APPLICATION FOR PERMIT TO CONSTRUCT...INSTRUCTIONS ACCESSORY STRUCTURES; Complete Sections 1, 3, 5...
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State of California Business, Transportation and Housing Agency Department of Housing and Community Development Division o f C o d e s and Standards Mobilehome and Special Occupancy Parks Programs A P P L I C A T I O N F O R P E R M I T T O C O N S T R U C T ( S E E R E V E R S E S I D E 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 B U I L D E R D E C L A R A T I O N S Not required for commercial modular or Recreational Vehicles 1 . L I C E N S E D C O N T R A C T O R S D E C L A R A T I O N 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 o f p e r j u r y t h a t I am licensed under provisions of Chapter 9 (commencing with Section 7000) o f D i v i s i o n 3 o f t h e B u s i n e s s a n d P r o f e s s i o n s C o d e , a n d m y l i c e n s e i s i n f u l l f o r c e a n d e f f e c t . L i c e n s e C l a s s Lic. No. Exp. Date Contractor Date 2 . O W N E R - B U I L D E R D E C L A R A T I O N 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 o f p e r j u r y that I a m e x e m p t f r o m t h e Contractors License L a w f o r t h e f o l l o w i n g reason (Sec. 7031.5), Business and P r o f e s s i o n s C o d e : A n y c i t y o r c o u n t y which requires a p e r m i t t o c o n s t r u c t , alter, improve, demolish, o r r e p a i r a n y s t r u c t u r e , prior to its issuance, a l s o r e q u i r e s t h e a p p l i c a n t f o r s u c h p e r m i t t o f i l e a s i g n e d s t a t e m e n t t h a t h e o r she i s l i c e n s e d pursuant to the p r o v i s i o n s o f t h e C o n t r a c t o r s License L a w ( C h a p t e r 9 (commencing w i t h S e c t i o n 7000) of Division 3 of the Business and Professions Code) or that he or she is e x e m p t t h e r e f r o m a n d t h e b a s i s f o r t h e a l l e g e d exemption. A n y v i o l a t i o n of Section 7031.5 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 more than five hundred dollars($500).): • I, as owner of the property, or my employees with wages as t h e i r s o l e compensation, will d o t h e work, and the structure is not intended of offered for sale (Sec. 7044, Business and P r o f e s s i o n s C o d e : T h e C o n t r a c t o r s License Law d o e s n o t a p p l y to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, p r o v i d e d t h a t s u c h i m p r o v e m e n t s are n o t i n t e n d e d o r o f f e r e d f o r s a l e . If, however, the building o r i m p r o v e m e n t is sold within o n e y e a r o f c o m p l e t i o n , the o w n e r - b u i l d e r w i l l have t h e b u r d e n o f p r o v i n g t h a t h e o r s h e d i d n o t b u i l d o r i m p r o v e f o r t h e purpose o f s a l e . ) . • 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 d o e s n o t apply to an o w n e r o f p r o p e r t y w h o b u i l d s o r i m p r o v e s thereon, and who c o n t r a c t s f o r such p r o j e c t s w i t h a contractor(s) l i c e n s e d p u r s u a n t t o t h e C o n t r a c t o r s L i c e n s e Law.). • I am e x e m p t u n d e r S e c . , B. & P.C. f o r t h i s r e a s o n : Owner Date 3 . W O R K E R S ' C O M P E N S A T I O N D E C L A R A T I O N I hereby affirm u n d e r p e n a l t y o f p e r j u r y o n e o f t h e following declarations: • l have and w i l l 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 s e l f - I n s u r e for workers' compensation, as provided for by Section 3700 of the Labor Code, f o r 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 permit is issued. • I h a v e a n d will maintain w o r k e r s ' c o m p e n s a t i o n insurance, a s r e q u i r e d b y S e c t i o n 3 7 0 0 o f t h e L a b o r C o d e , f o r t h e performance of the work f o r w h i c h t h i s p e r m i t is issued. My workers' compensation insurance c a r r i e r a n d p o l i c y n u m b e r are: Carrier Policy Number. ( T h i s s e c t i o n n e e d n o t be c o m p l e t e d i f t h e permit is f o r o n e h u n d r e d d o l l a r s ( $ 1 0 0 ) o r l e s s ) . • I c e r t i f y t h a t i n the performance o f t h e w o r k f o r w h i c h t h i s permit is issued, I s h a l l 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 t o b e c o m e subject t o w o r k e r s ' compensation l a w s o f California, a n d a g r e e t h a t I f I should b e c o m e s u b j e c t t o workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Applicant Date. W A R N I N G : F A I L U R E T O S E C U R E W O R K E R S ' 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 S H A L L S U B J E C T A N E M P L O Y E R T O C R I M I N A L P E N A L T I E S A N D C I V I L F I N E S U P T O O N E H U N D R E D 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 T H E C O S T O F C O M P E N S A T I O N , D A M A G E S A S P R O V I D E D F O R I N S E C T I O N 3 7 0 6 OF T H E L A B O R C O D E , I N T E R E S T , A N D A T T O R N E Y ' S F E E S . 4 . 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 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 p e r j u r y t h a t there i s a 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 f o r t h e p e r f o r m a n c e o f t h e work f o r w h i c h t h i s p e r m i t i s i s s u e d ( S e c . 3097, Civ. C.). Lender's Name Lender's Address 5 . C E R T I F I C A T I O N I c e r t i f y t h a t I h a v e r e a d t h i s a p p l i c a t i o n a n d s t a t e t h a t the above 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 and county ordinances and state laws relating to building construction, and hereby authorize representatives of this c o u n t y t o e n t e r u p o n the above-mentioned p r o p e r t y f o r inspection purposes. Signature of Applicant or Agent Date SECTION 1 - O W N E R / A P P L I C A N T I N F O R M A T I O N Park Name Park Address City County Zip Unincorporated Incorporated Park Owner APPLICANT CONTRACTOR OWNER Other Address Tel. No Architect/Engineer Lic. No. Address Tel. No. SECTION 2 - DESCRIPTION OF WORK AND VALUATION Valuation $ SECTION 3 - ACCESSORY B U I L D I N G S o r S T R U C T U R E S NEW REINSTALL Standard Plan Approval No. Awning Carport Porch C a b a n a Other (specify) OWNER Tel. No. Address RESIDENT Tel. No. Lot No. SECTION 4 - MANUFACTURED HOME/MOBILEHOME INSTALLATION Owner Tel. No. Address Resident Lot No. Serial Number(s) Date of MFG. Manufacturer N a m e / Model Name Insignia/HUD Label No. SECTION 5 - P A R K O W N E R , OPERATOR OR MANAGER SIGNATURE APPROVED: (Signature Required) Date DEPARTMENT USE ONLY ID. No. MP AS MHI Closed By Date Closed COLLECTION INFORMATION Collection # Fee Rec'd Collection Date Assigned To Routed By Upon Department approval to release, and payment of fees, this p e r m i t i s issued o n l y f o r i t e m s validated below. P E R M I T # MH ACC/S MP BLDG MHI MISC. TECH SER. PLC'K S.M.I. ISSUE TOTAL DIVISION PROCESS RECORD Application Local Planning Local Fire Local Health Public Works Environmental Impact Negative Declaration School Impact Fees Date Issued By Expires H C D 5 0 , S i d e 1 ( R e v . 7 / 0 4 ) DISTRIBUTION: W H I T E - D E P A R T M E N T , BLUE-APPLICANT, YELLOW – DISTRICT REPRESENTATIVE, PINK – ASSESSOR
Transcript of APPLICATION FOR PERMIT TO CONSTRUCT...INSTRUCTIONS ACCESSORY STRUCTURES; Complete Sections 1, 3, 5...
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S t a t e o f C a l i f o r n i a B u s i n e s s , 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 o f H o u s i n g a n d C o m m u n i t y D e v e l o p m e n t D i v i s i o n o f C o d e s a n d 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 P a r k s P r o g r a m s
A P P L I C A T I O N F O R P E R M I T T O C O N S T R U C T ( S E E R E V E R S E S I D E 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 B U I L D E R D E C L A R A T I O N S Not required for commercial modular or Recreational Vehicles
1 . L I C E N S E D C O N T R A C T O R S D E C L A R A T I O N 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 o f p e r j u r y t h a t I a m l i c e n s e d
u n d e r p r o v i s i o n s o f 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 7 0 0 0 ) o f D i v i s i o n 3 o f t h e B u s i n e s s a n d P r o f e s s i o n s C o d e , a n d m y l i c e n s e i s i n f u l l f o r c e a n d e f f e c t .
L i c e n s e C l a s s L i c . N o . E x p . D a t e
C o n t r a c t o r Date 2 . O W N E R - B U I L D E R D E C L A R A T I O N
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 o f p e r j u r y t h a t I a m e x e m p t f r o m t h e C o n t r a c t o r s L i c e n s e L a w f o r t h e f o l l o w i n g r e a s o n ( S e c . 7 0 3 1 . 5 ) , B u s i n e s s a n d P r o f e s s i o n s C o d e : A n y c i t y o r c o u n t y w h i c h r e q u i r e s a p e r m i t t o c o n s t r u c t , a l t e r , i m p r o v e , d e m o l i s h , o r r e p a i r a n y s t r u c t u r e , p r i o r t o i t s i s s u a n c e , a l s o r e q u i r e s t h e a p p l i c a n t f o r s u c h p e r m i t t o f i l e a s i g n e d s t a t e m e n t t h a t h e o r s h e i s l i c e n s e d p u r s u a n t t o t h e p r o v i s i o n s o f t h e C o n t r a c t o r sL i c e n s e L a w ( 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 7 0 0 0 ) o f D i v i s i o n 3 o f t h e B u s i n e s s a n d P r o f e s s i o n s C o d e ) o r t h a t h e o r 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 b a s i s f o r t h e a l l e g e d e x e m p t i o n . A n y v i o l a t i o n o f S e c t i o n 7 0 3 1 . 5 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 c i v i l p e n a l t y o f n o t m o r e t h a n f i v e h u n d r e d d o l l a r s ( $ 5 0 0 ) . ) :
• I , a s o w n e r o f t h e p r o p e r t y , o r m y e m p l o y e e s w i t h w a g e s a s t h e i r s o l e c o m p e n s a t i o n , w i l l 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 f o r s a l e ( S e c . 7 0 4 4 , B u s i n e s s a n d P r o f e s s i o n s 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 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 b u i l d s 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 h i s o r h e r o w n e m p l o y e e s , p r o v i d e d t h a t s u c h i m p r o v e m e n t s a r e n o t i n t e n d e d o r o f f e r e d f o r s a l e . I f , h o w e v e r , t h e b u i l d i n g o r i m p r o v e m e n t i s s o l d 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 w i l l h a v et h e b u r d e n o f p r o v i n g t h a t h e o r s h e d i d n o t b u i l d o r i m p r o v e f o r t h e p u r p o s e o f s a l e . ) .
• I , a s o w n e r o f t h e p r o p e r t y , a m e x c l u s i v e l y c o n t r a c t i n g w i t h l i c e n s e d c o n t r a c t o r s t o c o n s t r u c t t h e p r o j e c t ( S e c . 7 0 4 4 , B u s i n e s s a n d P r o f e s s i o n s 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 wd 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 b u i l d s 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 f o r s u c h p r o j e c t s w i t h a c o n t r a c t o r ( s ) l i c e n s e d p u r s u a n t t o t h e C o n t r a c t o r s L i c e n s e L a w . ) . • I a m e x e m p t u n d e r S e c . , B . & P . C . f o r t h i s r e a s o n :
O w n e r D a t e
3 . W O R K E R S ' C O M P E N S A T I O N D E C L A R A T I O N 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 o f p e r j u r y o n e o f t h e f o l l o w i n g d e c l a r a t i o n s : • l h a v e a n d w i l l 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 s e l f - I n s u r e f o r w o r k e r s ' c o m p e n s a t i o n , a s p r o v i d e d f o r b y S e c t i o n 3 7 0 0 o ft h e L a b o r C o d e , f o r 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 t h i s p e r m i t i s i s s u e d .• I h a v e a n d w i l l 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 , a s r e q u i r e d b y S e c t i o n 3 7 0 0 o f t h e L a b o r C o d e , f o r 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 t h i s p e r m i t i s i s s u e d . M y 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 c a r r i e r a n d p o l i c y n u m b e r a r e :
C a r r i e r
P o l i c y N u m b e r . ( T h i s 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 h u n d r e d d o l l a r s ( $ 1 0 0 ) o r l e s s ) . • 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 t h i s p e r m i t i s i s s u e d , I s h a l l n o t e m p l o y a n y p e r s o n i n a n y m a n n e r s o a s t o b e c o m e s u b j e c t t o w o r k e r s ' c o m p e n s a t i o n l a w s o fC a l i f o r n i a , a n d a g r e e t h a t I f I s h o u l d b e c o m e s u b j e c t t o w o r k e r s ' c o m p e n s a t i o n p r o v i s i o n s o f S e c t i o n 3 7 0 0 o f t h e L a b o r C o d e , I s h a l l f o r t h w i t h c o m p l y w i t h t h o s e p r o v i s i o n s .A p p l i c a n t
D a t e .
W A R N I N G : F A I L U R E T O S E C U R E W O R K E R S ' 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 S H A L L S U B J E C T A N E M P L O Y E R T O C R I M I N A L P E N A L T I E S A N D C I V I L F I N E S U P T O O N E H U N D R E D 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 T H E C O S T O F C O M P E N S A T I O N , D A M A G E S A S P R O V I D E D F O R I N S E C T I O N 3 7 0 6 O F T H E 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 .
4 . 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 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 o f p e r j u r y t h a t t h e r e i s a
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 f o r 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 t h i s p e r m i t i s i s s u e d ( S e c . 3 0 9 7 , C i v . C . ) .
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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 a l l c i t y a n d c o u n t y o r d i n a n c e s a n d s t a t e l a w s r e l a t i n g t o b u i l d i n g 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 t h i s 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 f o r i n s p e c t i o n p u r p o s e s .
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I N S T R U C T I O N S
A C C E S S O R Y S T R U C T U R E S ; 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 B u i l d e r D e c l a r a t i o n s . S u b m i t t h e c o m p l e t e d a p p l i c a t i o n 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 l i s t e d b e l o w .
M A N U F A C T U R E D H O M E / M O B I L E H O M E I N S T A L L A T I O N : C o m p l e t e S e c t i o n s 1 , 4 , 5 , a n d C o n t r a c t o r / O w n e r B u i l d e r D e c l a r a t i o n s . S u b m i t t h e 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 l i s t e d b e l o w ,
1 8 5 5 1 F O U N D A T I O N S Y S T E M : 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 B u i l d e r D e c l a r a t i o n s . S u b m i t t h e c o m p l e t e d a p p l i c a t i o n 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 l i s t e d b e l o w .
P A R K U T I L I T I E S : 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 B u i l d e r D e c l a r a t i o n s . S u b m i t t h e 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 l i s t e d b e l o w .
N E W P A R K S A N D P E R M A N E N T B U I L D I N G S : 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 B u i l d e r D e c l a r a t i o n s . S u b m i t t h e 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 l i s t e d b e l o w ,
N o r t h e r n A r e a O f f i c e 9 3 4 2 T e c h C e n t e r D r i v e , S u i t e 5 5 0 S a c r a m e n t o , C A 9 5 8 2 6 ( 9 1 6 ) 2 5 5 - 2 5 0 1
S o u t h e r n A r e a O f f i c e 3 7 3 7 M a i n S t . , S u i t e 4 0 0 R i v e r s i d e , C A 9 2 5 0 1 ( 9 5 1 ) 7 8 2 - 4 4 2 0
S E C T I O N 1 - O W N E R / A P P L I C A N T I N F O R M A T I O N : E n t e r t h e p a r k n a m e a n d a d d r e s s . I n d i c a t e I f t h e p a r k i s l o c a t e d i n a n u n i n c o r p o r a t e d a r e a o r a n i n c o r p o r a t e d a r e a : E n t e r t h e p a r k o w n e r ' s n a m e ( s ) . E n t e r t h e a p p l i c a n t ' s n a m e , a d d r e s s a n d t e l e p h o n e n u m b e r ( T h e D e p a r t m e n t w i l l c o n t a c t o r c o r r e s p o n d w i t h t h e p a r t y t h a t i s e n t e r e d a s t h e a p p l i c a n t . ) C h e c k t h e a p p r o p r i a t e b o x t o d e s c r i b e t h e a p p l i c a n t . I f t h e b o x " O t h e r " i s m a r k e d , p l e a s e i n d i c a t e t h e r e l a t i o n s h i p t o t h e o w n e r . I f t h e r e q u e s t e d s e r v i c e s i n v o l v e a n a r c h i t e c t o r e n g i n e e r , e n t e r t h e a r c h i t e c t o r e n g i n e e r ' s n a m e , a d d r e s s , t e l e p h o n e n u m b e r , a n d l i c e n s e n u m b e r .
S E C T I O N 2 - D E S C R I P T I O N O F W O R K A N D V A L U A T I O N : P r o v i d e a d e s c r i p t i o n o f t h e w o r k t o b e p e r f o r m e d ( i . e . , i n s t a l l i n g a m a n u f a c t u r e d h o m e o n a f o u n d a t i o n s y s t e m , e t c . ) E n t e r t h e t o t a l c o s t o f t h e w o r k t o b e p e r f o r m e d ( t o t a l c o n t r a c t p r i c e ) .
S E C T I O N 3 - A C C E S S O R Y B U I L D I N G S o r S T R U C T U R E S : C h e c k t h e a p p r o p r i a t e b o x t o i n d i c a t e i f t h e a c c e s s o r y b u i l d i n g / s t r u c t u r e i s a n e w i n s t a l l a t i o n o r a r e i n s t a l l a t i o n . A n e w I n s t a l l a t i o n m e a n s a n e w a c c e s s o r y b u i l d i n g o r s t r u c t u r e o r a n a c c e s s o r y b u i l d i n g o r s t r u c t u r e t h a t h a s n o t p r e v i o u s l y b e e n i n s t a l l e d w i t h t h e u n i t . A r e i n s t a l l a t i o n m e a n s a n a c c e s s o r y b u i l d i n g o r s t r u c t u r e t h a t i s b e i n g r e i n s t a l l e d f o r t h e s a m e p u r p o s e a s t h e o r i g i n a l I n s t a l l a t i o n . E n t e r t h e S t a n d a r d P l a n A p p r o v a l N u m b e r i f t h i s i s a n e w i n s t a l l a t i o n . C h e c k t h e a p p r o p r i a t e b o x t o i n d i c a t e t h e t y p e o f a c c e s s o r y b u i l d i n g / s t r u c t u r e , I f t h e b o x " O t h e r " i s c h e c k e d , e n t e r t h e t y p e o f b u i l d i n g / s t r u c t u r e o n t h e l i n e p r o v i d e d ( i . e . s t o r a g e b u i l d i n g , g r e e n h o u s e , e t c . ) . E n t e r t h e n a m e , t e l e p h o n e n u m b e r a n d a d d r e s s o f t h e o w n e r . I f t h e o c c u p a n t o f t h e m a n u f a c t u r e d h o m e / m o b i l e h o m e i s o t h e r t h a n t h e o w n e r , e n t e r t h e n a m e o f t h e r e s i d e n t , t e l e p h o n e n u m b e r a n d t h e l o t n u m b e r w h e r e t h e u n i t i s l o c a t e d .
S E C T I O N 4 - M A N U F A C T U R E D H O M E / M O B I L E H O M E I N S T A L L A T I O N : E n t e r t h e n a m e , t e l e p h o n e n u m b e r a n d a d d r e s s o f t h e o w n e r . I f t h e o c c u p a n t o f t h e m a n u f a c t u r e d h o m e / m o b i l e h o m e i s o t h e r t h a n t h e o w n e r , e n t e r t h e n a m e o f t h e r e s i d e n t a n d t h e l o t n u m b e r w h e r e t h e u n i t i s l o c a t e d . E n t e r t h e s e r i a l n u m b e r ( s ) o f t h e m a n u f a c t u r e d h o m e / m o b i l e h o m e . T h e s e r i a l n u m b e r ( s ) c a n b e l o c a t e d o n t h e M a n u f a c t u r e r ' s C e r t i f i c a t e o f O r i g i n , t h e C e r t i f i c a t e o f T i t l e , r e g i s t r a t i o n d o c u m e n t s o r o n t h e f r o n t c r o s s m e m b e r o f t h e u n i t . E n t e r t h e y e a r t h e u n i t w a s m a n u f a c t u r e d . E n t e r t h e m a n u f a c t u r e r ' s n a m e a n d M o d e l n a m e . T h i s i n f o r m a t i o n c a n b e o b t a i n e d f r o m t h e M a n u f a c t u r e r ' s C e r t i f i c a t e o f O r i g i n , t h e C e r t i f i c a t e o f T i t l e , r e g i s t r a t i o n d o c u m e n t s o r m a y b e d e s i g n a t e d o n t h e o u t s i d e o f t h e u n i t i t s e l f . E n t e r t h e C a l i f o r n i a I n s i g n i a N u m b e r ( s ) o r H U D L a b e l N u m b e r ( s ) i s s u e d f o r t h i s u n i t , i f k n o w n .
S E C T I O N 5 - P A R K O W N E R , O P E R A T O R O R M A N A G E R S I G N A T U R E : T h e s i g n a t u r e o f t h e p a r k o w n e r , o p e r a t o r o r m a n a g e r i s r e q u i r e d a l o n g w i t h t h e d a t e t h e f o r m i s s i g n e d . T h i s s i g n a t u r e i s a n a c k n o w l e d g m e n t t h a t t h e p a r k i s a w a r e a n d a p p r o v e s o f t h e s e r v i c e s b e i n g r e q u e s t e d i n t h i s a p p l i c a t i o n .
C O N T R A C T O R / O W N E R B U I L D E R D E C L A R A T I O N S
C o n t r a c t o r : C o n t r a c t o r s p r o p o s i n g c o n s t r u c t i o n a r e r e q u i r e d b y s t a t e l a w t o p r o v i d e t h e f o l l o w i n g i n f o r m a t i o n :
I t e m 1 - L i c e n s e d C o n t r a c t o r D e c l a r a t i o n : E n t e r t h e c o n t r a c t o r ' s l i c e n s e c l a s s , l i c e n s e n u m b e r , d a t e t h e l i c e n s e e x p i r e s , t h e c o n t r a c t o r ' s s i g n a t u r e a n d d a t e .
I t e m 3 - W o r k e r s ' C o m p e n s a t i o n D e c l a r a t i o n : P l a c e a c h e c k m a r k n e x t t o t h e d e c l a r a t i o n r e g a r d i n g t h e w o r k e r s ' c o m p e n s a t i o n c o v e r a g e t h a t a p p l i e s t o t h e c o n t r a c t o r . I f t h e s e c o n d d e c l a r a t i o n i s m a r k e d , t h e c o n t r a c t o r m u s t a l s o p r o v i d e t h e c a r r i e r ' s n a m e a n d p o l i c y n u m b e r . T h i s i t e m m u s t b e s i g n e d b y t h e c o n t r a c t o r a n d d a t e d .
I t e m 4 - 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 : I f t h e r e i s a 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 f o r 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 t h e s e r v i c e b e i n g r e q u e s t e d , e n t e r t h e n a m e a n d a d d r e s s o f t h e l e n d i n g a g e n c y . I f t h e r e i s n o l e n d i n g a g e n c y I n v o l v e d , e n t e r t h e w o r d " n o n e . "
I t e m 5 - C e r t i f i c a t i o n : T h e c e r t i f i c a t i o n m u s t b e s i g n e d a n d d a t e d b y t h e c o n t r a c t o r o r a g e n t o n b e h a l f o f t h e c o n t r a c t o r .
O w n e r B u i l d e r : I f t h e w o r k o r a c t i v i t y a s d e s c r i b e d o n t h e a p p l i c a t i o n , i s b e i n g c o m p l e t e d b y t h e o w n e r , t h e o w n e r m u s t c o m p l e t e t h e f o l l o w i n g I t e m s :
I t e m 2 - O w n e r - B u i l d e r D e c l a r a t i o n : P l a c e a c h e c k m a r k n e x t t o t h e d e c l a r a t i o n w h i c h i s a p p l i c a b l e . I f t h e t h i r d d e c l a r a t i o n i s m a r k e d , e n t e r t h e s e c t i o n n u m b e r f r o m t h e B u s i n e s s a n d P r o f e s s i o n C o d e w h i c h p r o v i d e s t h e e x e m p t i o n a n d t h e r e a s o n f o r t h e e x e m p t i o n . T h e o w n e r m u s t a l s o s i g n a n d d a t e t h i s s e c t i o n .
I t e m 5 - C e r t i f i c a t i o n : T h e c e r t i f i c a t i o n m u s t b e s i g n e d a n d d a t e d b y t h e o w n e r .
H C D 5 0 , S i d e 2 ( R e v . 7 / 0 4 )
License Class:: License No: :: of Architect/Engineer::
Expiry Date:: Contractor:: 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 of offered for sale (Sec: 7044, Business and Professions Code: ): Off
I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec: 7044, Business and Professions Code: ): Off
I am exempt: OffI am exempt under Section:: Reason for exemption:: Owner:: Date (Owner):: 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: OffI 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: OffInsurance Carrier:: Policy 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: OffApplicant:: Date (Applicant):: Lender's Name:: Lender's Address:: Signature Date of Applicant or Agent:: Park Address:: City:: County:: Zip:: Unincorporated:: Incorporated:: Park Owner:: Section 1 - APPLICANT:: OTHER:: Address (line 1):: Address (line 2):: Telephone No: of Applicant:: of Architect/Engineer::
Architect/Engineer:: Address of Architect/Engineer:: DESCRIPTION OF WORK AND VALUATION (line 1):: DESCRIPTION OF WORK AND VALUATION (line 2):: DESCRIPTION OF WORK AND VALUATION (line 3):: DESCRIPTION OF WORK AND VALUATION (line 4):: DESCRIPTION OF WORK AND VALUATION (line 5):: DESCRIPTION OF WORK AND VALUATION (line 6):: Valuation ($):: Standard Plan Approval No: ::
Specify other type of accessory building/structure:: Section 3 - OWNER:: Section 3 - Telephone No: of owner:: of Resident::
Section 3 - Address of owner:: Section 3 - RESIDENT:: Section 3 - Lot No: ::
Section 4 - Owner:: Section 4 - Address of Owner:: Section 4 - Resident:: Section 4 - Lot No: ::
Section 4 - Serial Number(s):: Date of manufacturing:: Manufacturer Name/Model Name:: Insignia/Housing and Community Development Label No: ::
Signature Date of Park Owner, Operator or Manager:: ID: NO: ::
Closed By:: Date Closed:: Collection # (line 1):: Collection # (line 2):: Fee Received (line 1):: Fee Received (line 2):: Collection Date:: Assigned To:: Routed By:: PERMIT #:: MH ACC/S:: MP:: BLDG:: MHI:: MISC: ::
TECH SER: ::
PLC'K:: ISSUE:: TOTAL:: Application:: Local Planning:: Local Fire:: Local Health:: Public Works:: Environmental Impact:: Negative Declaration:: School Impact Fees:: Date of DIVISION PROCESS RECORD:: Expires:: Date:: Park Name:: Section 4 - Telephone No: of Owner::
DESCRIPTION OF WORK AND VALUATION (line 7):: DESCRIPTION OF WORK AND VALUATION (line 8):: S: M: I: ::
Issued By (line 1):: Issued By (line 2):: CONTRACTOR/OWNER/OTHER: OffNEW/REINSTALL: OffAwning/Carport/Porch/Cabana/Other: OffMP/AS/MHI: OffBeginning:
