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H:\BUILDING\FORMS\_NEW FORMS\Application v: 6_8_23 CITY OF EL CERRITO I Community Development Department Building Division BUILDING PERMIT APPLICATION 10890 SAN PABLO AVE • EL CERRITO, CA • (510) 215-4360 Job Site Address: Description of Work includes (check which applies) PLUMBING ELECTRICAL MECHANICAL Valuation: TYPE OF PROJECT (Check which applies) CLASS OF WORK (Check which applies) RESIDENTIAL COMMERCIAL NEW CONSTRUCTION /ADU ACCESSORY STRUCTURE ADDITION-REPAIR/REPLACE-REMODEL/ALTERATION RE-ROOF________SQ.FT.* TEAR-OFF OVERLAY ELECTRICAL/PLUMBING/MECHANICAL DEMOLITION SPA/POOL SIGN SOLAR SITE WORK OTHER *Per ordinance 16.03.130, the City of El Cerrito requires all roof covering replacements that are more than 50 percent of the total roof area, to be a fire-retardant roof covering that is at least Class A. Does this work require any demolition? YES NO Property Owner Applicant (Check one) Property Owner Contractor Agent Design Professional Contractor (Check one) Licensed Contractor Owner-Builder TBD Contractors State License Number (required) Expiration Company City Business License 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 the City upon the above-mentioned property for inspection purposes. An application for a permit for any proposed work shall be deemed to have been abandoned 180 days after the date of filing, unless such application has been pursued in good faith or a permit has been issued. [2022 California Building Code Sec. 105.3.2] Signature of Applicant: All information provided in the application and permitting process are considered part of the public record and may be disclosed in full under the California Public Records Act. Submit this application along with supporting documents to [EMAIL REDACTED] ---PAGE BREAK--- PERMITTEE DECLARATION CA HEALTH & SAFETY CODE 19825 Licensed Contractor to complete Sections A & C -or- Owner-Builder to complete Sections B and section D if utilizing a construction lending agency. Project Permit A. LICENSED CONTRACTOR'S DECLARATION hereby affirm under penalty of perjury that I am under the provisions of Chapter 9 (commencing with Section Law 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Class: License Number: Signature of Contractor: Print Date: B. OWNER's ACKNOWLEDGEMENT AND VERIFICATION OF INFORMATION 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 application item(s) (Section 7031.5 Business and Profession Code: Any City or County that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to 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 Profession Code) or that he or she is exempt from the licensure and the basis for the alleged exemption. Any 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): 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 of offered for sale (Section 7044, Business and Profession 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 improvements 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. 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. am exempt from the 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 reside for at least one year prior to completion of the improvements covered by this permit, I cannot legally sell a structure that I 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, Section 7044 of the Business and Profession Code, is available upon request when this application is submitted or at the following Website: Signature of Property Owner or Authorized C. WORKERS’ COMPENSATION DECLARATION 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 Section 3706 of the Labor Code, interest, and attorney's fees. I hereby affirm under penalty of perjury one of the following declarations: have and will maintain a certificate of consent to self-insure for workers' compensation, issued by the Director of Industrial Relations as provided by for Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Policy Number: 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 carrier and policy numbers are: Carrier: Policy Number: Expiration Date: Name of Agent: Phone Number: _ 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 workers' compensation laws of California, and agree that, if I should become subject to workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Signature of D. DECLARATION REGARDING CONSTRUCTION LENDING AGENCY 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). Lender's Address: