Full Text
BUILDING PERMIT APPLICATION CITY OF MODESTO BUILDING SAFETY Bond Amount Application Date Of Applicant Construction Cost E-mail Project Address Suite OWNER Last Name First Address City State Zip Phone Owner Occupy Yes No E-mail CONTRACTOR Name Phone Address City State Zip E-mail Contractor State License City of Modesto Business License LICENSED ENGINEERING/ARCHITECTURAL FIRM Name Address City State Zip Phone License No. Email Address LEGAL DESCRIPTION (FOR NEW BUILDINGS) Subdivision/Parcel Map Block DESCRIPTION OF WORK I certify that I have read this application and state that the above information is CORRECT. I AGREE TO COMPLY with all city and county 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 Date Signature of Applicant/Agent Owner Contractor Agent In accordance with the requirements of Title II of the Americans with Disabilities Act (“ADA”) of 1990, the Fair Employment & Housing Act (“FEHA”), the Rehabilitation Act of 1973 (as amended), Government Code section 11135 and other applicable codes, the City of Modesto (“City”) will not discriminate against individuals on the basis of disability in the City’s services, programs, or activities. For more information, please visit the City of Modesto website at SIGN SIGN SIGN SIGN SIGN SIGN ---PAGE BREAK--- LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the 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. I have secured permission from the property owner to obtain this permit. Date Contractor License Class License No. 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: 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 Contractor’s License Law (Chapter 9, (commencing with Section 7000), of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom 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 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 Contractor’s License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself 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 burden 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 Contractor’s 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 Contractor’s License Law.). I am exempt under Sec. , B. & P. C. for this reason Date Owner 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, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 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: Carrier Policy No. (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. Date Applicant 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. DEPOSIT PERMITS Deposit applications may have a refund or additional fees due after the Final Inspection. Fees must be paid before the Certificate of Occupancy can be issued. Balances less than $5.00 will not be refunded. I hereby acknowledge that any remaining deposit will be returned to: Name Address City State Zip Phone Signature of Owner Contractor Agent CERTIFICATE OF OCCUPANCY Pick up at City of Modesto 1010 Tenth St. Suite 3100 Mail to listed person and address: Name Phone Address City State Zip CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which the permit is issued (Sec. 3097. Civ. Lender’s Name Lender’s Address HAZARDOUS MATERIALS DECLARATION 1) Does/will your business handle store or transport hazardous materials? Yes No 2) Is/will your business be located within 1,000 feet of a school (Grades K- 12)? Yes No SIGN SIGN SIGN SIGN SIGN SIGN SIGN SIGN SIGN SIGN