HCD MH 415: Application for Alteration, Technical Services or Insignia Inspection

Contractor / Owner-Builder Declarations are not required for Special Purpose Commercial Modular.

For Inspection to Obtain Insignia, complete Sections 1, 2, 3, 4, 5 and Contractor/Owner-Builder Declarations.

For Alteration, Addition or Conversion, complete Sections 1, 2, 3, 4, 5, and Contractor/Owner-Builder Declarations.

For Technical Services, complete Sections 1, 2, 3, and 5.

In Section 1, check one box to indicate the type of unit for which you are requesting services.

If Commercial Coach, also indicate the Occupancy Group Code (i.e. B2, E2, A1, etc.) in the space provided.

Enter the unit serial number(s), which can be located on the Manufacturer's Certificate of Origin, the Certificate of Title, registration documents or on the front cross member of the unit.

Enter the year the unit was manufactured and the manufacturer's name and/or trade name, which can be obtained from the Manufacturer's Certificate of Origin, the Certificate of Title, registration documents or may be designated on the outside of the unit itself.

Enter the decal or license number, which is located on the license plate issued by DMV or the decal issued by the Department of Housing.

Enter the California Insignia Number(s) or HUD Label Number(s) that were issued for this unit, if known.

In Section 2, enter the owner's name(s) and address of the unit.

If the address for the owner is different than the location of the unit, provide that information in the "Location Address" area.

If the applicant is other than the owner, enter the name, address and telephone number of the applicant. The Department will contact or correspond with the party that is entered as the applicant.

If the applicant is the same as the owner, the applicant information is not required to be completed.

In Section 3, if the services are being performed by a contractor, enter the contractor's name and address, and also enter the contractor's license expiration date.

If requested services involve an Architect or Engineer, enter the architect or engineer's name, address and license number.

In Section 4, provide a description of the work to be performed (i.e., installing a new roof, installing new windows, etc.) and enter the total cost of the work to be performed (total contact price).

Describe the proposed work/activity in detail. Attach additional pages if necessary. Where structural alterations or additions are proposed, complete plans, specifications, details, and calculations are required to be attached to this form. Provide the make and model of any appliance to be installed and provide complete electrical calculations for any electrical alternations or additions.

In Item 1, enter the contractor's license class, license number, license expiration date and the contractor's signature and date (Date of Declaration).

If the work or activity as described on the application is being completed by the owner, the owner must complete the following items. In Item 2, place a check mark next to the declaration which is applicable.

In Item 2, if the third declaration is marked, enter the section number from the Business and Profession Code which provides the exemption and the reason for the exemption. The owner must also sign and date this section (Date of Owner-builder Declaration).

In Item 3, place a check mark next to the declaration regarding the workers' compensation coverage that applies to the contractor.

If the second declaration is marked, the contractor must also provide the carrier's name and policy number. This item must be signed by the contractor and dated.

Mark this box only if, in the performance of the work, for which this permit is issued, you shall not employ any person in any manner so as to become subject to workers' compensation laws of California; you also agree that if you should become subject to workers' compensation provisions of Section 3700 of the Labor Code, you shall forthwith comply with those provisions.

In Item 4, if there is a construction lending agency for the performance of the work for the service being requested, enter the name and address of the lending agency. If there is no lending agency involved, enter the word "none".

When a contractor proposes the construction, in Item 5 the certification must be signed and dated by the contractor or agent on behalf of the contractor.

When the owner does the work, in Item 5 the certification must be signed and dated by the owner.

By certifying, you state that you have read this application and that the information is correct, agree to comply with all city and county ordinances and state laws relating to building construction, and authorize representatives of this county to enter upon the property for inspection purposes.

For Inspection to Obtain Insignia, Alteration, Addition or Conversion, and Technical Services, submit the completed application and required fees to the appropriate Area Office. The Southern Area Office is at 3737 Main Street, Suite 400, Riverside, CA 92501, (800) 952-8356. The Northern Area Office is at 9342 Tech Center Drive #550, Sacramento, CA 95826, (800) 952-8356. For Alternate Approval, complete Sections 1, 2, 3, 4, and 5, and submit the completed application and required fees to the Department of Housing and Community Development, Manufactured Housing Section, P.O. Box 278180, Sacramento, CA 95827-8180.

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 (checked November 1, 2026).