APPLICATION FOR PERMIT TO CONSTRUCT - California

1 State of California Business, T r a n s p o r t a t i o n a n d H o u s i n g A g e n c y D e p a r t m e n t of Housing a n d C o m m u n i t y D e v e l o p m e n t Division of C o d e s and S t a n d a r d s M o b i l e h o m e a n d S p e c i a l O c c u p a n c y Parks P r o g r a m s A P P L I C A T I O N FOR PERMIT TO C O N S T R U C T. (SEE REVERSE SIDE O F F O R M F O R I N S T R U C T I O N S A N D A D D I T I O N A L I N F O R M A T I O N ). C O N T R A C T O R / O W N E R BUILDER D E C L A R A T I O N S. Not required for commercial modular or Recreational Vehicles SECTION 1 - OWNER/APPLICANT INFORMATION D E P A R T M E N T USE O N L Y. 1. LICENSED C O N T R A C T O R S D E C L A R A T I O N.

2 I h e r e b y affirm u n d e r p e n a l t y of perjury t h a t I am licensed Park N a m e ID. N o . u n d e r provisions of C h a p t e r 9 ( c o m m e n c i n g w i t h S e c t i o n 7000) MP AS MHI. o f Division 3 o f t h e Business a n d Professions C o d e , a n d m y Park Address l i c e n s e i s i n full f o r c e a n d e f f e c t . Closed By License Class Lic. N o . Exp. D a t e City County Date Closed Contractor Date Zip Unincorporated Incorporated 2. OWNER-BUILDER D E C L A R A T I O N COLLECTION INFORMATION. I h e r e b y affirm u n d e r p e n a l t y o f perjury t h a t I a m e x e m p t Park Owner f r o m t h e C o n t r a c t o r s License L a w for t h e f o l l o w i n g r e a s o n (Sec.)

3 Collection #. 7 0 3 1 . 5 ) , Business a n d Professions C o d e : A n y c i t y o r c o u n t y w h i c h requires a PERMIT to CONSTRUCT , alter, i m p r o v e , d e m o l i s h , APPLICANT. or repair a n y structure, prior to its issuance, also requires t h e a p p l i c a n t for s u c h p e r m i t t o file a s i g n e d s t a t e m e n t t h a t h e o r CONTRACTOR OWNER Other she is licensed pursuant to t h e provisions of t h e C o n t r a c t o r s Fee Rec'd License Law ( C h a p t e r 9 ( c o m m e n c i n g with Section 7000) of Division 3 o f t h e Business a n d Professions C o d e ) o r t h a t h e o r Address s h e i s e x e m p t t h e r e f r o m a n d t h e basis for t h e a l l e g e d e x e m p t i o n.

4 A n y violation o f S e c t i o n b y a n y a p p l i c a n t f o r a p e r m i t s u b j e c t s t h e a p p l i c a n t t o a civil p e n a l t y o f n o t Tel. No m o r e t h a n five h u n d r e d dollars($500).): Collection Date Architect/Engineer Lic. No. I, as o w n e r of the property, or my employees with w a g e s as Assigned To t h e i r s o l e c o m p e n s a t i o n , will d o t h e w o r k , a n d t h e s t r u c t u r e i s n o t i n t e n d e d o f o f f e r e d for s a l e (Sec. 7044, Business a n d Address Tel. No. Professions C o d e : The C o n t r a c t o r s L i c e n s e L a w d o e s n o t a p p l y Routed By t o a n o w n e r o f p r o p e r t y w h o builds o r I m p r o v e s t h e r e o n , a n d w h o d o e s s u c h w o r k h i m s e l f o r h e r s e l f o r t h r o u g h his o r h e r o w n Upon Department approval to employees, provided that such improvements are not i n t e n d e d SECTION 2 - DESCRIPTION OF W O R K A N D V A L U A T I O N r e l e a s e , a n d p a y m e n t o f f e e s , this or o f f e r e d for sale.

5 If, h o w e v e r , t h e building or i m p r o v e m e n t is sold w i t h i n o n e y e a r o f c o m p l e t i o n , t h e o w n e r - b u i l d e r will h a v e PERMIT is issued only for items t h e burden of proving that he or she did n o t build or i m p r o v e validated below. for t h e p u r p o s e of sale.). I, as o w n e r of t h e property, am exclusively c o n t r a c t i n g with PERMIT #. licensed contractors to CONSTRUCT t h e p r o j e c t (Sec. 7044, Business a n d Professions C o d e : T h e C o n t r a c t o r s L i c e n s e L a w MH ACC/S. d o e s n o t a p p l y t o a n o w n e r o f p r o p e r t y w h o builds o r i m p r o v e s t h e r e o n , a n d w h o c o n t r a c t s for such projects w i t h a contractor(s) licensed pursuant to t h e Contractors License MP.

6 Law.). I am e x e m p t u n d e r S e c . , B. & for this r e a s o n : BLDG. MHI. Owner Date 3. WORKERS' COMPENSATION DECLARATION MISC. I h e r e b y affirm under p e n a l t y of perjury o n e of t h e following declarations: l h a v e a n d will m a i n t a i n a c e r t i f i c a t e o f c o n s e n t t o self-Insure T E C H SER. for workers' c o m p e n s a t i o n , a s p r o v i d e d for b y S e c t i o n 3 7 0 0 o f Valuation $. t h e L a b o r C o d e , for t h e p e r f o r m a n c e o f t h e w o r k f o r w h i c h this PLC'K. p e r m i t is issued. I h a v e a n d will m a i n t a i n w o r k e r s ' c o m p e n s a t i o n i n s u r a n c e , SECTION 3 - ACCESSORY BUILDINGS or STRUCTURES.

7 As required by Section 3700 of t h e Labor C o d e , for t h e p e r f o r m a n c e o f t h e w o r k for w h i c h this p e r m i t i s issued. M y NEW REINSTALL Standard Plan A p p r o v a l No. workers' c o m p e n s a t i o n insurance carrier a n d policy n u m b e r ISSUE. are: Awning Carport Porch C a b a n a Carrier TOTAL. Policy Number. Other (specify). (This s e c t i o n n e e d n o t b e c o m p l e t e d i f t h e p e r m i t i s f o r o n e DIVISION PROCESS RECORD. h u n d r e d d o l l a r s ( $ 1 0 0 ) o r less). I c e r t i f y t h a t i n t h e p e r f o r m a n c e o f t h e w o r k f o r w h i c h this OWNER Tel. No. APPLICATION p e r m i t is issued, I shall n o t e m p l o y a n y p e r s o n in a n y m a n n e r so as to b e c o m e subject to workers' c o m p e n s a t i o n laws of Address California , a n d a g r e e that If I should b e c o m e subject to Local Planning workers' c o m p e n s a t i o n provisions o f S e c t i o n 3700 o f t h e L a b o r C o d e , I shall f o r t h w i t h c o m p l y w i t h t h o s e provisions.

8 RESIDENT T e l . No. Applicant L o c a l Fire Date. L o t No. Local Health W A R N I N G : FAILURE TO SECURE WORKERS' C O M P E N S A T I O N. C O V E R A G E I S U N L A W F U L A N D SHALL SUBJECT A N EMPLOYER. T O C R I M I N A L PENALTIES A N D C I V I L FINES U P T O O N E H U N D R E D SECTION 4 - MANUFACTURED H O M E / M O B I L E H O M E INSTALLATION Public Works T H O U S A N D D O L L A R S ( $ 1 0 0 , 0 0 0 ) , I N A D D I T I O N T O THE C O S T O F. COMPENSATION, D A M A G E S AS PROVIDED FOR IN SECTION 3706 Environmental O F THE L A B O R C O D E , INTEREST, A N D A T T O R N E Y ' S F E E S . Owner Tel. No. Impact 4. CONSTRUCTION LENDING A G E N C Y Address I h e r e b y a f f i r m u n d e r p e n a l t y of perjury t h a t t h e r e is a Negative c o n s t r u c t i o n l e n d i n g a g e n c y for t h e p e r f o r m a n c e o f t h e w o r k Declaration f o r w h i c h this p e r m i t i s i s s u e d ( S e c.)

9 3 0 9 7 , C i v . C . ) . Resident Lot No. Lender's Name School Impact Serial N u m b e r ( s ) Fees Lender's Address Manufacturer N a m e /. Date of MFG. Model N a m e 5. CERTIFICATION Insignia/HUD Date I c e r t i f y t h a t I h a v e r e a d this a p p l i c a t i o n a n d s t a t e t h a t t h e Label No. a b o v e i n f o r m a t i o n i s c o r r e c t . I a g r e e t o c o m p l y w i t h all c i t y Issued By a n d c o u n t y ordinances a n d state laws relating to building c o n s t r u c t i o n , a n d h e r e b y a u t h o r i z e r e p r e s e n t a t i v e s o f this SECTION 5 - PARK O W N E R , OPERATOR OR M A N A G E R SIGNATURE. c o u n t y t o e n t e r u p o n t h e a b o v e - m e n t i o n e d p r o p e r t y for APPROVED: inspection purposes.

10 Expires Signature of Applicant or Agent Date (Signature Required) Date H C D 50, Side 1 (Rev. 7/04) DISTRIBUTION: WHITE - DEPARTMENT, BLUE-APPLICANT, YELLOW DISTRICT REPRESENTATIVE, PINK ASSESSOR. INSTRUCTIONS. A C C E S S O R Y STRUCTURES; C o m p l e t e S e c t i o n s 1 , 3 , 5 a n d C o n t r a c t o r / O w n e r Builder D e c l a r a t i o n s . Submit the c o m p l e t e d APPLICATION a n d t h e r e q u i r e d f e e s t o t h e a p p r o p r i a t e A r e a O f f i c e listed b e l o w . MANUFACTURED HOME/MOBILEHOME INSTALLATION: C o m p l e t e Sections 1, 4, 5, a n d C o n t r a c t o r / O w n e r Builder Declarations. Submit the c o m p l e t e d a p p l i c a t i o n a n d r e q u i r e d f e e s t o t h e a p p r o p r i a t e A r e a O f f i c e listed b e l o w , 18551 F O U N D A T I O N SYSTEM: C o m p l e t e S e c t i o n s 1 , 2 , 5 a n d C o n t r a c t o r / O w n e r Builder D e c l a r a t i o n s.