property for inspection purposes.
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SIGNATURE OF APPLICANT OR AGENT ;_________________________________
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DATE ____________
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Permit Finaled Date: __________
Inspector Name: __________________ Signature: __________________
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