Fillable Plumbing Permit Application (Page 2 of 2) in pdf

PERMIT DECLARATIONS (for FAX or Mail-In only)

LICENSED CONTRACTOR’S DECLARATION

I hereby affirm under penalty of perjury that I am licensed under provision 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.

License Class

Lic. No.

Date

Contractor

OWNER BUILDER DECLARATION

I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the following reason (Sec. 7031.5, Business and Professions Code:

Any city that requires a permit to construct, alter, improve, demolish or repair any structure, prior to its 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 Contrators’ State 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 ($500).):

I as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is no intended or offered for sale (Sec. 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 does the work himself or

herself or through his or her own employees, provided that the 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 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 contractor(s) licensed pursuant to the

Contractors’ State License Law.).

I am exempt under Sec.

, B. & P.C. for this reason

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 NUMBER:

(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 worker’s 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.

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.

CITY ORDINANCES (Ordinances available for view on request)

__ In conformance with the City of Berkeley Noise Ordinance, and/or Use Permit, I understand my obligation to comply and work within prescribed hours.

__ I am aware of my responsibilities under the Relocation Ordinance.

__ I certify that I have read and shall use to the maximum extent practicable applicable portions of the State Storm Water Best Management Practices Manual for construction.

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 (Sec. 3097, Civ. C.).

Lender’s Name:

Lender’s Address:

__ BUILDING & SAFETY – Certificate Of Compliance And Authorization Of Entry. I certify that I have read this application and state that the information given is correct. I agree to

comply with all state laws and city ordinances relating to building construction and authorize a representative of the City of Berkeley Building and Safety Division to enter upon the

property for which I have applied for this permit for the purpose of making inspections.

__ ENGINEERING – Certificate Of Compliance. I, hereby agree, to indemnify and hold harmless the City of Berkeley and its officers and employees from any and all claims arising

from or out of work connected with this permit to perform all work under BMC Title 16 and 17 as amended, specifications, detail plans and the Uniform Building Code of the City of

Berkeley, all special provision made a part of this permit, whether written or oral, and to the satisfaction of the Director of Public Works. I furthermore agree to comply agree to comply

with all regulations and ordinances of the City of Berkeley.

Signature of: Contractor or Owner (CIRCLE ONE)

Date

I hereby affirm under penalty of perjury that I am the authorized agent of the owner and/or contractor.

Authorized Agent for:

Contractor

Owner

PRINT NAME

Address:

NOTE: A permit applicant who files a signed document by facsimile transmission

(fax) with the City of Berkeley Permit Service Center represents that the original

signed document is in his or her possession or control. At any time after filing the