Building Permit Application - Building Division City Of Menlo Park (Page 2 of 3) in pdf

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LICENSED CONTRACTOR’S DECLARATION

I hereby affirm under penalty of perjury that I am licensed under provisions 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:____________________________________________

License Number:__________________________________

Expiration Date:_________________________

Date:____________________________________________________

Contractor Signature:_____________________________________________________________________________

OWNER-BUILDER DECLARATION

I hereby affirm under penalty of perjury that I am exempt from the Contractor’s License Law for the following reason: [Section 7031.5 Business and Professions Code: Any city or county which requires

a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the

provisions of the Contractor’s 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 not intended or offered for sale. (Section 7044, Business and

Professions Code: The Contractor’s License Law does not apply to an owner of property who builds or improves theron, and who does such work himself or herself or through his or her own

employees, provided that such 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. (Section 7044, Business and Professions Code: The Contractor’s License Law

does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor’s License Law.)

I am exempt under Section__________________ Business and Professions Code for the following reason: _________________________________________________________________

___________________________________________________________________________________________________________________________________________________________

Date:____________________________________________________

Owner Signature:__________________________________________________________________________________

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 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 workers’ compensation laws of California,

and agree that if I should become subject to the workers’ compensation provisions of Section 3700 of he Labor Code, I shall forwith comply with those provisions.

Date:___________________________________________________

Applicant Signature:________________________________________________________________________________

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 ($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.