A Permit From Hcd Details

Hcd 415 Form is a new healthcare ruling set to take effect on January 1, 2019. The purpose of this form is to identify and provide care for patients with high-cost chronic conditions. If you have a high-cost chronic condition, it's important to understand how the Hcd 415 Form will impact you and your loved ones. In this blog post, we'll provide an overview of the Hcd 415 Form and what you need to know in order to prepare for the new year. Stay tuned for additional blog posts with more in-depth information about the Hcd 415 Form.

Below is some data that may be handy in case you are looking to learn how much time it will take you to fill out hcd 415 form and the number of PDF pages it contains.

QuestionAnswer
Form NameHcd 415 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names415 application form, ca hcd 415 california, ca hcd 415 form, application hcd 415

Form Preview Example

State of California

Business, Transportation and Housing Agency

DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT

Division of Codes and Standards

HCD 415 APPLICATION FOR

Alteration

Addition or Conversion

Alternate Approval

Technical Services

Inspection To Obtain Insignia

CONTRACTOR / OWNER-BUILDER DECLARATIONS

Not required for Special Purpose Commercial Modular

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 there from 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))

SECTION 1 - UNIT INFORMATION

I / We are requesting services for the following unit(s): (Check Appropriate Box)

Manufactured Home/Mobilehome

Multifamily Manufactured Home

Commercial Modular (Occupancy Group _____________)

Special Purpose Commercial Modular

Decal Number ____________________________________________

Serial Number(s) / VIN Number______________________________

___________________________________________________________

Manufacturer Name / Model Name

___________________________________________________________

Year of Manufacture_______________________________________

_____________________

DTN / Permit No.

Fee

 

__

Date ___

__

AA No.

 

 

__

RT TO

 

__

RT BY

 

__

[] 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 _________________________________________________________________

[] 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 (Section 3097, Civil Code).

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

HCD 415 (Rev. 07/2013)

Insignia / HUD Label Number(s)_________________________ _______________________________________

SECTION 2 – OWNER / APPLICANT INFORMATION

Owner________________________________________________________________________________________

Address_______________________________________________________________________________________

City___________________________County_____________________________________Zip_________________

Location Address______________________________________________________________________________

Park Name (If Applicable) _______________________________________ Park ID#_____________________

Applicant_____________________________________________________________________________________

Address_______________________________________________________________________________________

City___________________________County_____________________________________Zip_________________

Telephone – Applicant______________________________ Homeowner ______________________________

(If Different than Applicant)

SECTION 3 – CONTRACTOR, ARCHITECT OR ENGINEER INFORMATION

Contractor’s Name____________________________________________________________________________

Address_______________________________________________________________________________________

Architect / Engineer Name_____________________________________________________________________

Registration No._______________________________________________________________________________

Address ___________________________________________________________________________ ___________

SECTION 4 – DESCRIPTION OF WORK / ACTIVITY AND VALUATION

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.

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

Indicate the Total Cost of the Work to be Performed____________________________________________

SECTION 5 - SIGNATURE AND CERTIFICATION

I / We hereby make application for the services designated above.

Signature _____________________________________________

Date_________________________________

 

**DEPARTMENT USE ONLY**

 

Permit Expiration Date_______________________________

APPROVED

CONDITIONS (see reverse side)

DISAPPROVED (see reverse side)

Issued By:

 

Date:

 

 

 

_______________________________________________________________________________________________

Closed / Signature of District Representative

 

Date

DISTRIBUTION:

YELLOW – DEPARTMENT

WHITE – AREA OFFICE

PINK – OWNER/APPLICANT

INSTRUCTIONS:

Inspection to Obtain Insignia: Complete Sections 1, 2, 3, 4, 5 and Contractor/Owner-Builder Declarations. Submit the application and the required fees to one of the appropriate Area Office listed below. Upon return receipt of your processed application (White Copy), contact the designated Area Office to schedule the inspection date.

Alteration, Addition or Conversion: Complete Sections 1, 2, 3, 4, 5, and Contractor/Owner-Builder Declarations. Submit the completed application and required fees to the appropriate Area Office listed below. Upon return receipt of your processed application (White Copy), contact the designated Area Office to schedule the inspection date.

Technical Services: Complete Sections 1, 2, 3, and 5. Submit the completed application and required fees to the appropriate Area Office listed below. Upon return receipt of your processed application (White Copy), contact the designated Area Office to schedule an appointment for services.

Southern Area Office

Northern Area Office

3737 Main Street, Suite 400

9342 Tech Center Drive #550

Riverside, CA 92501

Sacramento, CA 95826

(951) 782-4420

(916) 255-2501

Alternate Approval: Complete Sections 1, 2, 3, 4, and 5. Submit the completed application and required fees to: Department of Housing and Community Development, Manufactured Housing Section, P.O. Box 31, Sacramento, CA 95812-0031. If you have any questions you may contact the Department at (916) 445-3338.

SECTION 1 - UNIT INFORMATION: 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). The serial number(s) 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. Enter the manufacturer's name and/or trade name. This information 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. This number 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.

SECTION 2 - OWNER/APPLICANT INFORMATION: 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 is 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.

SECTION 3 - CONTRACTOR, ARCHITECT OR ENGINEER INFORMATION: If the services are being performed by a contractor, enter the contractor's name and address. 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.

SECTION 4 - DESCRIPTION OF WORK/ACTIVITY AND VALUATION: Provide a description of the work to be performed (i.e., installing a new roof, installing new windows, etc.) Enter the total cost of the work to be performed (total contact price).

SECTION 5 - SIGNATURE AND CERTIFICATION: The signature of the applicant is required along with the date the form is signed. If the

application is for a replacement insignia or HUD label, the signature must be of the owner of the unit.

CONTRACTOR/OWNER-BUILDER DECLARATIONS

Contractor: Contractors proposing construction are required by state law to provide the following information:

Item 1 - Licensed Contractor Declaration: Enter the contractor's license class, license number, license expiration date and the contractor's signature and date.

Item 3 - Workers' Compensation Declaration: 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.

Item 4 - Construction Lending Agency: 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".

Item 5 - Certification: The certification must be signed and dated by the contractor or and agent on behalf of the contractor.

Owner-Builder: If the work or activity as described on the application, is being completed by the owner, the owner must complete the following items:

Item 2 - Owner-Builder Declaration: Place a check mark next to the declaration which is applicable. 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.

Item 5 - Certification: The certification must be signed and dated by the owner.

DEPARTMENT USE ONLY

APPROVAL OF THIS APPLICATION IS CONDITIONED TO COMPLIANCE WITH REGULATIONS OF THE DEPARTMENT: Any approval issued by the Department pursuant to this application is conditioned upon the applicant's compliance with the applicable provisions of the California Administrative Code, Title 25, Chapter 3, and the Business and Professions Code as it relates to contracting.

________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________

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HCD 415, Side 2 (Rev. 07/2013)

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