Form Hcd 50Erbs – Fill Out and Use This PDF

CONTRACTOR/OWNER BUILDER DECLARATIONS

1. LICENSED CONTRACTORS 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______ Lic. No. ___________Exp. Date_________

Contractor___________________________ Date _________

2. OWNER-BUILDER DECLARATION

I hereby affirm under penalty of perjury that I am exempt from the Contractors License Law for the following reason (Sec. 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 Contractors 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 of offered for sale, Sec. 7044, Business and Professions Code: The Contractors License Law does not apply 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, 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 Sec. 7044, Business and Professions Code: The Contractors 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 Contractors License Law.

I am exempt under Sec. _______, B. & P.C. for this reason:

__________________________________________________

Owner_______________________________ Date__________

3. 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 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.

Applicant ____________________________Date__________

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.

4. 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 ____________________________________

5. CERTIFICATION

I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this county to enter upon the above-mentioned property for inspection purposes.

_________________________________________________

Signature of Applicant or Agent

Date

SECTION 1 - APPLICANT INFORMATION

Name _________________________________________________________

Address ________________________________________________________

City___________________________________________ Zip_____________

Telephone Number (_______)_________________________________

Check one as appropriate:

□ CONTRACTOR □ REGISTERED OWNER □ OTHER

(Other - relationship to installer)___________________________________

SECTION 2 – INSTALLATION SITE INFORMATION

Registered Owner Name _________________________________________

Address ________________________________________________________

Contact

Space / Lot Number_________ Telephone (________)___________________

Park Name ______________________________________________________

Site Address

____________________________________________________

City__________________________________ County___________________

SECTION 3 – EARTHQUAKE RESISTANT BRACING SYSTEM INFORMATION

NEW REINSTALL Certification No. _________________________

Manufacturer Name ____________________________________________

Brand Name____________________________________________________

Model Number _________________________________________________

SECTION 4 – APPLICANT SIGNITURE

I hereby certify under penalty of perjury that the information provided herein is true and correct.

Signature_______________________________________________________

(Applicant)

Date__________________________

NOTE: This application must be accompanied by a copy of the plans and manufacturer's installation instructions made from the original, bearing the Department's stamp of approval and by the appropriate fees in accordance with the California Code of Regulations, Title 25, Chapter 2.

DEPARTMENT USE ONLY

ID. No. ______________________

Closed By ___________________

Date Closed _________________

COLLECTION INFORMATION

____________________________

Collection #

____________________________

Fee Rec’d

____________________________

Collection Date

____________________________

Assigned to

____________________________

Routed By

Date _______________________

Issued By_____________________

Expires______________________