Form Ds-342 - Change Of Building Permit Record - City Of San Diego Development Services - 2015 Page 2
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City of San Diego • Development Services Department
Change of Building Permit Record
•
7. New Permit Holder:
This is the property owner, person, or entity that is granted authority by the property owner to be responsible for scheduling inspections, receiving
notices of failed inspections, permit expirations or revocation hearings, and who has the right to cancel the approval (in addition to the property owner).
SDMC Section
113.0103.
Name:
Telephone:
E-mail Address:
Address:
City:
State:
Zip Code:
8. Workers’ Compensation Declaration: I hereby affirm under penalty of perjury one of the following declarations:
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.
I hereby affirm under penalty of perjury one of the following declarations:
❏
a. I have and will maintain a certificate of consent to self-insure for workers’ compensation, issued by the Director of Indus-
trial Relations as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
issued.
❏
b. I have and will maintain workers’ compensation insurance, as required by Section 3700 of the Labor Code, for the perfor-
mance of the work for which this permit is issued. My workers’ compensation insurance carrier and policy number are:
Insurance Carrier: _____________________________________ Policy No.:__________________ Expiration Date: _________________
Name of Agent: ________________________________________ Phone No.:___________________________________________________
❏
c. 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.
A separate Owner-Builder Verification form (DS-3042) must also be signed by the owner.
9. Change to Owner-Builder:
Effective Date: _____________________________
Owner-Builder Declaration: I 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 applicable item(s). (Section 7031.5, Business and
Professions Code: Any city or county 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 Contractors’ 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 from 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).):
❏
a. I, 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 or offered for sale (Section 7044, Business and Professions 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 improvement
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).
❏
b. I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Busi-
ness and Professions Code: The Contractor’s License Law does not apply to an owner of property who builds or improves
thereon, and contracts for such projects with contractor(s) licensed pursuant to the Contractor’s License Law).
❏
c. I am exempt from 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 resided for at least one year prior
to completion of the improvements covered by this permit, I cannot legally sell a structure that I have 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 Professions Code, is available upon request when this application is submitted or at the following website:
Print Name: ____________________________________________________
Date: __________________________________
Owner Signature or Authorized Agent: ___________________________________________________________________________________
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