PROJECT ADDRESS: *
PLEASE FILL IN THE SQUARE FOOTAGES OF AREAS THAT APPLY:
CHECK ALL THAT APPLY:
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9
(commencing with section 7000)
of Divison 3 of the Business and Professions Code, and my license is in full force and
OWNER BUILDER DECLARATION
I, as owner of the property ,am exclusively contracting with licensed contractor to
construct the project (Sec.7044,Business and Profession Code. The contactors License
Law does not apply to an owner of property who builds or improves thereon, and who
contracts for such projects with a contractor(s) licensed pursuant to the Contractors
License Law ),
I have and will maintain a certificate of consent to self-insure for workers
compensation, as provided by for section 3700 of the Labor code, for the performance of the
work for which this permit
I have and will maintain worker 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 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 just to the workers compensation provision
Section 3700 of the Labor Code, I shall forthwith comply with those provisions.
CONSTRUCTION LENDING AGENCY
I hereby affirm penalty of perjury that there is a construction lending agency for
of the work for which this permit is issued (Sec. 3097, Civ. C).
I certify that I have read this application and the state that the above information
I agree to comply with all city and country ordinances and state laws relating to
building construction,and hereby authorize representatives of this country to enter
the above mentioned property for inspection purposes.