Construction Permit Application - City Of Oxnard Development Services (Page 2 of 2) in pdf

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

submitted

the

following

Web

site:

Property Owner or Authorized Agent signature_______________________________ Date ________________

Signatures Not Completed in the Presence of Department Staff Must be Notarized

IDENTIFY WORKERS’ COMPENSTATION COVERAGE AND LENDING AGENCY

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.

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, issued by

the Director of Industrial Relations as provided for by Section 3700 of the Labor Code, for the performance of

the work for which this permit is issued. Policy No. ________________________________________________

(_) 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_______________________ Expiration Date_____________

Name of Agent ____________________________________________ Tel No __________________________

(_) 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.

DECLARATION REGARDING 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 (Section 3097, Civil Code).

Lender’s Name and Address__________________________________________________________________

_________________________________________________________________________________________

DECLARATION BY CONSTRUCTION PERMIT APPLICANT

By my signature below, I certify to each of the following:

I am (_) a California licensed contractor or (_) the property owner* or (_) authorized to act on the

property owner’s behalf**.

I have read this construction permit application and the information I have provided is correct.

I agree to comply with all applicable city and county ordinances and state laws relating to building construction.

I authorize representatives of this city or county to enter the above-identified property for inspection purposes.

*requires separate verification form

California Licensed Contractor, Property Owner* or Authorized Agent**: **requires separate authorization form

Signature ________________________________________________

Date _________________________

Signatures Not Completed in the Presence of Department Staff Must be Notarized

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CALBO Jan 1, 2009 Permit Application Template

Construction Permit Application - Signatures.doc

Construction Permit Application - City Of Oxnard Development Services Page 2

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